What is the treatment for a patient having an active gout flare-up?

Treatment of Acute Gout Flares

For an active gout flare, immediately initiate treatment with one of three equally effective first-line agents: 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)—the single most critical factor for success is early initiation within 12 hours of symptom onset, not which agent you choose. 1

First-Line Treatment Selection Algorithm

The choice among the three first-line agents depends on patient-specific contraindications:

Colchicine (Preferred if no contraindications)

• Maximum dose: 1.8 mg total over one hour (1.2 mg, then 0.6 mg one hour later) 1, 2
• Most effective when started within 12 hours of symptom onset 1
• Low-dose colchicine (1.8 mg total) has similar efficacy to high-dose regimens but with significantly fewer adverse effects 1, 2

Critical contraindications to colchicine:

• Severe renal impairment (CrCl <30 mL/min): reduce to single 0.6 mg dose, do not repeat for 2 weeks 2
• Patients on dialysis: single 0.6 mg dose only, not repeated more than once every 2 weeks 2
• Concurrent use of strong CYP3A4 or P-glycoprotein inhibitors (can cause fatal toxicity) 3, 1

Oral Corticosteroids (Safest for multiple comorbidities)

• Prednisone 30-35 mg daily for 3-5 days 1
• Preferred agent for patients with: renal impairment, cardiovascular disease, uncontrolled hypertension, heart failure, peptic ulcer disease, or any gastrointestinal contraindication to NSAIDs 1, 4
• Similar efficacy to NSAIDs but safer profile in elderly and those with multiple comorbidities 5

NSAIDs (Avoid in elderly and those with organ dysfunction)

• Must be used at full FDA-approved anti-inflammatory doses 1
• Absolute contraindications: peptic ulcer disease, renal failure (CrCl <30 mL/min), uncontrolled hypertension, cardiac failure 1
• Should be avoided entirely in patients with cardiovascular disease or heart failure due to increased risk of adverse cardiovascular events 4

Special Situations

Monoarticular or Oligoarticular Flares (1-2 large joints)

• Intra-articular corticosteroid injection is highly effective and preferred 1
• Provides rapid relief with minimal systemic effects

Patients Unable to Take Oral Medications

• Parenteral glucocorticoids are strongly recommended over IL-1 inhibitors or ACTH 1
• More cost-effective and readily available

Patients with Contraindications to All First-Line Agents

• IL-1 inhibitors (canakinumab 150 mg subcutaneously) are conditionally recommended for patients with frequent flares 1, 5
• Absolute contraindication: current active infection 1
• Limited by high cost and modest clinical benefit relative to first-line agents 4

Critical Management Principles

Continue Urate-Lowering Therapy During Flares

• If the patient is already on allopurinol or other urate-lowering therapy, continue it without interruption during the acute flare 1, 6
• Stopping urate-lowering therapy worsens the flare and complicates long-term management 1, 6
• You may even conditionally start urate-lowering therapy during the flare with appropriate anti-inflammatory coverage 1, 6

Prophylaxis When Initiating Urate-Lowering Therapy

• Strongly recommended: concomitant anti-inflammatory prophylaxis for 3-6 months when starting urate-lowering therapy 3, 1, 7
• First-line prophylaxis: low-dose colchicine 0.5-0.6 mg once or twice daily 3, 1, 7
• Alternative: low-dose NSAIDs (naproxen 250 mg twice daily) if colchicine contraindicated 3, 7
• Prophylaxis prevents treatment-induced flares from crystal dispersion during initial urate deposit dissolution 3, 7

Adjunctive Measures

• Topical ice application is conditionally recommended as adjuvant therapy 1, 8
• Rest of the inflamed joint 8

Critical Pitfalls to Avoid

1. Delaying treatment initiation is the most critical error—early intervention within 12 hours is the most important determinant of success, not the choice of agent 1, 8

2. Never use colchicine in patients with severe renal impairment (CrCl <30 mL/min) at standard doses or in those on strong CYP3A4/P-glycoprotein inhibitors—this can result in fatal toxicity 3, 1, 2

3. Never prescribe NSAIDs in elderly patients with renal impairment, heart failure, cardiovascular disease, or peptic ulcer disease—use corticosteroids instead 1, 4

4. Never stop urate-lowering therapy during an acute flare—this worsens the flare and complicates long-term management 1, 6

5. Avoid high-dose colchicine regimens (>1.8 mg total)—they have similar efficacy to low-dose but significantly higher adverse effects 1, 2