What is the best treatment for a gout flare-up?

Treatment of Gout Flare-Up

For acute gout flares, oral colchicine, NSAIDs, or glucocorticoids are strongly recommended as first-line therapy, with the choice depending on patient-specific factors such as comorbidities and medication contraindications. 1, 2

First-Line Treatment Options

Colchicine

• Most effective when started within 12 hours of symptom onset
• FDA-approved dosing: 1.2 mg initially, followed by 0.6 mg one hour later (total 1.8 mg) 3
• Low-dose regimen is as effective as high-dose with fewer gastrointestinal side effects
• Avoid in patients with severe renal impairment (eGFR < 30 ml/min)
• Requires dose adjustment with CYP3A4 inhibitors (e.g., clarithromycin, ketoconazole)

NSAIDs

• Short-acting NSAIDs like naproxen 500 mg twice daily for 5 days
• Avoid in patients with:
  • Renal impairment
  • History of peptic ulcer disease
  • Uncontrolled hypertension
  • Heart failure

Glucocorticoids

• Oral prednisone 30-35 mg daily for 3-5 days
• Particularly useful in elderly patients or those with contraindications to NSAIDs/colchicine
• Intra-articular injections effective for 1-2 large joints
• Intramuscular or intravenous options for patients unable to take oral medications

Special Considerations

Renal Impairment

• For severe renal impairment (CrCl < 30 ml/min):
  • Avoid colchicine and NSAIDs
  • Prefer glucocorticoids
  • If colchicine must be used, reduce dose and monitor closely

Elderly Patients

• Prefer oral corticosteroids due to favorable safety profile 2
• Use NSAIDs with caution and only short-acting agents if necessary
• Consider reduced doses of colchicine

Combination Therapy

• For severe polyarticular flares, consider combination of two therapeutic modalities:
  • NSAIDs + colchicine
  • Oral corticosteroids + colchicine
  • Intra-articular injections with another modality

Adjunctive Measures

• Topical ice is conditionally recommended as an adjuvant treatment 1
• Rest of the affected joint
• Adequate hydration

Treatment Algorithm

1. Assess patient for contraindications to first-line agents:

   • Renal function (avoid NSAIDs/colchicine if eGFR < 30)
   • GI risk factors (avoid NSAIDs if history of ulcers)
   • Drug interactions (especially with colchicine)

2. Select appropriate agent:

   • If no contraindications and early in flare (<12 hours): Colchicine
   • If moderate renal function and no GI risk: NSAIDs
   • If contraindications to both: Glucocorticoids
   • For severe flares: Consider combination therapy

3. For inadequate response to initial therapy:

   • Switch to alternative agent
   • Consider IL-1 inhibitors for refractory cases

Common Pitfalls to Avoid

• Delaying treatment (efficacy decreases with delayed initiation)
• Not adjusting colchicine dose in renal impairment or with drug interactions
• Failing to recognize early signs of colchicine toxicity (gastrointestinal symptoms)
• Using NSAIDs in patients with renal impairment or GI risk factors
• Not providing prophylaxis when initiating urate-lowering therapy

Remember that treating the acute flare is only one component of comprehensive gout management, which should also include lifestyle modifications and consideration of urate-lowering therapy for patients with recurrent attacks.