What is the treatment for gout flares?

Treatment of Gout Flares

For acute gout flares, first-line treatment options include colchicine (1.2 mg at first sign of flare followed by 0.6 mg one hour later), NSAIDs (such as naproxen 500 mg twice daily), or glucocorticoids (oral, intraarticular, or intramuscular). 1, 2

First-Line Treatment Options

Colchicine

• Dosing: 1.2 mg (two tablets) at the first sign of flare, followed by 0.6 mg (one tablet) one hour later 3
• Maximum recommended dose for treatment of gout flares is 1.8 mg over a one-hour period 3
• Most effective when started at the earliest sign of a flare
• Dose adjustments required for:
  • Renal impairment: For severe impairment, treatment course should not be repeated more than once every two weeks 3
  • Hepatic impairment: No dose adjustment needed for mild to moderate impairment; for severe impairment, treatment should not be repeated more than once every two weeks 3
  • Drug interactions: Significant dose reductions needed when taken with CYP3A4 inhibitors 3

NSAIDs

• Full anti-inflammatory doses (e.g., naproxen 500 mg twice daily or indomethacin 50 mg three times daily) 2
• Use with caution in patients with cardiovascular disease, heart failure, or renal impairment 2
• Short half-life NSAIDs preferred in elderly patients 4

Glucocorticoids

• Oral prednisone/prednisolone (30-35 mg daily for 3-5 days) 2
• Intra-articular injection for monoarticular gout 2
• Particularly useful in patients with contraindications to colchicine or NSAIDs 2
• Systemic corticosteroids may be used for severe polyarticular flares 5

Treatment Selection Considerations

Factors influencing treatment choice:

1. Comorbidities:

   • Cardiovascular disease: Avoid NSAIDs
   • Renal impairment: Avoid colchicine and NSAIDs if severe (GFR <30 mL/min); use corticosteroids instead 2
   • Peptic ulcer disease: Avoid NSAIDs 4

2. Medication interactions:

   • Check for CYP3A4 inhibitors before prescribing colchicine 3
   • Adjust colchicine dose when used with interacting drugs 3

3. Timing of treatment:

   • Start treatment at the earliest sign of flare for best results
   • Continue prophylactic therapy if patient is on urate-lowering therapy 2

Adjunctive Measures

• Apply topical ice to affected joint 2
• Rest and elevate affected joint
• Stay well hydrated 2

Prophylaxis During Urate-Lowering Therapy

When initiating urate-lowering therapy (ULT), concomitant anti-inflammatory prophylaxis for at least 3-6 months is strongly recommended to prevent flares 1, 2:

• Low-dose colchicine (0.6 mg once or twice daily) 2, 6
• Low-dose NSAIDs 2, 6
• Low-dose corticosteroids if colchicine and NSAIDs are contraindicated 2

Long-Term Management

Consider urate-lowering therapy for patients with:

• Frequent gout flares (>2/year)
• Tophaceous gout
• Radiographic damage due to gout
• CKD stage >3
• Serum urate >9 mg/dL 1, 2

Allopurinol is the preferred first-line ULT, starting at ≤100 mg/day (lower in CKD) with gradual dose titration to achieve serum urate target of <6 mg/dL 1, 2

Common Pitfalls to Avoid

1. Delayed treatment: Starting treatment late reduces effectiveness
2. Inadequate dosing: Underdosing anti-inflammatory medications may lead to persistent symptoms
3. Stopping ULT during flares: ULT should be continued during acute flares 2
4. Neglecting prophylaxis: Failure to provide prophylaxis when initiating ULT increases risk of flares
5. Not adjusting doses: Failing to adjust medication doses for renal/hepatic impairment or drug interactions can lead to toxicity

Remember that treatment of gout flares is just one component of comprehensive gout management, which should also include lifestyle modifications and appropriate long-term urate-lowering therapy for eligible patients.