What is the recommended management for gout in flare?

Management of Acute Gout Flares

For acute gout flares, initiate treatment immediately with colchicine, NSAIDs, or oral corticosteroids—the choice of agent matters less than early initiation, which is the single most critical determinant of treatment success. 1, 2

First-Line Treatment Options (All Equally Effective)

The American College of Rheumatology strongly recommends three first-line agents for acute gout flares 1, 2:

• Colchicine: 1.2 mg (two tablets) at first sign of flare, followed by 0.6 mg (one tablet) one hour later; maximum dose 1.8 mg over one hour 3, 2

  • Most effective when started within 12 hours of symptom onset 2
  • Higher doses provide no additional benefit and increase adverse effects 2
  • Do NOT use traditional high-dose regimens—they cause marked side effects in 100% of patients 4

• NSAIDs: Full FDA-approved anti-inflammatory doses 1

  • No specific NSAID is superior to another; indomethacin has no advantage despite common practice 1
  • Contraindications: peptic ulcer disease, renal failure (CrCl <30 mL/min), uncontrolled hypertension, heart failure, cirrhosis 1, 2

• Oral corticosteroids: Prednisone/prednisolone 30-35 mg daily for 3-5 days 1, 2

  • Safest option for patients with renal impairment, cardiovascular disease, or gastrointestinal contraindications to NSAIDs 2
  • Particularly effective for flares with significant systemic inflammation 2

Treatment Selection Algorithm

For monoarticular or oligoarticular flares (1-2 large joints):

• Intra-articular corticosteroid injection is highly effective and preferred 1, 2
• Perform joint aspiration first to confirm diagnosis and remove inflammatory fluid 2

For polyarticular flares or inaccessible joints:

• If within 12 hours of symptom onset: colchicine 1.2 mg followed by 0.6 mg one hour later 2, 3
• If beyond 12 hours OR colchicine contraindicated: NSAIDs at full dose OR oral prednisone 30-35 mg daily for 3-5 days 2

For patients unable to take oral medications:

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

For refractory cases 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 2

Critical Management Principles During Flares

Continue urate-lowering therapy (ULT) during acute flares:

• Patients already on ULT should NOT stop it during a flare—interrupting therapy worsens the flare and complicates long-term management 2
• ULT can be conditionally started during a flare with appropriate anti-inflammatory coverage 2

Prophylaxis when initiating ULT:

• Strongly recommend concomitant anti-inflammatory prophylaxis for 3-6 months when starting ULT to prevent treatment-induced flares 2, 5
• Low-dose colchicine (0.5-0.6 mg once or twice daily) is first-line prophylaxis 2, 6
• Prophylaxis for 6 months provides greater benefit than 8 weeks, with no increase in adverse events 5

Dose Adjustments for Special Populations

Severe renal impairment (CrCl <30 mL/min):

• Colchicine for acute flare: 0.6 mg × 1 dose only; do not repeat for 2 weeks 3
• Avoid NSAIDs entirely 1, 2
• Oral corticosteroids are the safest option 2

Patients on dialysis:

• Colchicine: 0.6 mg × 1 dose; do not repeat for 2 weeks 3

Patients on strong CYP3A4 or P-glycoprotein inhibitors (clarithromycin, ritonavir, ketoconazole, etc.):

• Colchicine for acute flare: 0.6 mg × 1 dose, followed by 0.3 mg one hour later; do not repeat for 3 days 3
• Fatal colchicine toxicity has been reported with clarithromycin 3
• Avoid colchicine entirely in patients with severe renal impairment on these inhibitors 3

Adjunctive Measures

• Topical ice application is conditionally recommended as adjuvant therapy 2
• Rest of the inflamed joint 7

Critical Pitfalls to Avoid

• Delaying treatment initiation—early intervention is the most important determinant of success, not which agent is chosen 1, 2, 7
• Stopping ULT during acute flare—this worsens the flare and complicates long-term management 2
• Using colchicine in severe renal impairment or with strong CYP3A4/P-glycoprotein inhibitors—can result in fatal toxicity 2, 3
• Prescribing NSAIDs in elderly patients with renal impairment, heart failure, or peptic ulcer disease 2
• Using traditional high-dose colchicine regimens—no additional benefit with 100% incidence of side effects 4
• Providing inadequate prophylaxis duration when starting ULT—8 weeks is insufficient; 3-6 months is recommended 2, 5