What is the recommended dose and duration of treatment for a gout flare-up with Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), colchicine, and corticosteroids?

Treatment of Acute Gout Flare: Dose and Duration

For acute gout flares, initiate colchicine 1.2 mg immediately followed by 0.6 mg one hour later (total 1.8 mg), then continue 0.6 mg once or twice daily until the flare resolves; alternatively, use full-dose NSAIDs (e.g., naproxen, indomethacin) continued at full dose until complete resolution, or oral corticosteroids (prednisone 0.5 mg/kg/day or prednisolone 30-35 mg/day) for 5-10 days with or without taper. 1, 2, 3

Colchicine Dosing and Duration

Acute Treatment Protocol

• Administer 1.2 mg (two tablets) at the first sign of flare, followed by 0.6 mg (one tablet) one hour later for a total of 1.8 mg over one hour 1, 2, 3
• After initial dosing, continue with 0.6 mg once or twice daily until the acute attack completely resolves, typically within a few days 1, 2, 3
• Maximum dose for acute treatment is 1.8 mg over one hour—higher doses provide no additional benefit but substantially increase gastrointestinal toxicity 2, 3

Critical Timing Considerations

• Colchicine is most effective when started within 12 hours of symptom onset and should only be used if symptom onset was no greater than 36 hours prior to treatment 1, 2
• The "pill in the pocket" approach allows fully informed patients to self-medicate at the first warning symptoms 2

Important Contraindications

• Absolute contraindication: Concurrent use of strong CYP3A4 inhibitors (clarithromycin, erythromycin) or P-glycoprotein inhibitors (cyclosporine), especially in patients with severe renal impairment (GFR <30 mL/min) 2, 3
• Avoid in patients with both renal or hepatic impairment AND taking potent CYP3A4 or P-glycoprotein inhibitors 2

NSAID Dosing and Duration

Treatment Protocol

• Use full FDA-approved doses until the gouty attack has completely resolved—no specific duration limit, continue until symptoms resolve 1, 2
• FDA-approved NSAIDs for gout include naproxen, indomethacin, and sulindac 1, 2
• No evidence suggests one NSAID is more effective than another for gout treatment 2

Specific Dosing Examples

• Naproxen 250 mg twice daily (for prophylaxis) or full dose for acute treatment 1
• Continue at full dose without tapering until complete resolution 1, 2

Important Precautions

• Use cautiously in patients with renal disease, heart failure, or cirrhosis 2
• Non-selective NSAIDs increase withdrawals due to adverse events (mainly gastrointestinal) compared to COX-2 inhibitors (RR 2.3,95% CI 1.3 to 4.1) 4
• Avoid in patients with cardiovascular disease or heart failure when possible 5

Corticosteroid Dosing and Duration

Oral Corticosteroid Protocol

• Prednisone 0.5 mg/kg per day for 5-10 days at full dose, then stop 1
• Alternative: Continue for 2-5 days at full dose, then taper over 7-10 days 1
• Prednisolone 30-35 mg/day for 3-5 days is an effective alternative 1, 2

Parenteral Options

• Intramuscular triamcinolone acetonide 60 mg, then oral prednisone as above 1
• Intra-articular corticosteroid injection for monoarticular flares 6
• Parenteral glucocorticoids are strongly recommended over IL-1 inhibitors or ACTH when oral medications cannot be taken 1

Safety Considerations

• Short durations of low-dose glucocorticoids are efficacious and may be safe in patients with cardiovascular disease 5
• Concerns exist about synergistic gastrointestinal toxicity when combining NSAIDs with systemic corticosteroids 2

Combination Therapy for Severe Flares

• For severe attacks involving multiple large joints or polyarticular arthritis, combination therapy with colchicine and NSAIDs is appropriate 2
• The combination provides synergistic anti-inflammatory effects targeting different inflammatory pathways 2
• Continue both agents at full dose until complete resolution 2

Treatment Selection Algorithm

First-Line Options (Choose Based on Patient Factors)

1. Colchicine (if <36 hours from onset and no contraindications): 1.2 mg then 0.6 mg one hour later 1, 2, 3
2. NSAIDs (if no renal/cardiac/GI contraindications): Full dose until resolution 1, 2
3. Corticosteroids (if colchicine and NSAIDs contraindicated): Prednisone 0.5 mg/kg/day for 5-10 days 1, 2

For Severe/Polyarticular Flares

• Consider combination colchicine + NSAID therapy 2

For Patients Unable to Take Oral Medications

• Use parenteral glucocorticoids (intramuscular, intravenous, or intra-articular) 1

Common Pitfalls to Avoid

• Do NOT use the obsolete high-dose colchicine regimen (0.5 mg every 2 hours)—this causes severe diarrhea in most patients with no additional benefit 2
• Do NOT delay treatment beyond 12-36 hours after symptom onset, which significantly reduces effectiveness 1, 2
• Do NOT stop treatment prematurely—continue at full dose until the gouty attack has completely resolved 1, 2
• Do NOT use NSAIDs in patients with significant cardiovascular disease or heart failure 2, 5
• Do NOT give colchicine to patients on strong CYP3A4/P-gp inhibitors, especially with renal impairment 2, 3

Prophylaxis During Urate-Lowering Therapy Initiation

• When initiating urate-lowering therapy, strongly recommend concomitant anti-inflammatory prophylaxis (colchicine 0.6 mg once or twice daily, low-dose NSAIDs, or prednisone/prednisolone <10 mg/day) 1
• Continue prophylaxis for 3-6 months rather than <3 months, with ongoing evaluation 1
• For patients with tophi, continue for 6 months after achieving target serum urate 1