What is the recommended treatment for a gout flare-up?

Treatment for Gout Flare-Up

For acute gout flares, first-line treatment options include colchicine (within 12 hours of symptom onset), NSAIDs, or oral corticosteroids, with the choice based on patient factors and timing of treatment. 1, 2

First-Line Treatment Options

Colchicine

• Most effective when given within 12 hours of symptom onset 1, 2
• Recommended dosing: 1 mg loading dose followed 1 hour later by 0.5 mg on day 1 1, 3
• Contraindications:
  • Severe renal impairment
  • Concomitant use of strong P-glycoprotein/CYP3A4 inhibitors (e.g., clarithromycin, cyclosporin) 1, 3

NSAIDs

• Can be used as monotherapy or in combination with colchicine for severe flares 1
• Should be avoided in patients with:
  • Severe renal impairment
  • History of peptic ulcer disease
  • Uncontrolled hypertension
  • Heart failure 4
• Short-acting NSAIDs (diclofenac, ketoprofen) are preferred in elderly patients 4

Oral Corticosteroids

• Prednisolone 30-35 mg daily for 3-5 days 1, 2
• Alternative regimen: 0.5 mg/kg/day for 5-10 days at full dose then stop, or 2-5 days at full dose followed by a 7-10 day taper 2
• Particularly useful in patients with contraindications to colchicine or NSAIDs 2
• Monitor blood glucose in diabetic patients 2

Treatment Selection Algorithm

1. If symptoms started <12 hours ago:

   • Colchicine is preferred (1 mg followed by 0.5 mg one hour later) 1, 2, 3

2. If symptoms started >12 hours ago:

   • NSAIDs or oral corticosteroids are preferred 1

3. If patient has renal impairment:

   • Avoid colchicine and NSAIDs
   • Use oral corticosteroids (prednisolone 30-35 mg daily for 3-5 days) 1, 2, 4

4. If patient has cardiovascular disease:

   • Avoid NSAIDs
   • Use colchicine (if renal function is normal) or oral corticosteroids 2

5. For severe or polyarticular flares:

   • Consider combination therapy (colchicine plus NSAIDs or colchicine plus corticosteroids) 1
   • Intra-articular corticosteroid injections can be added for specific affected joints 2

Important Clinical Considerations

• Early treatment is crucial for optimal efficacy 1, 2
• The "pill in the pocket" approach is recommended to allow patients to self-medicate at the first warning symptoms 1
• Continue treatment until the flare completely resolves 2
• Underdosing may lead to incomplete resolution of symptoms 2
• When initiating urate-lowering therapy (ULT), prophylactic anti-inflammatory therapy should be used for 3-6 months to prevent flares 1, 2, 5

Common Pitfalls to Avoid

1. Delaying treatment beyond 12-36 hours, which significantly decreases efficacy 2
2. Using colchicine in patients with severe renal impairment 1, 3
3. Using NSAIDs in elderly patients with comorbidities 4
4. Failing to provide prophylaxis when initiating urate-lowering therapy 1, 5
5. Treating pain only without addressing the underlying inflammatory process 3
6. Extended use of steroids beyond the recommended duration, increasing risk of adverse effects 2

Following these evidence-based recommendations will help effectively manage gout flares while minimizing adverse effects and improving patient outcomes.