What is the recommended treatment for a gout flare?

Treatment of Acute Gout Flare

For an acute gout flare, initiate treatment immediately with one of three equally effective first-line options: 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), with the choice based on patient comorbidities and contraindications. 1

Critical Principle: Early Treatment is Key

• The single most important factor for treatment success is early initiation, not which specific agent you choose. 1
• Treatment should ideally begin within 12 hours of symptom onset for maximum effectiveness. 1
• Consider a "pill in the pocket" approach for well-informed patients to self-initiate treatment at the first warning symptoms. 2

First-Line Treatment Selection Algorithm

Option 1: Colchicine

• Dosing: 1.2 mg (two tablets) at first sign of flare, followed by 0.6 mg (one tablet) one hour later; maximum 1.8 mg over one hour. 1, 3
• Most effective when: Started within 12 hours of symptom onset. 1
• Avoid in: Severe renal impairment (CrCl <30 mL/min), patients on strong CYP3A4/P-glycoprotein inhibitors (cyclosporine, clarithromycin), or severe hepatic impairment. 1, 3
• Renal dosing adjustments: For dialysis patients, use single 0.6 mg dose only, not to be repeated more than once every two weeks. 3

Option 2: NSAIDs

• Dosing: Full FDA-approved anti-inflammatory doses (e.g., naproxen 500 mg twice daily, indomethacin 50 mg three times daily). 1
• Avoid in: Peptic ulcer disease, renal failure (CrCl <30 mL/min), uncontrolled hypertension, heart failure, elderly patients with multiple comorbidities. 1

Option 3: Oral Corticosteroids (Often the Safest Choice)

• Dosing: Prednisone 30-35 mg daily for 3-5 days, or 0.5 mg/kg/day for 5-10 days then stop. 1, 4, 2
• Preferred when: Patient has renal impairment, cardiovascular disease, gastrointestinal contraindications to NSAIDs, uncontrolled hypertension, heart failure, or significant systemic inflammation (elevated CRP, leukocytosis). 1, 4
• Advantages: Generally safer than NSAIDs with fewer adverse effects, particularly effective for flares with significant systemic inflammation. 4, 2
• Contraindication: Systemic fungal infections. 2

Special Situations

Monoarticular or Oligoarticular Flares (1-2 Large Joints)

• Intra-articular corticosteroid injection is highly effective and preferred. 1, 4
• Can be combined with any other systemic therapy if needed. 2

Patients Unable to Take Oral Medications

• Use parenteral glucocorticoids (intramuscular, intravenous, or intra-articular) over IL-1 inhibitors or ACTH. 1, 4

Severe Gout with Multiple Joint Involvement

• Consider combination therapy: oral corticosteroids plus colchicine, or colchicine plus NSAIDs. 4, 2

Patients with Contraindications to All First-Line Agents

• IL-1 inhibitors (canakinumab 150 mg subcutaneously) are conditionally recommended for patients with frequent flares. 1
• Absolute contraindication: Current active infection. 1

Management of Urate-Lowering Therapy During Flare

• Continue urate-lowering therapy (ULT) if already prescribed; do not stop during acute flare. 1, 2
• Stopping ULT can worsen the flare and complicate long-term management. 1
• Starting ULT during an acute flare (with appropriate anti-inflammatory coverage) is conditionally recommended and does not significantly prolong flare duration. 1, 2

Prophylaxis When Initiating Urate-Lowering Therapy

• When starting ULT, provide concomitant anti-inflammatory prophylaxis for 3-6 months to prevent treatment-induced flares. 1, 2
• First-line prophylaxis: Low-dose colchicine 0.5-0.6 mg once or twice daily. 1
• Second-line prophylaxis: Low-dose prednisone (<10 mg/day) if colchicine or NSAIDs are contraindicated or not tolerated. 2

Adjunctive Measures

• Topical ice application is conditionally recommended as adjuvant therapy for additional pain relief. 1, 2
• Rest the affected joint during acute inflammation. 5

Critical Pitfalls to Avoid

• Delaying treatment initiation: This is the most critical error; early intervention determines success more than agent selection. 1, 2
• Using colchicine in severe renal impairment or with strong CYP3A4/P-glycoprotein inhibitors: Can result in fatal toxicity. 1, 3
• Prescribing NSAIDs in elderly patients with renal impairment, heart failure, or peptic ulcer disease. 1
• Stopping urate-lowering therapy during acute flare: Worsens the flare and complicates long-term management. 1, 2
• Failing to rule out septic arthritis: In patients with significant leukocytosis and elevated CRP, infection must be excluded before starting immunosuppressive therapy. 4
• Using IL-1 blockers in patients with active infection. 1