What is the recommended management for an acute gout flare?

Management of Acute Gout Flares

For acute gout flares, first-line treatment options include colchicine, NSAIDs, or corticosteroids, with treatment initiated as early as possible for optimal outcomes. 1, 2

First-Line Treatment Options

Colchicine

• Most effective when administered within 12 hours of symptom onset 3, 2
• Recommended dosing: 1.2 mg (loading dose) followed by 0.6 mg one hour later, for a total of 1.8 mg over one hour 3, 4
• Low-dose regimen is as effective as higher doses with fewer gastrointestinal side effects 3, 2
• Contraindicated in patients with severe renal impairment and those taking strong P-glycoprotein/CYP3A4 inhibitors (e.g., clarithromycin) 3, 5

NSAIDs

• Should be used at full anti-inflammatory doses 2
• No evidence that indomethacin is more effective than other NSAIDs like naproxen or ibuprofen 3
• Consider adding a proton pump inhibitor in patients with gastrointestinal risk factors 3, 2
• Contraindicated in patients with renal disease, heart failure, or cirrhosis 3

Corticosteroids

• Oral prednisone or prednisolone at 30-35 mg/day for 3-5 days is effective 3, 1
• Intra-articular corticosteroid injection is appropriate for monoarticular gout 3, 2
• Generally safer in patients with renal impairment or cardiovascular disease 3, 2
• Contraindicated in patients with systemic fungal infections 3

Treatment Selection Based on Patient Factors

Timing of Treatment

• Treat as early as possible, ideally within 12-24 hours of symptom onset 3, 2
• Educate patients to self-medicate at the first warning symptoms using the "pill in the pocket" approach 3, 2

Renal Impairment

• For patients with severe renal impairment:
  • Corticosteroids are preferred 3, 2
  • Avoid NSAIDs and colchicine 3, 5
  • If colchicine must be used, dose reduction is necessary 4

Cardiovascular Disease

• In patients with cardiovascular disease, corticosteroids are preferred over NSAIDs 2
• NSAIDs may worsen hypertension and are contraindicated in many cardiovascular conditions 5

Joint Involvement

• For monoarticular gout, consider intra-articular corticosteroid injection 3, 2
• For polyarticular involvement, systemic therapy with oral medications is appropriate 2

Special Considerations

Concomitant Medications

• Adjust colchicine dosing for patients on P-glycoprotein/CYP3A4 inhibitors 4
• Be aware of potential neurotoxicity and muscular toxicity when colchicine is used with statins 5

Elderly Patients

• Use caution with dose selection in elderly patients 4
• Corticosteroids may be preferred due to lower risk of serious adverse effects compared to NSAIDs 2

Urate-Lowering Therapy

• Continue established urate-lowering therapy without interruption during an acute attack 2
• Do not initiate urate-lowering therapy during an acute flare 3

Prophylaxis After Acute Flare

• Prophylaxis against future flares is recommended during the first 6 months of urate-lowering therapy 3, 1
• Recommended prophylactic treatment is colchicine 0.5-1 mg/day, with dose reduction in patients with renal impairment 3, 5
• If colchicine is not tolerated or contraindicated, low-dose NSAIDs can be considered 3
• Urate-lowering therapy should be considered in patients with recurrent flares, tophi, urate arthropathy, or renal stones 3, 1

Common Pitfalls to Avoid

• Delaying treatment of acute gout flares (treatment should begin as early as possible) 3, 2
• Using inappropriate dosing of colchicine (high doses increase toxicity without improving efficacy) 3, 4
• Discontinuing urate-lowering therapy during an acute attack 2
• Failing to provide prophylaxis when initiating urate-lowering therapy 3, 1
• Not adjusting medication doses in patients with renal or hepatic impairment 4