What is the recommended initial treatment for managing a gout flare?

Management of Gout Flare

For an acute gout flare, start immediately with colchicine (1.2 mg followed by 0.6 mg one hour later), NSAIDs at full anti-inflammatory doses, or oral corticosteroids (prednisone 30-35 mg daily for 3-5 days)—all three are equally effective first-line options, and the single most critical factor for success is early initiation, not which agent you choose. 1, 2

First-Line Treatment Selection Algorithm

The choice among the three first-line agents should be driven by patient-specific contraindications rather than perceived superiority of one agent over another:

Colchicine

• Most effective when initiated within 12 hours of symptom onset 2, 3
• FDA-approved 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 4
• Strongly recommend low-dose colchicine over high-dose colchicine due to similar efficacy with lower risk of adverse effects 1
• Absolute contraindications: severe renal impairment, concurrent use of strong CYP3A4/P-glycoprotein inhibitors (cyclosporine, clarithromycin) due to risk of fatal toxicity 2, 3, 4

NSAIDs

• Use full FDA-approved anti-inflammatory doses (e.g., naproxen, indomethacin) 3
• Contraindications: peptic ulcer disease, renal failure, uncontrolled hypertension, cardiac failure 2
• Consider adding proton pump inhibitor for gastrointestinal protection 3
• Avoid in elderly patients with renal impairment, heart failure, or peptic ulcer disease 2

Oral Corticosteroids

• Prednisone 30-35 mg daily for 3-5 days is the safest option for patients with renal impairment, cardiovascular disease, or gastrointestinal contraindications to NSAIDs 2, 3
• Particularly effective for flares with significant systemic inflammation 2
• Can be given as 0.5 mg/kg per day for 5-10 days then stopped, or for 2-5 days then tapered over 7-10 days 3

Special Situations

Monoarticular or Oligoarticular Flares

• Intra-articular corticosteroid injection is highly effective and preferred for 1-2 large joints 2

Patients Unable to Take Oral Medications

• Strongly recommend parenteral glucocorticoids (intramuscular, intravenous, or intraarticular) over IL-1 inhibitors or ACTH 1, 2, 3

Severe or Polyarticular Attacks

• Combination therapy (colchicine with NSAIDs, or either agent with corticosteroids) may be more effective than monotherapy 3
• Monotherapy is appropriate for mild to moderate pain (≤6/10) affecting 1-3 small joints or 1-2 large joints 3

Contraindications to All First-Line Agents

• Conditionally recommend IL-1 inhibitors (canakinumab 150 mg subcutaneously) for patients with frequent flares and contraindications to colchicine, NSAIDs, and corticosteroids 2, 3
• Current infection is an absolute contraindication to IL-1 blockers 2, 3

Critical Management Principles

Continue Urate-Lowering Therapy During Flare

• If patient is already on urate-lowering therapy (allopurinol, febuxostat), continue it during the acute flare 2, 3
• Interrupting urate-lowering therapy can worsen the flare and complicate long-term management 2, 3

Starting Urate-Lowering Therapy During a Flare

• When the decision is made that urate-lowering therapy is indicated, conditionally recommend starting it during the gout flare rather than waiting for resolution 1
• Must provide concomitant anti-inflammatory prophylaxis 1

Prophylaxis When Initiating Urate-Lowering Therapy

• Strongly recommend concomitant anti-inflammatory prophylaxis (colchicine, NSAIDs, or corticosteroids) when starting urate-lowering therapy 1
• Continue prophylaxis for 3-6 months rather than <3 months, with ongoing evaluation and continued prophylaxis as needed if flares persist 1, 2
• Low-dose colchicine (0.5-0.6 mg once or twice daily) is first-line prophylaxis 2, 3

Adjunctive Measures

• Topical ice application is conditionally recommended as adjuvant therapy 1, 2
• Rest of the inflamed joint is useful 5

Critical Pitfalls to Avoid

• Delaying treatment initiation is the most critical error—early intervention is the most important determinant of success, regardless of which first-line agent is chosen 2, 3, 5, 6
• Never use colchicine in patients with severe renal impairment or on strong CYP3A4/P-glycoprotein inhibitors—this can result in fatal toxicity 2, 4
• Avoid NSAIDs in elderly patients with renal impairment, heart failure, or peptic ulcer disease 2, 7
• Never stop urate-lowering therapy during an acute flare—this worsens the flare and complicates long-term management 2, 3
• Do not use higher doses of colchicine than recommended—doses above 1.8 mg over one hour have not been found more effective and increase toxicity risk 4

Patient Self-Management

• Educate patients to self-medicate at the first warning symptoms using a "pill in the pocket" approach 3
• Fully informed patients should be involved in choosing the specific agent based on contraindications, previous experience, and timing after flare onset 3