What is the recommended treatment for an acute gout flare?

Treatment of Acute Gout Flare

First-line treatment options for acute gout flares include colchicine, NSAIDs, or corticosteroids, with treatment initiated as early as possible after symptom onset for optimal effectiveness. 1, 2

Initial Management Approach

• Treat acute gout flares as early as possible, ideally within 12-24 hours of symptom onset for maximum efficacy 1, 2
• Educate patients to self-medicate at the first warning symptoms using the "pill in the pocket" approach 1
• The choice of medication should be based on:
  • Presence of contraindications
  • Patient's previous experience with treatments
  • Time since symptom onset
  • Number and type of joints involved 1, 2

First-Line Treatment Options

Colchicine

• Most effective when given within 12 hours of symptom onset 1
• Recommended dosing: 1.2 mg (two tablets) at the first sign of flare followed by 0.6 mg (one tablet) one hour later, for a maximum dose of 1.8 mg over a one-hour period 3, 2
• Low-dose regimen is as effective as higher doses with fewer gastrointestinal side effects 1, 2
• Contraindications:
  • Severe renal impairment
  • Concomitant use of strong P-glycoprotein and/or CYP3A4 inhibitors (e.g., cyclosporin, clarithromycin) 1, 3

NSAIDs

• Use at full FDA-approved anti-inflammatory/analgesic doses 2, 1
• Options include naproxen (500 mg twice daily for 5 days), indomethacin, or other NSAIDs 1, 2
• Consider adding a proton pump inhibitor in patients with gastrointestinal risk factors 1
• Contraindications:
  • Renal disease
  • Heart failure
  • Cirrhosis 1, 4

Corticosteroids

• Oral prednisone or prednisolone (30-35 mg/day for 3-5 days) 1
• Intra-articular corticosteroid injection for monoarticular gout 1, 4
• Generally safer option in patients with renal impairment or cardiovascular disease 1, 4
• Potential adverse effects include dysphoria, mood disorders, elevated blood glucose, and fluid retention 1, 2

Treatment Based on Severity and Joint Involvement

Mild to Moderate Pain with Limited Joint Involvement

• Monotherapy with any of the first-line agents is appropriate 2, 1

Severe Pain or Polyarticular Involvement

• Combination therapy may be more effective 1
• Acceptable combinations include:
  • Colchicine plus NSAIDs
  • Oral corticosteroids plus colchicine
  • Intra-articular steroids with any other modality 1, 2

Special Populations

Patients with Renal Impairment

• Corticosteroids are generally safer than NSAIDs or colchicine 1, 4
• For colchicine in severe renal impairment: treatment course should not be repeated more than once every two weeks 3
• NSAIDs should be avoided 1, 4

Patients with Cardiovascular Disease

• Oral corticosteroids are preferred over NSAIDs 4, 1
• Low-dose colchicine is an appropriate alternative if not contraindicated 4, 3

Elderly Patients

• Dose selection should be cautious, reflecting the greater frequency of decreased renal function and concomitant diseases 3, 2
• Corticosteroids may be preferred due to lower risk of serious adverse effects compared to NSAIDs 1, 4

Important Considerations

• Continue established urate-lowering therapy without interruption during an acute attack 2, 5
• Ice application to affected joints can provide additional pain relief 4, 6
• For patients not responding adequately to initial monotherapy, adding a second appropriate agent is acceptable 1
• Avoid combining NSAIDs and systemic corticosteroids due to potential synergistic gastrointestinal toxicity 1, 7