What is the recommended management for acute gout in flare?

Management of Acute Gout Flare

Acute gout flares should be treated as early as possible, ideally within 12-24 hours of symptom onset, with colchicine, NSAIDs, or corticosteroids as first-line therapy options. 1

First-Line Treatment Options

Colchicine

• Most effective when administered within 12 hours of symptom onset 1
• Recommended dosing: 1.2 mg (two tablets) at first sign of flare, followed by 0.6 mg (one tablet) one hour later, for a maximum dose of 1.8 mg over a one-hour period 2
• Avoid in patients with severe renal impairment (GFR <30 mL/min) 3
• Contraindicated in patients receiving strong P-glycoprotein and/or CYP3A4 inhibitors such as cyclosporin or clarithromycin 3

NSAIDs

• Use at full FDA-approved anti-inflammatory doses until the gouty attack resolves 1
• Options include naproxen, indomethacin, or other NSAIDs 1
• Consider adding a proton pump inhibitor in patients with gastrointestinal risk factors 1
• Avoid in patients with renal disease, heart failure, or cirrhosis 1, 4

Corticosteroids

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

Treatment Based on Clinical Scenario

For Patients with Normal Renal Function

• Any of the first-line agents (colchicine, NSAIDs, or corticosteroids) can be used based on patient preference and previous experience 3
• For severe pain or polyarticular involvement, combination therapy may be more effective 5

For Patients with Renal Impairment

• Avoid colchicine in severe renal impairment (GFR <30 mL/min) 3
• Avoid NSAIDs in any degree of renal impairment 1
• Corticosteroids are the preferred option 1, 4
• If colchicine must be used in moderate renal impairment, monitor closely for adverse effects 2

For Patients with Cardiovascular Disease

• Avoid NSAIDs due to increased cardiovascular risk 1
• Corticosteroids or properly dosed colchicine are preferred options 1

For Patients with Contraindications to First-Line Therapies

• IL-1 blockers (canakinumab) can be considered for patients with contraindications to colchicine, NSAIDs, and corticosteroids 3
• Current infection is a contraindication to IL-1 blockers 3

Important Considerations

• Patients should be educated to self-medicate at the first warning symptoms using the "pill in the pocket" approach 3, 1
• Continue established urate-lowering therapy without interruption during an acute attack 1
• Ice application to affected joints can provide additional pain relief 1
• For patients not responding to initial monotherapy, adding a second appropriate agent is acceptable 1
• Avoid combining NSAIDs and systemic corticosteroids due to potential synergistic gastrointestinal toxicity 5

Prevention of Recurrent Flares

• Prophylaxis is recommended during the first 6 months of urate-lowering therapy 3
• Recommended prophylactic treatment is colchicine 0.5-1 mg/day, with dose reduction in patients with renal impairment 3
• If colchicine is not tolerated or contraindicated, low-dose NSAIDs can be used if not contraindicated 3
• Prophylaxis for 6 months appears to provide greater benefit than 8 weeks, with no increase in adverse events 6

Common Pitfalls to Avoid

• Delaying treatment beyond 12-36 hours after symptom onset significantly reduces effectiveness 5
• Using high-dose colchicine regimens, which have similar efficacy but more side effects compared to low-dose regimens 7
• Failing to adjust colchicine dosing in patients with renal impairment or those taking interacting medications 2
• Discontinuing urate-lowering therapy during an acute attack, which can worsen the flare 1