Treatment of Acute Gout Flare
For an acute gout flare, immediately initiate treatment 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, 2
First-Line Treatment Options
The American College of Rheumatology strongly recommends three equally effective first-line agents 1:
Colchicine: Most effective when started within 12 hours of symptom onset at a loading dose of 1.2 mg (two tablets) followed by 0.6 mg (one tablet) one hour later, with a maximum dose of 1.8 mg over one hour 1, 3
NSAIDs: Use at full FDA-approved anti-inflammatory doses (e.g., naproxen 500 mg twice daily or indomethacin 50 mg three times daily) 1, 2
Oral corticosteroids: Prednisone/prednisolone 30-35 mg daily for 3-5 days, or alternatively 0.5 mg/kg per day for 5-10 days at full dose then stop 1, 2
Treatment Selection Algorithm
The single most critical factor for treatment success is early initiation, not which specific agent is chosen. 1 Select based on the following patient factors:
Choose Oral Corticosteroids When:
- Renal impairment is present (safer than NSAIDs or colchicine) 1, 2
- Cardiovascular disease exists 1
- Gastrointestinal contraindications to NSAIDs are present 1
- Uncontrolled hypertension or heart failure exists 1
Choose Intra-articular Corticosteroid Injection When:
- Monoarticular or oligoarticular flares involve 1-2 large joints (highly effective and preferred in this scenario) 1, 2
Avoid Colchicine When:
- Severe renal impairment (GFR <30 mL/min) is present 1, 3
- Patient is taking strong CYP3A4 or P-glycoprotein inhibitors (clarithromycin, cyclosporine, ritonavir, ketoconazole) - fatal toxicity can occur 1, 3
Avoid NSAIDs When:
- Peptic ulcer disease, renal failure, uncontrolled hypertension, or cardiac failure is present 1
Special Situations
Severe Polyarticular Flares:
- Consider combination therapy with oral corticosteroids plus colchicine, or colchicine plus NSAIDs 2
Unable to Take Oral Medications:
- Use parenteral glucocorticoids (intramuscular, intravenous, or intra-articular) over IL-1 inhibitors 1
Contraindications to All First-Line Agents:
- IL-1 inhibitors (canakinumab 150 mg subcutaneously) are conditionally recommended for patients with frequent flares, but current infection is an absolute contraindication 1
Critical Management Principles
Continue Urate-Lowering Therapy During Flare:
- If the patient is already on urate-lowering therapy, continue it during the acute flare - stopping it can worsen the flare and complicate long-term management 1, 2
Starting Urate-Lowering Therapy During Flare:
- The American College of Rheumatology conditionally recommends starting urate-lowering therapy during the flare rather than waiting for resolution, with concomitant anti-inflammatory prophylaxis 4, 1
Dose Adjustments for Renal Impairment
For colchicine in patients with severe renal impairment (CrCl <30 mL/min) 3:
- Treatment dose: Single dose of 0.6 mg, with treatment course repeated no more than once every two weeks
- For dialysis patients: Single dose of 0.6 mg, not repeated more than once every two weeks
Adjunctive Measures
- Topical ice application is conditionally recommended as adjuvant therapy 1, 2
- Rest of the inflamed joint 5
Critical Pitfalls to Avoid
- Delaying treatment initiation - this is the most critical error, as early intervention is the most important determinant of success 1
- Using colchicine 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 management 1
- Using high-dose colchicine - low-dose colchicine has similar efficacy with fewer adverse effects 1, 2