What is the recommended treatment for a patient experiencing a gout flare?

Treatment of Acute Gout Flare

For a patient experiencing an acute gout flare, initiate treatment immediately 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). 1

First-Line Treatment Selection Algorithm

The choice among the three first-line agents should be driven by patient-specific factors:

Colchicine is preferred when:

• Treatment can be initiated within 12 hours of symptom onset (maximum effectiveness window) 2, 3
• Patient has no severe renal impairment (CrCl >30 mL/min) 3
• Patient is not taking strong CYP3A4 or P-glycoprotein inhibitors (clarithromycin, cyclosporine, ritonavir, ketoconazole) 2, 4
• FDA-approved dosing: 1.2 mg immediately, followed by 0.6 mg one hour later (maximum 1.8 mg over one hour) 1, 3
• Strongly use low-dose colchicine over high-dose colchicine—similar efficacy with significantly fewer adverse effects 1

Oral corticosteroids are preferred when:

• Patient has renal impairment, cardiovascular disease, or heart failure (safer than NSAIDs) 2, 5
• Patient has peptic ulcer disease or gastrointestinal contraindications to NSAIDs 2
• Flare involves significant systemic inflammation (elevated CRP, leukocytosis) 5, 4
• Dosing: Prednisone 30-35 mg daily for 3-5 days, or 0.5 mg/kg/day for 5-10 days then stop 5, 4

NSAIDs are preferred when:

• No contraindications exist (avoid in renal failure, uncontrolled hypertension, cardiac failure, peptic ulcer disease) 2
• Must be used at full FDA-approved anti-inflammatory doses 1, 2

Intra-articular corticosteroid injection is preferred when:

• Only 1-2 large joints are affected (monoarticular or oligoarticular flares) 2, 5
• This is highly effective and avoids systemic side effects 2

Critical Timing Principle

The single most important factor for treatment success is early initiation, not which specific agent is chosen. 2 Delaying treatment significantly reduces effectiveness regardless of the agent selected. 2, 4

Parenteral Options for Patients Unable to Take Oral Medications

For patients who cannot take oral medications, use parenteral glucocorticoids (intramuscular, intravenous, or intra-articular) over IL-1 inhibitors or ACTH. 1 This is a strong recommendation based on efficacy, safety, and cost considerations. 1

Second-Line Treatment

IL-1 inhibitors (canakinumab 150 mg subcutaneously) are conditionally recommended only when colchicine, NSAIDs, and corticosteroids are all ineffective, poorly tolerated, or contraindicated. 1 Current infection is an absolute contraindication to IL-1 blockers. 2

Adjunctive Measures

• Topical ice application is conditionally recommended as adjuvant therapy for additional symptom relief 1

Management of Urate-Lowering Therapy During Flare

Continue urate-lowering therapy (allopurinol, febuxostat) during the acute flare—do not stop it. 2, 4 Interrupting urate-lowering therapy can worsen the flare and complicate long-term management. 2 You may even conditionally start urate-lowering therapy during the flare with appropriate anti-inflammatory coverage. 2, 4

Combination Therapy for Severe Flares

For particularly severe acute gout involving multiple joints, combination therapy is appropriate: 4

• Oral corticosteroids plus colchicine 5, 4
• Intra-articular steroids with any other modality 4
• Colchicine plus NSAIDs 4

Critical Pitfalls to Avoid

Fatal Drug Interactions with Colchicine:

• Never use colchicine in patients with severe renal impairment (CrCl <30 mL/min) or on strong CYP3A4/P-glycoprotein inhibitors—this can cause fatal toxicity 2, 4, 3
• For patients on moderate CYP3A4 inhibitors, reduce colchicine dose to 0.6 mg × 1 dose, followed by 0.3 mg one hour later, not to be repeated for at least 3 days 3

NSAID Contraindications:

• Do not prescribe NSAIDs in elderly patients with renal impairment, heart failure, or peptic ulcer disease 2

Treatment Timing Error:

• Delaying treatment initiation is the most critical error—early intervention determines success more than agent selection 2

Urate-Lowering Therapy Mismanagement:

• Never stop urate-lowering therapy during acute flares—this worsens the flare 2, 4

Dose Adjustments for Renal Impairment

For colchicine in patients with severe renal impairment (CrCl <30 mL/min): 3

• Treatment course should not be repeated more than once every two weeks 3
• For dialysis patients: single dose of 0.6 mg only, not to be repeated more than once every two weeks 3