Management of Acute Gout Flares
For acute gout flares, first-line treatment should be colchicine, NSAIDs, or oral corticosteroids initiated as early as possible after symptom onset. 1
First-Line Treatment Options
- Colchicine is most effective when started within 12 hours of symptom onset, using the FDA-approved low-dose regimen of 1.2 mg initially followed by 0.6 mg one hour later 1, 2
- NSAIDs at full anti-inflammatory doses are effective when started promptly but should be avoided in patients with renal disease, heart failure, or cirrhosis 1, 3
- Oral corticosteroids (prednisone/prednisolone 30-35 mg daily for 3-5 days) are particularly effective for gout flares with significant inflammation 1, 4
- For monoarticular gout, intra-articular corticosteroid injection is an excellent option 1, 3
Treatment Selection Considerations
- Early treatment initiation is crucial for optimal effectiveness; the "medication-in-pocket" approach is recommended for fully informed patients to self-medicate at the first warning symptoms 1
- Treatment selection should be driven by patient factors (comorbidities, access, past experience) as part of shared decision-making 1
- For patients unable to take oral medications, parenteral glucocorticoids (intramuscular, intravenous, or intra-articular) are strongly recommended 1
Adjunctive Measures
- Topical ice can be used as an adjuvant treatment for additional pain relief 1
- Rest of the affected joint is recommended during acute flares 5
Special Considerations
- In patients with renal impairment, corticosteroids are generally safer than NSAIDs or colchicine 3, 2
- Colchicine should be avoided in patients receiving strong P-glycoprotein and/or CYP3A4 inhibitors such as cyclosporin or clarithromycin 1, 2
- For patients with severe renal impairment, colchicine dosing must be adjusted, and a treatment course should not be repeated more than once every two weeks 2
Prevention of Recurrent Flares
- Prophylaxis is strongly recommended when initiating urate-lowering therapy (ULT) 1, 6
- Low-dose colchicine (0.5-1 mg/day) or low-dose NSAIDs are recommended for prophylaxis during the first 6 months of ULT 1
- Prophylactic colchicine dose should be reduced in patients with renal impairment 1, 2
- For patients with contraindications to colchicine and NSAIDs, low-dose corticosteroids can be considered for prophylaxis 1, 7
Long-Term Management
- ULT should be considered for all patients with recurrent flares, tophi, urate arthropathy, or renal stones 1, 3
- Allopurinol is recommended as first-line ULT, starting at a low dose (100 mg/day) and increasing by 100 mg increments every 2-4 weeks to reach the target serum urate level <6 mg/dL 1, 3
- ULT should be continued lifelong to maintain serum urate levels below 6 mg/dL 1
Common Pitfalls to Avoid
- Delaying treatment significantly reduces effectiveness; acute gout should be treated as soon as possible 1
- Using traditional high-dose colchicine regimens can lead to significant side effects; lower-dose regimens are now recommended 1, 2
- Discontinuing ULT during acute flares is not recommended - it should be continued with appropriate anti-inflammatory coverage 1, 3
- Inadequate duration of anti-inflammatory prophylaxis when initiating ULT (should be 3-6 months) 1, 6