What is the recommended treatment for an acute gout flare?

Treatment of Acute Gout Flare

First-line treatment for acute gout flares should be initiated as early as possible (ideally within 12-24 hours of symptom onset) with NSAIDs, colchicine, or corticosteroids based on patient-specific factors and contraindications. 1, 2

First-Line Treatment Options

Colchicine

• Most effective when administered within 12 hours of symptom onset 1, 3
• Recommended dosing: 1.2 mg at first sign of flare followed by 0.6 mg one hour later (maximum 1.8 mg over one hour) 1, 4
• Low-dose regimen is as effective as higher doses with fewer gastrointestinal side effects 3
• Contraindicated in patients with severe renal impairment (GFR <30 mL/min) and those taking strong P-glycoprotein and/or CYP3A4 inhibitors 3, 4

NSAIDs

• Should be used at full FDA-approved anti-inflammatory doses until the attack resolves 1, 3
• Options include naproxen, indomethacin, or other NSAIDs 1, 5
• Consider adding a proton pump inhibitor for patients with gastrointestinal risk factors 1
• Contraindicated in patients with renal disease, heart failure, and cirrhosis 1, 3, 2

Corticosteroids

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

Treatment Selection Based on Patient Factors

Severity and Joint Involvement

• For mild to moderate pain with limited joint involvement: monotherapy with any first-line agent 1
• For severe pain or polyarticular involvement: combination therapy may be more effective 1, 3
• Combination of colchicine and NSAIDs is particularly beneficial for severe attacks involving multiple joints 3

Special Populations

• Renal impairment: prefer corticosteroids; avoid NSAIDs; adjust colchicine dosing 1, 2, 4
  • For severe renal impairment: colchicine treatment course should not be repeated more than once every two weeks 4
  • For dialysis patients: reduce colchicine to a single dose of 0.6 mg 4
• Cardiovascular disease: prefer corticosteroids over NSAIDs 1, 2
• Hepatic impairment: monitor closely with all agents; consider dose reduction for colchicine 4
• Elderly patients: use caution with all agents; corticosteroids may have lower risk of serious adverse effects compared to NSAIDs 1, 4

Important Considerations

• Start treatment as early as possible, ideally within 12-24 hours of symptom onset 1, 3
• Continue established urate-lowering therapy without interruption during an acute attack 1
• Ice application to affected joints can provide additional pain relief 1
• For inadequate response to initial monotherapy, adding a second appropriate agent is acceptable 1
• Avoid combining NSAIDs and systemic corticosteroids due to potential synergistic gastrointestinal toxicity 3
• Patients should be educated to self-medicate at the first warning symptoms using the "pill in the pocket" approach 1

Common Pitfalls to Avoid

• Delaying treatment beyond 12-36 hours after symptom onset significantly reduces effectiveness 3
• Using high-dose colchicine regimens, which cause unnecessary gastrointestinal side effects 3
• Discontinuing urate-lowering therapy during an acute attack, which can prolong the flare 1
• Failing to adjust medication doses in patients with renal or hepatic impairment 4
• Combining NSAIDs with systemic corticosteroids, which increases risk of gastrointestinal toxicity 3