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

Treatment for First Gout Flare-Up

For a first gout flare-up, the recommended treatment is colchicine 1.2 mg (two tablets) at the first sign of the flare followed by 0.6 mg (one tablet) one hour later, or alternatively NSAIDs at full anti-inflammatory doses or corticosteroids if colchicine is contraindicated. 1, 2

First-Line Treatment Options

Colchicine

• Start with 1.2 mg (two tablets) at first sign of flare, followed by 0.6 mg (one tablet) one hour later 2
• Maximum recommended dose for treatment of gout flares is 1.8 mg over a one-hour period 2
• Low-dose regimen has similar efficacy to high-dose with fewer side effects 3

NSAIDs

• Use at full FDA-approved anti-inflammatory doses until the attack resolves 1
• No evidence that any specific NSAID is superior to others 1
• Examples include naproxen 500 mg twice daily or indomethacin 50 mg three times daily 3

Corticosteroids

• As effective as NSAIDs with fewer adverse effects 1
• Recommended dosing: prednisolone 35 mg daily for 5 days 1
• Can be administered orally, intramuscularly, or intra-articularly depending on the number of joints affected and patient factors 3

Treatment Selection Algorithm

1. First choice: Colchicine (if within 24 hours of symptom onset and no contraindications)
2. Alternative options (if colchicine contraindicated or >24 hours since onset):
   • NSAIDs (if no renal impairment, heart disease, or GI risk factors)
   • Corticosteroids (if NSAIDs and colchicine contraindicated)

Special Considerations

Renal Impairment

• Avoid colchicine and NSAIDs in patients with GFR <30 mL/min 1
• Use corticosteroids instead 1
• If colchicine must be used, reduce dose appropriately 2

Cardiovascular Disease

• Avoid NSAIDs 1
• Use colchicine (if renal function normal) or corticosteroids 1

Drug Interactions

• Reduce colchicine dose when co-administered with CYP3A4 or P-glycoprotein inhibitors 2
• Avoid colchicine with strong CYP3A4 inhibitors (e.g., clarithromycin, ketoconazole) 2

Advanced Options for Refractory Cases

For patients with contraindications to all first-line therapies:

• IL-1 inhibitors (canakinumab, anakinra) can be considered 4, 1
• Current infection is a contraindication to IL-1 blockers 4

Prophylaxis After Initial Treatment

After treating the acute flare, consider prophylaxis if initiating urate-lowering therapy:

• Colchicine 0.5-1 mg/day for up to 6 months 1, 5
• Alternative: Low-dose NSAIDs (e.g., naproxen 250 mg twice daily) 1, 5

Urate-Lowering Therapy (ULT) Considerations

For a first gout flare, ULT is generally not immediately initiated unless:

• Patient has CKD stage ≥3, serum urate >9 mg/dL, or urolithiasis 4
• Radiographic damage attributable to gout is present 4
• Subcutaneous tophi are present 4

Non-Pharmacological Measures

• Apply ice to affected joint for pain relief 1
• Rest and elevate the affected joint
• Maintain adequate hydration
• Avoid alcohol, especially beer 1, 6
• Limit intake of purine-rich foods (organ meats, shellfish) 6
• Avoid beverages sweetened with high-fructose corn syrup 6

Follow-up

• Schedule follow-up appointment in 1-2 weeks to assess response and discuss potential long-term management 1
• Consider serum uric acid testing to establish baseline levels
• Educate patient about gout triggers and management strategies