Treatment for Gout Flares
The recommended first-line treatment for an acute gout flare is colchicine 1.2 mg (two 0.6 mg tablets) at the first sign of the flare followed by 0.6 mg (one tablet) one hour later, for a maximum total dose of 1.8 mg over a one-hour period. 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 1, 2
- Maximum dose: 1.8 mg over a one-hour period
- Most effective when started within the first 12-24 hours of symptom onset
- If a patient is already on prophylactic colchicine when a flare occurs:
- Administer 1.2 mg at first sign of flare, followed by 0.6 mg one hour later
- Wait 12 hours before resuming prophylactic dose 1
NSAIDs
- Full anti-inflammatory doses of NSAIDs are an effective alternative 1, 3
- Examples include:
- Naproxen 500 mg twice daily
- Indomethacin 50 mg three times daily
- Continue until flare resolves (typically 5-7 days)
- Caution: Avoid in patients with cardiovascular disease, heart failure, or renal impairment 1, 4
Corticosteroids
- As effective as NSAIDs with potentially fewer adverse effects 1
- Options include:
- Particularly useful in patients with contraindications to colchicine or NSAIDs
Special Considerations
Renal Impairment
- For mild to moderate renal impairment (CrCl 30-80 mL/min):
- Standard colchicine dosing can be used with close monitoring 2
- For severe renal impairment (CrCl <30 mL/min):
- For patients on dialysis:
- Reduce colchicine to a single dose of 0.6 mg
- Do not repeat treatment more than once every two weeks 2
Cardiovascular Disease
- Colchicine is considered safe and may potentially reduce the risk of myocardial infarction 4
- Avoid NSAIDs due to increased cardiovascular risk 1, 4
- Short courses of low-dose corticosteroids are a reasonable alternative 4
Hepatic Impairment
- For mild to moderate hepatic impairment:
- Standard colchicine dosing with close monitoring 2
- For severe hepatic impairment:
- Standard colchicine dosing but do not repeat treatment more than once every two weeks 2
- Consider alternative therapy for repeated flares
Drug Interactions
- Colchicine has significant interactions with strong CYP3A4 inhibitors and P-glycoprotein inhibitors 1, 2
- Examples include clarithromycin, ketoconazole, ritonavir
- Dose adjustment required when used with these medications 2
Combination Therapy
For severe, multiarticular gout flares, combination therapy may be considered:
- Colchicine plus NSAID
- Colchicine plus corticosteroid 1
Prevention of Future Flares
After treating the acute flare, consider:
Prophylactic therapy when starting urate-lowering treatment (ULT)
Long-term ULT should be considered for:
- Patients with radiographic damage attributable to gout
- Frequent gout flares (>2/year)
- Presence of tophi
- CKD stage >3, serum urate >9 mg/dl, or urolithiasis 6
First-line ULT is allopurinol, starting at ≤100 mg/day with gradual dose titration 6, 1
Common Pitfalls to Avoid
- Delaying treatment - efficacy decreases with delayed initiation
- Using high-dose colchicine regimens - these cause significant gastrointestinal side effects
- Discontinuing ULT during acute flares - this can worsen and prolong the flare
- Not providing prophylaxis when initiating ULT - this increases risk of flares
- Not addressing underlying hyperuricemia after treating acute flares - this leads to recurrent attacks
Remember that early intervention with appropriate therapy is crucial for effective management of gout flares and prevention of future attacks.