How to manage a gout flare with swelling in a patient on allopurinol (xanthine oxidase inhibitor) 100 mg and colchicine (anti-inflammatory) every 24 hours?

Management of Acute Gout Flare in a Patient on Allopurinol and Colchicine

For acute gout flare with swelling in a patient already on allopurinol 100 mg and daily colchicine prophylaxis, first-line treatment should be an NSAID or oral glucocorticoid, with ice as an adjunctive therapy. 1

First-Line Treatment Options

NSAIDs

• Use full anti-inflammatory doses of any NSAID (if no contraindications)
• Continue until flare resolves
• Examples:
  • Naproxen 500 mg twice daily
  • Indomethacin 50 mg three times daily
  • Ibuprofen 800 mg three times daily

Oral Glucocorticoids

• Prednisone 20-40 mg daily for 3-5 days 2
• Taper over 7-10 days for more severe flares
• Preferred in patients with renal impairment or NSAID contraindications

Adjunctive Therapy

• Apply topical ice to affected joint(s) for 20-30 minutes several times daily 1
• Continue adequate hydration (at least 2 liters of fluid daily) 2

Management Algorithm

1. Assess current therapy:

   • Verify patient is taking allopurinol 100 mg daily and colchicine prophylaxis
   • Check if colchicine dose is appropriate (should be 0.6 mg once or twice daily) 1, 3

2. For the acute flare:

   • Do NOT increase colchicine dose if already on daily prophylaxis 3
   • Choose either NSAID or glucocorticoid based on patient factors:
     • If normal renal function and no GI contraindications → NSAID
     • If renal impairment or NSAID contraindications → Glucocorticoid
   • For severe pain or polyarticular involvement, consider:
     • Intramuscular or intraarticular glucocorticoid injection 1

3. Optimize long-term therapy:

   • Continue allopurinol during the flare (do not stop) 1
   • After flare resolves, assess if allopurinol dose needs titration:
     • Target serum uric acid <6 mg/dL 2, 4
     • Increase allopurinol by 100 mg increments every 2-4 weeks until target reached 4
     • Continue colchicine prophylaxis for 3-6 months after reaching target 1

Important Considerations

• Flares are common when initiating or titrating allopurinol, even with prophylaxis 5, 6
• Continuing allopurinol during a flare is recommended to maintain progress toward urate lowering 1
• Adequate prophylaxis (colchicine 0.6 mg daily or twice daily) should be continued for 3-6 months after reaching target uric acid level 1, 2
• For patients with renal impairment, adjust colchicine dosing accordingly 3

Common Pitfalls to Avoid

1. Stopping allopurinol during a flare - This disrupts urate-lowering therapy and prolongs the time to reach target serum urate levels
2. Inadequate anti-inflammatory dosing - Use full anti-inflammatory doses of NSAIDs or glucocorticoids
3. Overuse of colchicine during acute flare - If already on prophylactic colchicine, adding more increases toxicity risk without additional benefit
4. Insufficient duration of prophylaxis - Continue prophylaxis for 3-6 months after reaching target uric acid level 1
5. Failure to address the swelling component - Use ice and ensure adequate anti-inflammatory dosing

By following this approach, you can effectively manage the acute gout flare while maintaining progress toward long-term urate control and preventing future attacks.