What is the initial treatment for a gout flare?

Initial Treatment for Gout Flares

The first-line treatment for an acute gout flare is colchicine (within 12 hours of flare onset) at a loading dose of 1 mg followed 1 hour later by 0.5 mg on day 1, and/or an NSAID (with a proton pump inhibitor if appropriate), or oral corticosteroids (30-35 mg/day of equivalent prednisolone for 3-5 days). 1

First-Line Treatment Options

Colchicine

• Most effective when given within 12 hours of symptom onset 1
• FDA-approved dosing: 1.2 mg (two tablets) at the first sign of flare followed by 0.6 mg (one tablet) one hour later 2
• Maximum recommended dose for treatment of gout flares is 1.8 mg over a one-hour period 2
• Should be avoided in patients with severe renal impairment 1
• Should not be given to patients receiving strong P-glycoprotein and/or CYP3A4 inhibitors such as cyclosporin or clarithromycin 1

NSAIDs

• As effective as colchicine when started promptly 1
• Should be avoided in patients with severe renal impairment 1
• Consider adding a proton pump inhibitor for gastrointestinal protection if appropriate 1
• The most important determinant of therapeutic success is how soon NSAID therapy is initiated 3

Oral Corticosteroids

• Prednisolone (30-35 mg/day for 3-5 days) is an effective option 1
• Particularly useful when colchicine and NSAIDs are contraindicated 1
• Has been shown to have analgesic effectiveness equivalent to indomethacin in clinical trials 1

Joint Aspiration and Injection of Corticosteroids

• Effective option for monoarticular gout 1
• Particularly useful when oral medications are contraindicated 1

Special Considerations

For Patients Unable to Take Oral Medications

• Treatment with glucocorticoids (intramuscular, intravenous, or intraarticular) is strongly recommended over IL-1 inhibitors or ACTH 1

For Patients with Contraindications to First-Line Therapies

• IL-1 blockers 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

Adjunctive Therapy

• Topical ice is conditionally recommended as an adjuvant treatment for patients experiencing a gout flare 1
• Rest of the inflamed joint is useful during acute attacks 3

Patient Education and Self-Management

• Patients should be educated to self-medicate at the first warning symptoms ("pill in the pocket" approach) 1
• Early initiation of any treatment for flare leads to better effectiveness 1
• Fully informed patients should be involved in the choice of drug(s) based on:
  • Presence of contraindications
  • Previous experience with treatments
  • Time of initiation after flare onset
  • Number and type of joint(s) involved 1

Common Pitfalls to Avoid

• Delaying treatment - early intervention is critical for effective management 1
• Using high-dose colchicine regimens - low-dose colchicine (1.8 mg total) has similar efficacy to high-dose regimens with fewer side effects 2
• Failing to adjust medication for patients with renal impairment - colchicine and NSAIDs should be avoided in severe renal impairment 1
• Not considering drug interactions - particularly with colchicine and strong P-glycoprotein/CYP3A4 inhibitors 1

By promptly initiating appropriate treatment based on patient characteristics and comorbidities, acute gout flares can be effectively managed to reduce pain, inflammation, and improve quality of life.