What is the recommended treatment for a gout flare?

Treatment of Acute Gout Flares

For an acute gout flare, immediately initiate treatment with 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)—all three are equally effective first-line options, and the single most critical factor for success is early initiation, not which agent you choose. 1

First-Line Treatment Selection Algorithm

The choice among the three first-line agents depends primarily on contraindications rather than efficacy:

Colchicine

• Most effective when started within 12 hours of symptom onset 1, 2
• FDA-approved dosing: 1.2 mg (two tablets) at first sign of flare, followed by 0.6 mg (one tablet) one hour later—maximum 1.8 mg over one hour 3
• Absolute contraindications: severe renal impairment (CrCl <30 mL/min), concurrent use of strong CYP3A4/P-glycoprotein inhibitors (clarithromycin, cyclosporine, ritonavir, ketoconazole, itraconazole)—fatal toxicity has been reported with these combinations 1, 2, 3
• For patients on dialysis, reduce to single 0.6 mg dose, not to be repeated more than once every two weeks 3

NSAIDs

• Use full FDA-approved anti-inflammatory doses (e.g., naproxen 500 mg twice daily, indomethacin 50 mg three times daily) 1, 2
• Contraindications: peptic ulcer disease, renal failure (CrCl <30 mL/min), uncontrolled hypertension, cardiac failure 1, 2
• Consider adding proton pump inhibitor for gastrointestinal protection 2
• Particularly dangerous in elderly patients with renal impairment or heart failure 1

Oral Corticosteroids

• Prednisone 30-35 mg daily for 3-5 days (or 0.5 mg/kg/day for 5-10 days then stop, or taper over 7-10 days) 1, 2
• Preferred option for patients with renal impairment, cardiovascular disease, gastrointestinal contraindications to NSAIDs, uncontrolled hypertension, or heart failure 1
• Particularly effective for flares with significant systemic inflammation 1

Special Situations

Monoarticular or Oligoarticular Flares (1-2 Large Joints)

• Intra-articular corticosteroid injection is highly effective and preferred 1

Severe or Polyarticular Attacks

• Combination therapy (colchicine + NSAIDs, or either with corticosteroids) may be more effective than monotherapy 2

Patients Unable to Take Oral Medications

• Parenteral glucocorticoids (intramuscular, intravenous, or intra-articular) are strongly recommended over IL-1 inhibitors or ACTH 1, 2

Patients with Contraindications to All First-Line Agents

• IL-1 inhibitors (canakinumab 150 mg subcutaneously) are conditionally recommended for patients with frequent flares 1, 2
• Current infection is an absolute contraindication to IL-1 blockers 1, 2

Critical Management Principles

Continue Urate-Lowering Therapy During Flares

• If patient is already on allopurinol or febuxostat, continue it during the acute flare—interrupting ULT worsens the flare and complicates long-term management 1, 2

Starting ULT During a Flare

• You may conditionally start urate-lowering therapy during a gout flare rather than waiting for resolution, but must provide concomitant anti-inflammatory prophylaxis 1

Prophylaxis When Initiating ULT

• Strongly recommended: provide anti-inflammatory prophylaxis for 3-6 months when starting urate-lowering therapy to prevent treatment-induced flares 1
• First-line prophylaxis: low-dose colchicine 0.5-0.6 mg once or twice daily 1
• Alternative: low-dose NSAIDs (naproxen 250 mg twice daily) or low-dose corticosteroids if colchicine/NSAIDs contraindicated 2, 4

Adjunctive Measures

• Topical ice application is conditionally recommended as adjuvant therapy 1

Critical Pitfalls to Avoid

• Delaying treatment initiation is the most critical error—early intervention is the most important determinant of success, regardless of which agent is chosen 1, 2
• Never use colchicine in patients with severe renal impairment or on strong CYP3A4/P-glycoprotein inhibitors—fatal toxicity can occur 1, 3
• Never prescribe NSAIDs in elderly patients with renal impairment, heart failure, or peptic ulcer disease 1
• Never stop urate-lowering therapy during an acute flare—this worsens the flare and complicates long-term management 1, 2
• Never treat a gout flare with colchicine in patients already receiving prophylactic colchicine plus strong CYP3A4 inhibitors 3