What is the management approach for a gout flare-up?

Management of Acute Gout Flares

For acute gout flares, first-line treatment should be colchicine, NSAIDs, or glucocorticoids based on patient-specific factors, with treatment initiated within 24 hours of symptom onset for optimal efficacy. 1

First-Line Treatment Options

Colchicine

• Low-dose regimen preferred: 1.2 mg initially, followed by 0.6 mg one hour later, then continue with prophylactic dosing (0.6 mg once or twice daily) until flare resolves 1, 2
• Most effective when started within 12-36 hours of symptom onset 1, 2
• Avoid in patients with severe renal impairment (CrCl <30 mL/min) or those on prophylactic colchicine already 1, 3

NSAIDs

• Use full FDA-approved doses (e.g., naproxen, indomethacin, sulindac) 1
• Continue at full dose until gout attack completely resolves 1
• Avoid in patients with significant cardiovascular disease, renal impairment, or history of GI bleeding 2

Glucocorticoids

• Options include:
  • Oral: Prednisone 0.5 mg/kg/day for 5-10 days then stop, or 2-5 days at full dose then taper for 7-10 days 1
  • Intra-articular: Dose varies by joint size (particularly effective for monoarticular gout) 1, 2
  • Intramuscular: Triamcinolone acetonide 60 mg 1
• Preferred for patients with renal impairment or when oral medications are contraindicated 1, 2

Treatment Selection Algorithm

1. If patient can take oral medications:

   • For patients with normal renal function and no cardiovascular disease: Any first-line agent (colchicine, NSAIDs, or oral glucocorticoids)
   • For patients with renal impairment (GFR <30 mL/min): Avoid colchicine and NSAIDs; use glucocorticoids 2
   • For patients with cardiovascular disease: Avoid NSAIDs; use colchicine (if renal function normal) or glucocorticoids 2
   • For patients with diabetes: Use colchicine or NSAIDs; if using glucocorticoids, monitor blood glucose closely 2

2. If patient cannot take oral medications:

   • Use parenteral glucocorticoids (intramuscular or intravenous) 1
   • Intra-articular injections for monoarticular gout 2

Adjunctive Measures

• Topical ice: Apply to affected joint as an adjuvant treatment 1, 2
• Continue urate-lowering therapy: Do not interrupt during acute flares 1
• For severe, multiarticular flares, combination therapy may be considered (e.g., oral corticosteroids plus colchicine) 2

Second-Line Options

• IL-1 inhibitors (anakinra, canakinumab): Consider only when first-line agents are contraindicated, ineffective, or poorly tolerated 1, 2

Common Pitfalls to Avoid

1. Delaying treatment: Initiate therapy within 24 hours of symptom onset for optimal efficacy 1
2. Using high-dose colchicine: Low-dose regimen has similar efficacy with fewer side effects 1
3. Stopping urate-lowering therapy during flares: Continue existing therapy to prevent worsening of flare 1
4. Neglecting renal function: Adjust medication choice and dosing based on renal function 2, 3
5. Inadequate duration of treatment: Continue treatment until flare completely resolves 1

Long-Term Management Considerations

• Initiate prophylaxis when starting urate-lowering therapy to prevent flares 4
• Options for prophylaxis include low-dose colchicine (0.6 mg once or twice daily) or low-dose NSAIDs for up to 6 months 1, 4
• Consider lifestyle modifications: limit alcohol intake, purine-rich foods, and high-fructose corn syrup 1, 2

The recent CONTACT trial found no significant difference in pain reduction between naproxen and low-dose colchicine, but naproxen caused fewer side effects (particularly gastrointestinal), supporting its use as first-line when not contraindicated 5.