What is the recommended management for a gout flare?

Management of Acute Gout Flares

First-line treatment for acute gout flares includes 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 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
• Timing: Most effective when given 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 or taking interacting medications 2

NSAIDs

• Options: Naproxen 500 mg twice daily or indomethacin 50 mg three times daily 1
• Duration: Until flare resolves (typically 5-7 days)
• 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
• Alternative routes: Intraarticular or intramuscular injections may be appropriate for monoarticular flares
• Advantage: Potentially fewer adverse effects than NSAIDs, particularly useful in patients with contraindications to colchicine or NSAIDs 1

Special Populations and Considerations

Renal Impairment

• Mild to moderate impairment (CrCl 30-80 mL/min): Standard colchicine dosing with close monitoring 1, 2
• Severe impairment (CrCl <30 mL/min): Avoid colchicine and NSAIDs; use corticosteroids instead 1, 2
• For patients on dialysis requiring colchicine: Reduced dose of 0.6 mg as a single dose, with no repeat treatment for at least 2 weeks 2

Hepatic Impairment

• Mild to moderate impairment: Standard dosing with close monitoring 2
• Severe impairment: Standard dose but limit repeat treatments to no more than once every two weeks 2

Drug Interactions

• Colchicine dose must be adjusted when used with CYP3A4 and P-glycoprotein inhibitors 2
• For strong inhibitors (e.g., clarithromycin, ketoconazole): Reduce colchicine dose to 0.6 mg initially, followed by 0.3 mg one hour later 2

Common Pitfalls to Avoid

1. Delayed treatment: Initiate therapy at the earliest sign of a flare for optimal efficacy
2. Inappropriate dosing: Higher doses of colchicine do not improve efficacy but increase toxicity risk 2
3. Failure to adjust for comorbidities: Always consider renal function, hepatic function, and drug interactions
4. Interrupting urate-lowering therapy: Do not stop urate-lowering medications during acute flares 1
5. Overlooking prophylaxis: When initiating urate-lowering therapy, provide prophylaxis with low-dose colchicine (0.6 mg once or twice daily) or low-dose NSAIDs for 3-6 months 1

Follow-up and Long-term Management

• Schedule follow-up appointment in 1-2 weeks to discuss potential long-term urate-lowering therapy (ULT) 1
• Consider 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
• First-line ULT is allopurinol, starting at ≤100 mg/day with gradual dose titration to achieve serum urate <6 mg/dL 1

By following these evidence-based recommendations, acute gout flares can be effectively managed while minimizing adverse effects and preventing recurrence.