What is the recommended management for a gout flare?

Management of Gout Flare

The recommended first-line treatment options for acute gout flares are oral colchicine (within 12 hours of flare onset), NSAIDs, or oral corticosteroids, with the specific choice based on patient factors including comorbidities, contraindications, and timing of treatment initiation. 1

First-Line Treatment Options

• Colchicine should be administered at a loading dose of 1.2 mg followed 1 hour later by 0.6 mg on day 1, with treatment initiated as early as possible after symptom onset (ideally within 12 hours) 1
• NSAIDs at full FDA-approved doses with proton pump inhibitors if appropriate 1
• Oral corticosteroids (30-35 mg/day of equivalent prednisolone for 3-5 days) 1, 2
• Intra-articular aspiration and injection of corticosteroids if only 1-2 joints are affected 1, 2

Treatment Selection Considerations

• Treatment should be initiated as early as possible after symptom onset, with fully informed patients educated to self-medicate at the first warning symptoms ("medication-in-pocket" strategy) 1
• Low-dose colchicine is strongly recommended over high-dose colchicine due to similar efficacy and fewer adverse effects 1
• For patients unable to take oral medications, parenteral glucocorticoids (intramuscular, intravenous, or intra-articular) are strongly recommended 1
• Topical ice can be used as an adjuvant treatment for additional pain relief 1, 2

Contraindications and Special Considerations

• Colchicine and NSAIDs should be avoided in patients with severe renal impairment 1, 2
• Colchicine should not be given to patients receiving strong P-glycoprotein and/or CYP3A4 inhibitors such as cyclosporin or clarithromycin 1, 3
• For patients with renal impairment taking colchicine, dose adjustment is required:
  • Mild to moderate impairment (CrCl 30-80 mL/min): No dose adjustment needed but monitor closely 3
  • Severe impairment (CrCl <30 mL/min): Treatment course should not be repeated more than once every two weeks 3
  • Dialysis patients: Reduced to a single dose of 0.6 mg, not repeated more than once every two weeks 3

Second-Line Treatment Options

• IL-1 inhibitors should be considered for treating flares in patients with frequent flares and contraindications to colchicine, NSAIDs, and corticosteroids 1
• Current infection is a contraindication to the use of IL-1 blockers 1

Prevention of Recurrent Flares

• Prophylaxis against flares is strongly recommended during the first 6 months of urate-lowering therapy (ULT) 1
• Recommended prophylactic treatment is colchicine 0.5-1 mg/day, with dose reduction in patients with renal impairment 1, 4
• If colchicine is not tolerated or contraindicated, prophylaxis with NSAIDs at low dosage should be considered 1, 5
• Prophylaxis should continue for 3-6 months rather than less than 3 months, with ongoing evaluation and continued prophylaxis as needed if the patient continues to experience flares 1, 4

Long-Term Management

• ULT should be considered and discussed with every patient with a definite diagnosis of gout from the first presentation 1
• When initiating ULT, start with low doses and titrate upward until the serum urate target (<6 mg/dL) is reached 1
• Allopurinol is recommended as the preferred first-line ULT agent for all patients, including those with chronic kidney disease 1, 6

Common Pitfalls to Avoid

• Delaying treatment significantly reduces effectiveness; acute gout should be treated as soon as possible after symptom onset 2, 7
• Using high-dose colchicine regimens, which have similar efficacy but more adverse effects compared to low-dose regimens 1, 8
• Discontinuing ULT during acute flares - it is now recommended to continue ULT with appropriate anti-inflammatory coverage 1, 2
• Inadequate duration of prophylaxis when initiating ULT (should be 3-6 months) 1, 4
• Failing to adjust colchicine dosing in patients with renal impairment or those taking interacting medications 3