Can I administer an in-office injection of torsemide (loop diuretic) for a patient experiencing a gout flare who already has colchicine (anti-gout medication) at home?

Management of Acute Gout Flare: Torsemide Injection vs. Colchicine

Torsemide injection is not recommended for the treatment of acute gout flares; the patient should be instructed to use their colchicine at home according to appropriate dosing guidelines.

First-Line Treatments for Acute Gout Flares

The 2020 American College of Rheumatology (ACR) and 2017 European League Against Rheumatism (EULAR) guidelines strongly recommend three first-line options for acute gout flare management:

1. Colchicine - Most effective when started within 12-36 hours of symptom onset

   • Low-dose regimen: 1.2 mg initially, followed by 0.6 mg one hour later 1, 2
   • Continue with 0.6 mg once or twice daily until flare resolves

2. NSAIDs - With proton pump inhibitor if appropriate

3. Corticosteroids - Oral (30-35 mg/day of prednisolone for 3-5 days) or intra-articular injection 1

Why Torsemide Is Not Appropriate for Gout Flares

Torsemide is a loop diuretic that has no direct anti-inflammatory properties needed to treat acute gout flares 3. Furthermore:

• Loop diuretics like torsemide can actually worsen hyperuricemia by increasing uric acid reabsorption in the proximal tubule
• Torsemide may cause dehydration, which can concentrate uric acid and potentially worsen a gout flare
• There is no evidence supporting torsemide's use for treating gout flares in any guidelines 1, 2

Appropriate Use of Patient's Home Colchicine

Since the patient already has colchicine at home, instruct them to:

1. Take colchicine as soon as possible (ideally within 12-36 hours of symptom onset) 2
2. Follow the FDA-approved dosing regimen: 1.2 mg initially, followed by 0.6 mg one hour later 1, 2
3. Continue with 0.6 mg once or twice daily until the flare resolves

Important Considerations for Colchicine Use

• Renal function: Adjust dosing if the patient has renal impairment 2

  • For severe CKD (CrCl <30 mL/min): 0.6 mg as a single dose, not to be repeated more than once every two weeks

• Drug interactions: Check for medications that may interact with colchicine 2

  • Avoid co-administration with P-glycoprotein/CYP3A4 inhibitors (clarithromycin, cyclosporine, verapamil, ketoconazole, ritonavir)
  • Use caution if patient is on statins due to increased risk of myopathy 4

• Common side effects: Diarrhea (occurs in most patients after a median time of 24 hours), nausea, vomiting 5

Alternative Options if Colchicine Is Contraindicated

If the patient has contraindications to colchicine (severe renal impairment, drug interactions):

1. Oral corticosteroids: Prednisone 30-35 mg daily for 3-5 days 1
2. Intra-articular corticosteroid injection: For monoarticular gout 1, 2
3. IL-1 inhibitors: Consider only if other first-line treatments are ineffective, poorly tolerated, or contraindicated 1

Follow-up Recommendations

1. Evaluate for initiation of urate-lowering therapy (ULT) if this is not the first flare
2. Target serum urate level <6 mg/dL (<5 mg/dL for severe gout with tophi) 2
3. Consider prophylactic colchicine (0.6 mg daily) when initiating ULT to prevent flares 1, 2

By following evidence-based guidelines for gout management, you can effectively treat the patient's acute flare while minimizing adverse effects and preventing future attacks.