What are the treatment options for a gout flare?

Treatment of Acute Gout Flares

For acute gout flares, first-line treatment options include oral colchicine, NSAIDs, or glucocorticoids (oral, intraarticular, or intramuscular) based on patient factors and preferences. 1

First-Line Treatment Options

Colchicine

• Dosing: 1.2 mg (two tablets) at first sign of flare, followed by 0.6 mg (one tablet) one hour later 2
• Maximum dose: 1.8 mg over a one-hour period 2
• Best when started: At the earliest sign of a flare for maximum effectiveness
• Caution: Reduce dose in renal impairment, hepatic impairment, or with drug interactions (especially CYP3A4 inhibitors) 2

NSAIDs

• Options: Naproxen 500 mg twice daily or indomethacin 50 mg three times daily 1
• Duration: Continue until flare resolves (typically 5-7 days)
• Caution: Avoid in patients with cardiovascular disease, heart failure, renal impairment, or history of GI bleeding

Glucocorticoids

• Options:
  • Oral prednisone/prednisolone 35 mg daily for 5 days 1
  • Intramuscular, intravenous, or intraarticular injection (when oral medications cannot be taken) 3
• Particularly useful: In patients with contraindications to colchicine or NSAIDs

Adjunctive Measures

• Apply topical ice as an adjuvant therapy 3
• Rest and elevate the affected joint
• Maintain adequate hydration
• Avoid alcohol and purine-rich foods during flare

Special Populations

Renal Impairment

• Mild to moderate impairment: Standard dosing of NSAIDs or colchicine with close monitoring 2
• Severe impairment (CrCl <30 mL/min):
  • Avoid colchicine and NSAIDs
  • Use glucocorticoids as first-line therapy 1
  • If colchicine must be used, reduce to 0.6 mg × 1 dose only, with no repeat course within 2 weeks 2

Hepatic Impairment

• Mild to moderate impairment: Standard dosing with close monitoring
• Severe impairment: Treatment course should not be repeated more than once every two weeks 2

Follow-up Care

• Schedule follow-up in 1-2 weeks to discuss long-term management 1
• 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

Prophylaxis When Starting ULT

• Strongly recommended: Initiate prophylactic therapy when starting ULT 3
• Options: Low-dose colchicine (0.6 mg once or twice daily), low-dose NSAIDs, or low-dose prednisone 1
• Duration: Continue prophylaxis for 3-6 months after starting ULT 3

Lifestyle Modifications

• Weight loss if overweight/obese
• Limit alcohol consumption (especially beer)
• Reduce intake of purine-rich foods (organ meats, shellfish)
• Avoid high-fructose corn syrup and sugary beverages
• Stay well hydrated 1

Common Pitfalls to Avoid

1. Delayed treatment: Efficacy decreases with delayed initiation; start treatment at first sign of flare
2. Inappropriate dosing: Using high-dose colchicine regimens increases toxicity without improving efficacy
3. Stopping ULT during flares: Continue ULT even during acute flares
4. Inadequate prophylaxis: Failure to provide prophylaxis when initiating ULT leads to increased flare risk
5. Overlooking drug interactions: Especially with colchicine and CYP3A4 inhibitors

Remember that early intervention is key to successful management of gout flares. The "medication-in-pocket" strategy allows patients to self-administer treatment at the earliest signs of a flare for maximum effectiveness.