Treatment of Acute 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, with the choice guided by patient comorbidities. 1
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 1, 2
- Maximum dose: 1.8 mg over a one-hour period 2
- Best when: Started at the earliest sign of a flare
- Contraindications: Severe renal impairment (CrCl <30 mL/min), concomitant use of strong CYP3A4 inhibitors 2
- Dose adjustment: Required for patients with renal impairment, hepatic impairment, or taking interacting medications 2
NSAIDs
- Options: Naproxen 500 mg twice daily or indomethacin 50 mg three times daily 1
- Duration: Typically 5-7 days or until flare resolves
- Caution: Use with care in patients with cardiovascular disease, heart failure, or renal impairment 1
Corticosteroids
- Options:
- Oral prednisone/prednisolone 35 mg daily for 5 days 1
- Intraarticular injection (for single joint involvement)
- Intramuscular injection
- Advantage: Potentially fewer adverse effects than NSAIDs, particularly useful in patients with contraindications to colchicine or NSAIDs 1
Treatment Algorithm
Assess patient for contraindications to first-line therapies:
Select appropriate therapy based on assessment:
- For most patients without contraindications: Colchicine at recommended dose
- For patients with contraindications to colchicine: NSAIDs or corticosteroids
- For patients with contraindications to both colchicine and NSAIDs: Corticosteroids
Monitor response and adjust as needed:
- If inadequate response within 24-48 hours, consider adding or switching to another agent
- For severe or polyarticular flares, combination therapy may be considered
Special Considerations
Renal Impairment
- Mild to moderate impairment (CrCl 30-80 mL/min): Standard colchicine dosing with monitoring 1
- Severe impairment (CrCl <30 mL/min): Avoid colchicine and NSAIDs; use corticosteroids 1
- For patients on dialysis requiring colchicine: Reduce to single dose of 0.6 mg, with treatment course no more than once every two weeks 2
Hepatic Impairment
- Mild to moderate impairment: No dose adjustment needed for acute treatment, but monitor closely 2
- Severe impairment: Treatment course should not be repeated more than once every two weeks 2
Concomitant Medications
- Significant dose reductions needed when colchicine is taken with CYP3A4 inhibitors 1, 2
- For strong CYP3A4 inhibitors: Reduce colchicine to 0.6 mg × 1 dose, followed by 0.3 mg one hour later 2
Prevention of Recurrent Flares
Consider urate-lowering therapy (ULT) for patients with:
- Frequent gout flares (>2/year)
- Tophaceous gout
- Radiographic damage due to gout
- CKD stage >3
- Serum urate >9 mg/dL 1
When starting ULT, prophylactic therapy should be used to prevent flares:
- Low-dose colchicine (0.6 mg once or twice daily) or
- Low-dose NSAIDs for 3-6 months 1
Common Pitfalls to Avoid
- Delayed treatment: Initiate therapy at the earliest sign of a flare for best results
- Inappropriate dosing: Follow recommended dosing guidelines, especially for colchicine
- Failure to adjust for comorbidities: Consider renal function, hepatic function, and drug interactions
- Discontinuing ULT during flares: Continue ULT even during acute flares 1
- Inadequate prophylaxis: When starting ULT, use prophylactic therapy to prevent flares
Lifestyle Modifications
- Weight loss if overweight/obese
- Limit alcohol consumption
- Reduce intake of purine-rich foods
- Avoid high-fructose corn syrup and sugary beverages
- Stay well hydrated 1