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

Treatment of Gout Flare-Ups

For acute gout flares, oral colchicine, NSAIDs, or glucocorticoids are strongly recommended as first-line therapy, with the specific choice based on patient comorbidities and contraindications. 1

First-Line Treatment Options

Colchicine

• Dosing: 1.2 mg (two tablets) at first sign of flare, followed by 0.6 mg (one tablet) one hour later 2
• Most effective when given within 12 hours of symptom onset 1
• Low-dose regimen preferred over high-dose due to similar efficacy with fewer side effects 3
• Contraindicated in severe renal impairment and with strong P-glycoprotein/CYP3A4 inhibitors 1

NSAIDs

• Options include naproxen, indomethacin, or sulindac 1
• Consider adding proton pump inhibitor if appropriate 1
• Avoid in patients with cardiovascular disease, heart failure, or renal impairment 4

Oral Corticosteroids

• Prednisone/prednisolone 30-35 mg daily for 3-5 days 1
• Can be administered by maintaining full dose then stopping, or by maintaining full dose for 2-5 days then tapering for 7-10 days 1
• Methylprednisolone dose pack is an acceptable option 1

Patient-Specific Considerations

Renal Impairment

• Severe renal impairment: Avoid colchicine and NSAIDs; use oral corticosteroids 1
• Moderate renal impairment: Reduce colchicine dose 1

Cardiovascular Disease

• Avoid NSAIDs 4
• Use colchicine (if renal function is normal) or oral corticosteroids 1, 4
• Colchicine may potentially reduce risk of myocardial infarction in patients with cardiovascular disease 4

Diabetes

• Monitor for hyperglycemia when using prednisone 1

Adjunctive Therapies

• Topical ice is conditionally recommended as an adjuvant treatment 3
• For severe, multiarticular flares, combination therapy (e.g., oral corticosteroids plus colchicine) can be considered 1
• Intra-articular corticosteroid injection may be added for specific affected joints 1

Second-Line Options

• If first-line agents are contraindicated, not tolerated, or ineffective, IL-1 inhibitors (e.g., anakinra, canakinumab) can be used 3, 1
• For patients unable to take oral medications, intramuscular or intravenous glucocorticoids are strongly recommended over IL-1 inhibitors 3

Treatment Duration

• Continue treatment until the flare completely resolves 1
• Do not stop urate-lowering therapy during an acute gout attack 1

Prophylaxis When Starting Urate-Lowering Therapy

• Prophylactic anti-inflammatory therapy (colchicine, NSAIDs, or prednisone/prednisolone) should be continued for 3-6 months when initiating urate-lowering therapy 3, 1
• Low-dose colchicine (0.5-0.6 mg once or twice daily) or low-dose NSAIDs are recommended first-line options for prophylaxis 5

Lifestyle Modifications

• Limit alcohol intake, particularly beer 3, 6
• Limit purine-rich foods (e.g., organ meats, shellfish) 3, 6
• Limit high-fructose corn syrup intake 3, 6
• Weight loss program for overweight/obese patients 3
• Encourage consumption of vegetables and low-fat or nonfat dairy products 6

By following these evidence-based recommendations, acute gout flares can be effectively managed while minimizing adverse effects and preventing recurrent attacks.