What is the first line treatment for a gout flare?

First-Line Treatment for Acute Gout Flares

The first-line treatment for an acute gout flare is low-dose colchicine, NSAIDs, or corticosteroids, with the choice depending on patient-specific factors such as comorbidities and contraindications. 1, 2

Treatment Options

Colchicine

• Recommended dosing: 1.2 mg (two tablets) at first sign of flare, followed by 0.6 mg (one tablet) one hour later 3
• Low-dose regimen is as effective as higher doses with fewer gastrointestinal side effects 1
• Contraindicated in patients with:
  • Severe renal impairment (GFR <30 mL/min)
  • Concomitant use of strong CYP3A4 inhibitors
  • Hepatic impairment 3

NSAIDs

• Should be used at full FDA-approved anti-inflammatory doses until flare resolves 2
• Options include naproxen, indomethacin, or other NSAIDs
• No evidence that indomethacin is more effective than other NSAIDs 1
• Contraindicated in patients with:
  • Renal disease
  • Heart failure
  • Cirrhosis
  • History of GI bleeding 1, 2

Corticosteroids

• Can be administered via oral, intra-articular, or intramuscular routes 2
• Oral prednisone/prednisolone: 30-35 mg daily for 3-5 days 2
• Intra-articular injections: Particularly useful for monoarticular gout
• Consider as first-line therapy in patients without contraindications due to safety profile and cost-effectiveness 1

Patient-Specific Selection Algorithm

1. For patients with normal renal function and no cardiovascular disease:

   • Any first-line agent can be used (colchicine, NSAIDs, or corticosteroids)
   • Consider patient preference and prior response

2. For patients with renal impairment (GFR <30 mL/min):

   • Avoid colchicine and NSAIDs
   • Use corticosteroids (oral, intra-articular, or intramuscular) 2

3. For patients with cardiovascular disease:

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

4. For patients with diabetes:

   • Monitor blood glucose when using corticosteroids
   • Consider colchicine or NSAIDs if no contraindications exist 2

5. For patients unable to take oral medications:

   • Use intramuscular or intravenous corticosteroids 2

Important Considerations

• Treatment should be initiated within 24 hours of symptom onset for optimal efficacy 2
• Continue treatment until flare completely resolves 2
• Do not interrupt urate-lowering therapy during acute flares 2
• For severe, multiarticular flares, combination therapy may be considered 2
• Topical ice can be applied as an adjuvant treatment 2

Common Pitfalls to Avoid

1. Delaying treatment initiation (should begin within 24 hours of symptom onset)
2. Using high-dose colchicine regimens (associated with more adverse effects)
3. Failing to consider renal function when selecting therapy
4. Discontinuing urate-lowering therapy during acute flares
5. Not adjusting medication doses for patients with renal or hepatic impairment
6. Neglecting prophylaxis when initiating urate-lowering therapy

By following this approach and considering patient-specific factors, acute gout flares can be effectively managed to reduce pain, inflammation, and long-term joint damage.