Treatment of Acute Gout Flare with Elevated Uric Acid Levels
For an acute gout flare, immediately treat the inflammation with colchicine, NSAIDs, or corticosteroids while simultaneously addressing the elevated uric acid, but the acute flare treatment and urate-lowering therapy serve distinct purposes and should both be initiated. 1
Immediate Management of the Acute Flare
First-Line Anti-Inflammatory Options
Colchicine is highly effective when started early 1:
- Loading dose: 1.2 mg (two tablets) at first sign of flare, followed by 0.6 mg one hour later 2
- Maximum dose for acute treatment: 1.8 mg over one hour 2
- Lower doses (1.2 mg total) are as effective as higher doses with fewer gastrointestinal side effects 1
- Reduce dose if creatinine clearance 30-50 mL/min 3
- Avoid with strong CYP3A4 inhibitors (macrolides, diltiazem, verapamil, ketoconazole) 1, 2
NSAIDs are equally effective as colchicine 1:
- Any NSAID works; choice matters less than early initiation 4
- Standard dosing: naproxen 500 mg twice daily or indomethacin 50 mg three times daily 1
- Avoid in patients with CKD, cardiovascular disease, or gastrointestinal risk 1, 3
Corticosteroids are preferred when colchicine and NSAIDs are contraindicated 1:
- Oral: prednisolone 30-35 mg daily for 3-5 days 3
- Intra-articular injection for monoarticular flares 1
- Particularly useful in patients with renal impairment or multiple comorbidities 1, 3
Urate-Lowering Therapy (ULT) Initiation
When to Start ULT
Initiate ULT early in patients with elevated uric acid, especially with comorbidities or uric acid >8 mg/dL 1:
- After first flare if CKD stage ≥3, uric acid >9 mg/dL, or urolithiasis 1
- After >1 flare, even if infrequent 1
- Strongly recommended with tophi or radiographic damage 1
Timing Relative to Acute Flare
ULT can be initiated during an acute flare or immediately after—do not delay treatment 1:
- Small trials show starting allopurinol during acute attacks does not prolong or worsen flares 1
- The key is ensuring adequate anti-inflammatory prophylaxis is in place 1
First-Line ULT: Allopurinol
Start allopurinol at 100 mg daily and titrate up by 100 mg every 2-4 weeks until uric acid <6 mg/dL 1, 5:
- Target: serum uric acid <6 mg/dL (360 μmol/L) for all patients 1
- Target <5 mg/dL for severe gout (tophi, chronic arthropathy, frequent attacks) 1
- Maximum dose: 800 mg daily 5
- Adjust for renal impairment: 200 mg daily if creatinine clearance 10-20 mL/min; 100 mg daily if <10 mL/min 5
If allopurinol fails to reach target or is not tolerated, switch to febuxostat or add/switch to uricosuric agent 1
Mandatory Flare Prophylaxis During ULT Initiation
All patients starting ULT must receive prophylaxis for at least 6 months to prevent mobilization flares 1, 2:
- Dose: 0.5-1 mg daily (typically 0.6 mg daily)
- Duration: minimum 6 months, continue until uric acid at target for 3-6 months 1, 6
- Reduce to 0.5 mg daily or every other day if creatinine clearance 30-50 mL/min 3
Alternative: Low-dose NSAID if colchicine contraindicated 1:
Low-dose corticosteroids if both colchicine and NSAIDs contraindicated 1, 7
Critical Pitfalls to Avoid
Drug interactions with colchicine 1, 2:
- Fatal toxicity reported with strong CYP3A4 inhibitors (clarithromycin, ketoconazole, ritonavir) 2
- Increased myopathy risk with statins 1
- Avoid P-glycoprotein inhibitors 1
Premature discontinuation of prophylaxis 1, 7:
- Flare rate doubles when prophylaxis stopped at 8 weeks versus 6 months 1, 7
- Poor adherence to ULT often results from inadequate prophylaxis 1, 7
Failure to titrate allopurinol adequately 1, 5:
- Many patients remain on 100-300 mg without dose adjustment 1
- Must titrate to achieve uric acid target, not just prescribe fixed dose 1
Addressing Modifiable Risk Factors
Lifestyle modifications are mandatory alongside pharmacotherapy 1, 3:
- Weight loss if obese 1, 3
- Eliminate beer, spirits, and sugar-sweetened beverages 1, 3, 6
- Reduce red meat and seafood intake 3, 6
- Encourage low-fat dairy products 3