What is the treatment for an acute gout (gouty arthritis) flare?

From the Guidelines

For treating an active gout flare, the most effective treatment option is to start with an anti-inflammatory medication as soon as possible after symptoms begin, with first-line options including corticosteroids, nonsteroidal anti-inflammatory drugs (NSAIDs), or colchicine, as recommended by the American College of Physicians 1. The choice of medication should be based on the presence of contraindications, the patient’s previous experience with treatments, time of initiation after flare onset, and the number and type of joint(s) involved.

• Corticosteroids, such as prednisolone at a dose of 35 mg for 5 days, are a safe and low-cost treatment option and should be considered as first-line therapy in patients without contraindications 1.
• NSAIDs, such as naproxen or indomethacin, are also effective options, but may have adverse effects such as dyspepsia and potential gastrointestinal perforations, ulcers, and bleeding 1.
• Colchicine is another effective option, using a loading dose of 1 mg followed 1 hour later by 0.5 mg on day 1, and should be avoided in patients with severe renal impairment or those receiving strong P-glycoprotein and/or CYP3A4 inhibitors 1. In addition to medication, joint rest, ice application for 20 minutes several times daily, and elevation of the affected joint can help manage pain. Maintaining adequate hydration by drinking 8-10 glasses of water daily during a flare and avoiding alcohol and purine-rich foods (organ meats, shellfish, red meat) during the acute phase can also help alleviate symptoms. These medications work by reducing inflammation caused by urate crystal deposition in the joints, which triggers the intense pain, swelling, and redness characteristic of gout flares. Once the acute attack resolves, discussing long-term urate-lowering therapy with a healthcare provider to prevent future flares is essential, with the goal of maintaining serum uric acid levels at <6 mg/dL (360 mmol/L) and <5 mg/dL (300 mmol/L) in those with severe gout 1.

From the FDA Drug Label

The recommended dose of Colchicine Tablets, USP for treatment of a gout flare is 1.2 mg (two tablets) at the first sign of the flare followed by 0.6 mg (one tablet) one hour later. Treatment for active gout flare:

• The initial dose is 1.2 mg (two tablets) at the first sign of the flare.
• Followed by 0.6 mg (one tablet) one hour later.
• The maximum recommended dose for treatment of gout flares is 1.8 mg over a one hour period 2.

From the Research

Treatment Options for Active Gout Flare

• Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used to treat acute gout, with low-certainty evidence suggesting they may improve pain at 24 hours and have little to no effect on function, inflammation, or adverse events 3.
• COX-2 inhibitors and non-selective NSAIDs are probably equally beneficial in terms of improvement in pain, function, inflammation, and treatment success, although non-selective NSAIDs may increase withdrawals due to adverse events and total adverse events 3.
• Systemic glucocorticoids and NSAIDs are probably equally beneficial in terms of pain relief, improvement in function, and treatment success, with similar withdrawals due to adverse events but more total adverse events with NSAIDs 3.
• Colchicine is also effective for the treatment of acute gout, with low-dose colchicine demonstrating a comparable tolerability profile to placebo and a significantly lower side effect profile to high-dose colchicine 4, 5.
• Interleukin-1 (IL-1) inhibitors, such as canakinumab, have evidence to suggest efficacy in the treatment of acute gout, particularly in subjects refractory to or with contraindications to NSAIDs and/or colchicine 4, 5.

Comparison of Treatment Options

• NSAIDs versus placebo: low-certainty evidence suggests NSAIDs may improve pain at 24 hours and have little to no effect on function, inflammation, or adverse events 3.
• NSAIDs versus COX-2 inhibitors: moderate-certainty evidence suggests little to no difference in pain, swelling, treatment success, or quality of life, but non-selective NSAIDs may increase withdrawals due to adverse events and total adverse events 3.
• NSAIDs versus glucocorticoids: moderate-certainty evidence suggests little to no difference in pain relief, improvement in function, and treatment success, with similar withdrawals due to adverse events but more total adverse events with NSAIDs 3.
• Colchicine versus placebo: low-quality evidence suggests both high- and low-dose colchicine are more effective than placebo, with low-dose colchicine safer than high-dose colchicine 5.