What is the recommended treatment for a gout flare?

Treatment of Acute Gout Flares

For an acute gout flare, initiate treatment immediately with colchicine (1.2 mg followed by 0.6 mg one hour later), NSAIDs at full FDA-approved doses, or oral corticosteroids (prednisone 30-35 mg daily for 3-5 days) as first-line monotherapy, with the choice guided by patient comorbidities and contraindications. 1, 2

First-Line Treatment Options

The 2020 American College of Rheumatology guidelines strongly recommend three equally effective first-line agents for acute gout flares 1:

Colchicine

• FDA-approved dosing: 1.2 mg (two tablets) at first sign of flare, followed by 0.6 mg (one tablet) one hour later 2
• Maximum dose for treatment is 1.8 mg over one hour 2
• Most effective when initiated within 12 hours of symptom onset 1, 3
• Critical contraindications: severe renal impairment (GFR <30 mL/min), concurrent use of strong P-glycoprotein or CYP3A4 inhibitors (cyclosporin, clarithromycin, ketoconazole, ritonavir), and concomitant statin therapy due to risk of neurotoxicity/myotoxicity 1, 2

NSAIDs

• Use full FDA-approved anti-inflammatory doses (e.g., naproxen, indomethacin) 1, 3
• Contraindications: peptic ulcer disease, renal failure (GFR <30 mL/min), uncontrolled hypertension, cardiac failure 1, 4
• Consider adding proton pump inhibitor for gastrointestinal protection 1
• Short half-life NSAIDs (diclofenac, ketoprofen) preferred in elderly patients 4

Oral Corticosteroids

• Prednisone 30-35 mg daily for 3-5 days (or 0.5 mg/kg/day for 5-10 days then stop) 1, 5, 3
• Particularly effective for flares with significant systemic inflammation (elevated inflammatory markers) 5
• Safer than NSAIDs in patients with renal impairment, cardiovascular disease, or gastrointestinal contraindications 5

Treatment Selection Algorithm

The single most important factor for treatment success is early initiation—not which agent is chosen 1, 6, 7

For monoarticular or oligoarticular flares (1-2 large joints):

• Intra-articular corticosteroid injection is highly effective and preferred 1, 5
• Provides rapid relief with minimal systemic effects 1

For patients unable to take oral medications:

• Parenteral glucocorticoids (intramuscular, intravenous, or intra-articular) are strongly recommended over IL-1 inhibitors or ACTH 1, 5

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

• Use monotherapy with colchicine, NSAIDs, or corticosteroids 3

For severe or polyarticular attacks:

• Combination therapy may be more effective (e.g., colchicine plus NSAIDs, or either agent with corticosteroids) 3

Dose Adjustments for Renal Impairment

Colchicine dosing with renal dysfunction 2:

• Mild-to-moderate impairment (CrCl 30-80 mL/min): No dose adjustment needed, but monitor closely
• Severe impairment (CrCl <30 mL/min): Treatment course should not be repeated more than once every two weeks
• Dialysis patients: Single dose of 0.6 mg only; do not repeat more than once every two weeks

NSAIDs:

• Avoid in severe renal impairment (GFR <30 mL/min) 1, 4

Corticosteroids:

• No dose adjustment needed; preferred option in renal impairment 5

Special Populations and Situations

Elderly patients:

• Extreme caution with NSAIDs—increased risk of adverse effects 4
• Corticosteroids or low-dose colchicine preferred 4
• Colchicine poorly tolerated and best avoided in very elderly 4

Patients with contraindications to all first-line agents:

• IL-1 inhibitors (canakinumab 150 mg subcutaneously) conditionally recommended 1
• Current infection is absolute contraindication to IL-1 blockers 1
• Reserved for patients with frequent flares and contraindications to colchicine, NSAIDs, and corticosteroids 1

Patients already on urate-lowering therapy:

• Continue ULT during acute flare—do not interrupt allopurinol or febuxostat 1, 3
• Interrupting ULT can worsen the flare and complicate long-term management 3

Adjunctive Measures

• Topical ice application conditionally recommended as adjuvant therapy 1
• Rest of the inflamed joint 6

Critical Pitfalls to Avoid

1. Delaying treatment initiation—early intervention is the most important determinant of success, not which agent is chosen 1, 6, 7
2. Using colchicine in patients with severe renal impairment or on strong CYP3A4/P-glycoprotein inhibitors—risk of fatal toxicity 1, 2
3. Prescribing NSAIDs in elderly patients with renal impairment, heart failure, or peptic ulcer disease 1, 4
4. Stopping urate-lowering therapy during acute flare—continue allopurinol/febuxostat with appropriate anti-inflammatory coverage 1, 3
5. Using higher colchicine doses than FDA-approved—no additional benefit and 100% incidence of side effects with traditional high-dose regimens 8, 2
6. Failing to provide "pill-in-pocket" strategy for patients who can recognize early flare symptoms—enables immediate self-treatment 1, 3

Duration of Treatment

• Continue anti-inflammatory therapy until the flare has completely resolved 5, 6
• Typical course: 3-5 days for corticosteroids 1, 5
• For colchicine: single treatment course as per FDA dosing; do not repeat within 3 days in normal renal function 2