What is the treatment for a gout flare?

Treatment of Acute Gout Flares

For an acute gout flare, initiate treatment immediately with one of three equally effective first-line options: oral corticosteroids (prednisone 30-35 mg daily for 3-5 days), NSAIDs at full anti-inflammatory doses, or colchicine (1.2 mg followed by 0.6 mg one hour later, maximum 1.8 mg in one hour). 1, 2, 3

First-Line Treatment Selection Algorithm

The choice among the three first-line agents depends primarily on patient comorbidities and contraindications, not on comparative efficacy—early initiation matters far more than which agent you select 2, 4:

Oral Corticosteroids (Preferred for Most Patients)

• Prednisone 30-35 mg daily for 3-5 days (or 0.5 mg/kg/day for 5-10 days at full dose then stop) 1
• Safest option for patients with:
  • Renal impairment (any stage) 1, 5
  • Cardiovascular disease 2
  • Gastrointestinal contraindications to NSAIDs 2
  • Uncontrolled hypertension 2
  • Heart failure 2
• Monitor for: elevated blood glucose (especially in diabetics), dysphoria, mood disorders, fluid retention 1
• Contraindicated in: systemic fungal infections 1

NSAIDs at Full FDA-Approved Doses

• Examples: indomethacin 50 mg three times daily, naproxen 500 mg twice daily 1, 2
• Contraindicated in:
  • Peptic ulcer disease 2
  • Renal failure 2
  • Uncontrolled hypertension 2
  • Cardiac failure 2
  • Elderly patients with renal impairment 2

Colchicine (Most Effective When Started Early)

• Dosing: 1.2 mg (two 0.6 mg tablets) at first sign of flare, followed by 0.6 mg one hour later; maximum 1.8 mg over one hour 1, 2, 3
• Critical timing: Most effective when initiated within 12 hours of symptom onset 1, 2, 5
• Absolute contraindications:
  • Severe renal impairment (GFR <30 mL/min) 5, 3
  • Concurrent use of strong CYP3A4 or P-glycoprotein inhibitors (clarithromycin, cyclosporine, ritonavir, ketoconazole, itraconazole) 5, 3
• Dose adjustments for renal impairment:
  • Mild-moderate impairment (GFR 30-80 mL/min): No dose adjustment needed, but monitor closely 3
  • Severe impairment (GFR <30 mL/min): Single 0.6 mg dose only; do not repeat for 2 weeks 3
  • Dialysis patients: Single 0.6 mg dose; do not repeat for 2 weeks 3
• Caution with statins: Risk of neurotoxicity and myopathy 5
• Safe in hypertension (unlike NSAIDs, does not affect blood pressure control) 5

Special Situations

Monoarticular or Oligoarticular Flares (1-2 Large Joints)

• Intra-articular corticosteroid injection is highly effective and preferred 1, 2
• Can be combined with any other modality 1

Severe Polyarticular Flares

• Consider combination therapy: 1, 2
  • Oral corticosteroids + colchicine
  • Intra-articular steroids + any other modality
  • Colchicine + NSAIDs

Patients Unable to Take Oral Medications

• Use parenteral glucocorticoids (intramuscular, intravenous, or intra-articular) over IL-1 inhibitors 2

Refractory Cases (All First-Line Agents Contraindicated)

• IL-1 inhibitors (canakinumab 150 mg subcutaneously) conditionally recommended for patients with frequent flares 2, 5
• Contraindicated if active infection 2, 5

Critical Management Principles

Continue Urate-Lowering Therapy During Flares

• Do not stop existing urate-lowering therapy during an acute flare—interrupting it worsens the flare and complicates long-term management 2
• If ULT is indicated but not yet started, you may conditionally start it during the flare (with appropriate anti-inflammatory coverage) 6

Duration of Treatment

• Continue treatment until the flare has completely resolved 1
• Typical course: 3-5 days for corticosteroids 1

Adjunctive Measures

• Topical ice application can provide additional pain relief 1, 2

Common Pitfalls to Avoid

1. Delaying treatment initiation—this is the single most critical error; early intervention determines success regardless of agent chosen 2, 4

2. Using colchicine in patients on strong CYP3A4/P-gp inhibitors—can result in fatal toxicity 2, 5, 3

3. Prescribing NSAIDs to elderly patients with renal impairment, heart failure, or peptic ulcer disease 2

4. Stopping urate-lowering therapy during acute flare—worsens the flare 2

5. Inadequate colchicine dosing—the FDA-approved regimen is 1.2 mg followed by 0.6 mg one hour later (total 1.8 mg), not the outdated high-dose regimens 3

6. Failing to adjust colchicine dose in renal impairment—severe renal impairment requires single-dose therapy only 3

Prophylaxis During Urate-Lowering Therapy Initiation

When initiating urate-lowering therapy, strongly recommend concomitant anti-inflammatory prophylaxis for 3-6 months to prevent treatment-induced flares 6:

• First-line: Low-dose colchicine (0.5-0.6 mg once or twice daily) 6, 1
• Second-line: Low-dose prednisone (<10 mg/day) if colchicine/NSAIDs contraindicated 1
• Continue prophylaxis with ongoing evaluation; extend if flares persist 6