What is the initial treatment for a gout flare-up?

Initial Treatment for Gout Flare-Ups

For an acute gout flare-up, treatment should be initiated within 24 hours of symptom onset with either colchicine, NSAIDs, or corticosteroids based on patient-specific factors. 1, 2

Diagnostic Approach

• Joint aspiration with synovial fluid analysis for monosodium urate crystals is the gold standard for diagnosis when the clinical diagnosis is uncertain or when there is concern for septic arthritis 3
• Clinical diagnosis can be made using validated clinical prediction rules in typical presentations 3

First-Line Treatment Options

Colchicine

• Most effective when started within 12 hours of symptom onset 2
• Recommended dosing: 1.2 mg (two tablets) at first sign of flare, followed by 0.6 mg (one tablet) one hour later (maximum 1.8 mg over a one-hour period) 4
• Avoid in patients with severe renal impairment or those taking strong P-glycoprotein/CYP3A4 inhibitors 2, 4

NSAIDs

• Use full FDA-approved anti-inflammatory/analgesic doses 1
• FDA-approved options include naproxen, indomethacin, and sulindac 1
• Consider adding a proton pump inhibitor for gastrointestinal protection in at-risk patients 2
• Avoid in patients with severe renal impairment, peptic ulcer disease, or uncontrolled hypertension 5

Corticosteroids

• Oral prednisone (0.5 mg/kg per day for 5-10 days then stop, or for 2-5 days then taper for 7-10 days) 1
• Alternative options include intramuscular triamcinolone acetonide (60 mg) or intra-articular corticosteroids for single joint involvement 1
• Particularly useful when colchicine and NSAIDs are contraindicated 2

Treatment Selection Algorithm

1. For mild/moderate pain (≤6/10) affecting 1-3 small joints or 1-2 large joints:

   • Monotherapy with colchicine, NSAIDs, or corticosteroids 1

2. For severe pain or polyarticular attacks:

   • Consider combination therapy (see below) 1

3. Patient-specific considerations:

   • Renal impairment: Avoid colchicine and NSAIDs; use corticosteroids 5
   • GI risk factors: Avoid NSAIDs or use with PPI; consider colchicine or corticosteroids 2
   • Diabetes: Use caution with corticosteroids; prefer colchicine or NSAIDs if not contraindicated 1

Combination Therapy Options

• For severe or polyarticular attacks, combination therapy may be more effective 1
• Options include combining colchicine with NSAIDs, or either agent with corticosteroids 1

Important Considerations

Do Not Interrupt Urate-Lowering Therapy

• Continue established urate-lowering therapy (e.g., allopurinol, febuxostat) during acute flares 1
• Interrupting ULT can worsen the flare and complicate long-term management 1

Patient Education

• Educate patients to self-medicate at first warning symptoms ("pill in the pocket" approach) 2
• Instruct on dietary modifications: limit purine-rich foods (organ meats, shellfish), alcoholic beverages (especially beer), and high-fructose corn syrup beverages 6
• Encourage consumption of vegetables and low-fat dairy products 6

Common Pitfalls to Avoid

• Delaying treatment beyond 24 hours of symptom onset significantly reduces effectiveness 2
• Failing to adjust medication doses for patients with renal impairment 2
• Using colchicine in patients taking strong CYP3A4 inhibitors (e.g., clarithromycin) 4
• Stopping urate-lowering therapy during an acute attack 1

Prophylaxis After Initial Treatment

• Consider prophylaxis with low-dose colchicine (0.6 mg once or twice daily) or low-dose NSAIDs when initiating urate-lowering therapy 7
• Prophylaxis should be continued for up to 6 months after starting urate-lowering therapy 1, 7