What is the recommended treatment for an acute gout flare?

Treatment of Acute Gout Flare

For an acute gout flare, initiate treatment within 12-24 hours with first-line options including low-dose colchicine (1.2 mg followed by 0.6 mg one hour later), full-dose NSAIDs, or oral corticosteroids (30-35 mg prednisone daily for 3-5 days), selecting based on contraindications and comorbidities rather than perceived efficacy differences. 1, 2

Timing is Critical

• Treatment must be initiated within 24 hours of symptom onset for optimal outcomes, with colchicine being most effective when started within 12 hours 3, 1
• Educate patients to use a "pill in the pocket" approach, self-medicating at the first warning symptoms 1
• Colchicine effectiveness drops significantly if started more than 36 hours after symptom onset 4, 2

First-Line Treatment Selection Algorithm

Colchicine (Preferred if started early)

• Dosing: 1.2 mg at first sign of flare, followed by 0.6 mg one hour later (total 1.8 mg over one hour) 1, 2
• This low-dose regimen is equally effective as high-dose colchicine (4.8 mg) but with significantly fewer gastrointestinal side effects 4
• Continue 0.6 mg once or twice daily until attack resolves 4, 2

Absolute contraindications for colchicine:

• Severe renal impairment (GFR <30 mL/min) 1, 2
• Concurrent use of strong CYP3A4 inhibitors (clarithromycin, erythromycin, ketoconazole) or P-glycoprotein inhibitors (cyclosporine) 1, 2
• Combined renal/hepatic impairment with these drug interactions 4

Dose adjustments:

• Mild-moderate renal impairment (GFR 30-80 mL/min): No adjustment needed but monitor closely 2
• Dialysis patients: 0.6 mg single dose, repeat no more than once every 2 weeks 2

NSAIDs (Preferred if contraindications to colchicine)

• Use full FDA-approved anti-inflammatory doses until attack completely resolves 3, 1
• FDA-approved options: naproxen, indomethacin, sulindac 4
• No evidence suggests one NSAID is superior to another 4
• Add proton pump inhibitor in patients with GI risk factors 1

Contraindications for NSAIDs:

• Renal disease, heart failure, cirrhosis 1, 5
• Active peptic ulcer disease 5
• Significant cardiovascular disease 1

Corticosteroids (Preferred in renal impairment or cardiovascular disease)

• Oral: Prednisone 30-35 mg daily for 3-5 days 1, 5
• Intra-articular injection: Highly effective for monoarticular gout 1, 5
• Corticosteroids are safer than NSAIDs or colchicine in patients with renal impairment 1, 5
• Safer than NSAIDs in elderly patients 1

Adverse effects to monitor:

• Dysphoria, mood disorders, elevated blood glucose, fluid retention 1

Treatment Based on Severity

Mild-Moderate Pain (1-2 joints involved)

• Monotherapy with any first-line agent is appropriate 1
• Select based on contraindications and patient comorbidities 1

Severe Pain (≥7/10) or Polyarticular Involvement (≥3 joints)

• Combination therapy is more effective 3, 5
• Options include:
  • Colchicine + NSAIDs 4, 5
  • Oral corticosteroids + colchicine 5
  • Intra-articular steroids + any other modality 5
• Avoid combining NSAIDs with systemic corticosteroids due to synergistic GI toxicity 1, 4

Special Populations

Renal Impairment

• Corticosteroids are the safest option 1, 5
• Avoid colchicine if GFR <30 mL/min 1, 2
• NSAIDs should be avoided 1

Cardiovascular Disease

• Oral corticosteroids preferred over NSAIDs 1
• Avoid NSAIDs in heart failure 5

NPO (Nil Per Os) Patients

• 1-2 affected joints: Intra-articular corticosteroid injection 5
• Multiple joints: IV/IM methylprednisolone (0.5-2.0 mg/kg) or subcutaneous ACTH (25-40 IU) 5

Elderly Patients

• Corticosteroids preferred due to lower risk of serious adverse effects compared to NSAIDs 1
• Dose selection should be cautious 2

Management of Inadequate Response

Define inadequate response as:

• <20% improvement in pain within 24 hours, OR
• <50% improvement after 24 hours 3, 5

If inadequate response:

• Switch to another monotherapy agent 5
• Add a second recommended agent (if not already on combination therapy) 5
• For severe refractory attacks: Consider IL-1 inhibitors (canakinumab, anakinra) - though off-label 3, 5

Critical Management Principles

• Continue established urate-lowering therapy without interruption during acute attacks 3, 5
• Topical ice application provides additional pain relief 5
• If treating a flare while on prophylactic colchicine: Give 1.2 mg followed by 0.6 mg one hour later, wait 12 hours, then resume prophylactic dose 2

Common Pitfalls to Avoid

• Delaying treatment beyond 24 hours significantly reduces effectiveness 1, 5
• Using high-dose colchicine regimens (>1.8 mg in first hour) provides no additional benefit but substantially increases GI toxicity 4
• The obsolete regimen of colchicine 0.5 mg every 2 hours until relief or toxicity causes severe diarrhea in most patients 4
• Discontinuing urate-lowering therapy during acute flares leads to prolonged disease activity 5
• Missing critical drug interactions with colchicine (CYP3A4/P-gp inhibitors) can cause fatal toxicity 1, 2
• Combining NSAIDs with systemic corticosteroids increases GI bleeding risk 1, 4