What is the first line treatment for a gout (gouty arthritis) flare-up?

First-Line Treatment for Gout Flare-Up

For an acute gout flare, use oral NSAIDs at full anti-inflammatory doses, oral colchicine (1.2 mg followed by 0.6 mg one hour later), or oral corticosteroids (prednisone 30-35 mg daily for 3-5 days) as first-line therapy—all three options are equally appropriate and the choice should be based on patient comorbidities and contraindications. 1

Treatment Initiation Timing

• Initiate pharmacologic therapy within 24 hours of symptom onset for optimal effectiveness 1
• For colchicine specifically, treatment should be started within 36 hours of flare onset for maximum benefit 1
• The most important determinant of therapeutic success is how soon treatment is initiated, not which specific agent is chosen 2

First-Line Treatment Options

NSAIDs (Full Anti-inflammatory Doses)

• FDA-approved NSAIDs for acute gout include naproxen, indomethacin, and sulindac, though any NSAID at full anti-inflammatory/analgesic doses may be effective 1
• Continue the NSAID at full dose until the acute attack completely resolves 1
• No single NSAID is preferentially recommended over another—the choice depends on patient factors 1
• For patients with GI contraindications, COX-2 inhibitors like etoricoxib (not available in US) are options, though celecoxib requires high doses (800 mg once, then 400 mg on day 1, then 400 mg twice daily) with unclear risk-benefit ratio 1

Colchicine (Low-Dose Regimen)

• Recommended dosing: 1.2 mg (two tablets) at first sign of flare, followed by 0.6 mg (one tablet) one hour later 1, 3
• Maximum dose for treatment is 1.8 mg over one hour 3
• After the initial loading dose, resume prophylactic dosing (0.6 mg once or twice daily) 12 hours later until the flare resolves 1
• Only use colchicine if the flare onset was no greater than 36 hours prior to treatment initiation 1
• Low-dose colchicine (1.8 mg total) has similar efficacy to high-dose regimens with fewer adverse effects 1

Corticosteroids

• Oral prednisone/prednisolone 30-35 mg daily for 3-5 days is an appropriate first-line option 4, 5
• Alternative dosing: 0.5 mg/kg per day for 5-10 days at full dose then stop 4
• For monoarticular or oligoarticular involvement (1-2 joints), intra-articular corticosteroid injection (e.g., triamcinolone acetonide 40 mg for large joints) is an excellent option 4, 5
• For patients unable to take oral medications, parenteral glucocorticoids (intramuscular or intravenous) are strongly recommended over IL-1 inhibitors or ACTH 1, 4

Algorithm for Choosing First-Line Therapy

Step 1: Assess contraindications

• Renal impairment (CKD stage ≥3): Prefer corticosteroids over NSAIDs; adjust colchicine dose 1, 5
• GI contraindications/active ulcer disease: Avoid NSAIDs; use corticosteroids or colchicine 1
• Uncontrolled diabetes or active infection: Avoid corticosteroids; use NSAIDs or colchicine 5
• Severe hepatic impairment: Avoid NSAIDs and adjust colchicine dose 1

Step 2: Consider timing

• If >36 hours since symptom onset: Colchicine efficacy is reduced; prefer NSAIDs or corticosteroids 1
• If <24 hours since onset: All three options are equally appropriate 1

Step 3: Consider extent of involvement

• Monoarticular or oligoarticular (1-2 large joints): Intra-articular corticosteroid injection is highly effective 4, 5
• Polyarticular (≥4 joints) or severe pain: Consider combination therapy (see below) 1

Combination Therapy for Severe Flares

• For severe polyarticular attacks, combination therapy is appropriate 1
• Acceptable combinations include:
  • Colchicine + NSAIDs 1
  • Oral corticosteroids + colchicine 1
  • Intra-articular steroids + any other modality 1
• Avoid combining NSAIDs with systemic corticosteroids due to synergistic GI toxicity 1

Critical Dosing Adjustments

Colchicine Drug Interactions

• With strong CYP3A4 inhibitors (clarithromycin, ketoconazole, ritonavir, etc.): Reduce dose to 0.6 mg × 1 dose, followed by 0.3 mg one hour later; do not repeat for at least 3 days 1, 3
• With moderate CYP3A4 inhibitors: Adjust dose accordingly 1, 3

Renal Impairment

• For NSAIDs: Consider dose tapering in patients with renal impairment 1
• For colchicine: Dose adjustment required in moderate to severe CKD 1, 3

Alternative Therapies (Second-Line)

• IL-1 inhibitors (canakinumab, anakinra) are conditionally recommended only when colchicine, NSAIDs, and corticosteroids are ineffective, poorly tolerated, or contraindicated 1
• Moderate-quality evidence shows canakinumab 150 mg is superior to triamcinolone 40 mg for pain relief, but costs are prohibitively high and adverse events are increased 6

Adjunctive Measures

• Topical ice application is conditionally recommended as adjuvant treatment 1, 4
• Rest of the inflamed joint during acute attack 2

Critical Management Principles

• Do NOT interrupt ongoing urate-lowering therapy (ULT) during an acute flare—continue allopurinol or febuxostat without interruption 1, 5
• Do NOT use colchicine as an analgesic—it is not effective for pain from other causes 3
• Treatment should continue until the acute attack has completely resolved 1, 4

Common Pitfalls to Avoid

• Delaying treatment initiation: Effectiveness decreases significantly after 24 hours 1, 2
• Using high-dose colchicine regimens: The old high-dose regimen (4.8 mg total) has no additional benefit and significantly more adverse effects 1, 3
• Stopping ULT during flares: This is outdated practice; continue ULT with appropriate anti-inflammatory coverage 1, 5
• Failing to rule out septic arthritis: In patients with significant leukocytosis and elevated inflammatory markers, infection must be excluded 4
• Combining NSAIDs with systemic corticosteroids: This increases GI toxicity risk 1
• Using colchicine beyond 36 hours of symptom onset: Efficacy is markedly reduced 1