What is the treatment for acute gout flare?

Treatment of Acute Gout Flare

For acute gout flares, first-line treatment should be corticosteroids, NSAIDs, or colchicine, with corticosteroids preferred as first-line therapy in patients without contraindications due to their safety profile and low cost. 1

First-Line Medication Options

Corticosteroids

• Preferred first-line option for patients without contraindications 1
• Dosing: Prednisolone 35 mg daily for 5 days 1
• Benefits: As effective as NSAIDs with fewer adverse effects 1
• Contraindications: Systemic fungal infections 1
• Side effects: Mood disorders, elevated blood glucose, immune suppression, fluid retention 1

Colchicine

• Recommended dosing: 1.2 mg at first sign of flare, followed by 0.6 mg one hour later (maximum 1.8 mg over one hour) 2, 3
• Most effective when started within 36 hours of symptom onset 2
• Side effects: Gastrointestinal symptoms (diarrhea, nausea, vomiting, abdominal pain) 2
• Contraindicated in:
  • Severe renal impairment (GFR <30 mL/min) 2
  • Concomitant use of strong CYP3A4 inhibitors 3
  • Hepatic impairment 2

NSAIDs

• Use at full FDA-approved anti-inflammatory doses until attack resolves 2
• No evidence that any specific NSAID (including indomethacin) is superior 1
• Contraindications: Renal disease, heart failure, cirrhosis, history of GI bleeding 2
• Side effects: Dyspepsia, GI perforations, ulcers, bleeding 1

Patient-Specific Treatment Algorithm

1. For patients without contraindications:

   • Corticosteroids (prednisolone 35 mg for 5 days) as first-line therapy 1

2. For patients with cardiovascular disease:

   • Avoid NSAIDs 4
   • Use colchicine (if renal function normal) or corticosteroids 4

3. For patients with renal impairment:

   • If GFR <30 mL/min: Avoid colchicine and NSAIDs 2
   • Use glucocorticoids with careful monitoring 2

4. For severe, multiarticular flares:

   • Consider combination therapy with oral corticosteroids plus colchicine 2

5. For limited joint involvement (1-2 large joints):

   • Consider intra-articular corticosteroid injection 2

Adjunctive Measures

• Apply topical ice to affected joint 2, 5
• Rest the inflamed joint 5
• Maintain adequate hydration 2

Important Considerations

• Start treatment as early as possible for best results 2
• If a patient is already on prophylactic colchicine, they can still receive treatment-dose colchicine for an acute flare (1.2 mg followed by 0.6 mg one hour later), then resume prophylactic dose after 12 hours 3
• Do not interrupt urate-lowering therapy during acute flares 2
• IL-1 inhibitors (anakinra, canakinumab) can be considered when first-line agents are contraindicated, ineffective, or poorly tolerated 2

Follow-up

• Schedule follow-up appointment in 1-2 weeks to discuss potential long-term urate-lowering therapy 2
• Monitor serum uric acid levels 2
• Consider prophylactic therapy when initiating urate-lowering therapy to prevent future flares 2