What is the recommended treatment for a gout flare-up?

Treatment of Acute Gout Flare

Start treatment immediately with colchicine, NSAIDs, or oral corticosteroids—the speed of initiation matters far more than which agent you choose. 1

First-Line Treatment Options (All Equally Effective)

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

Colchicine

• Dosing: 1.2 mg (two tablets) at first sign of flare, followed by 0.6 mg (one tablet) one hour later 1, 2
• Maximum dose: 1.8 mg over one hour 1, 2
• Timing is critical: Most effective when started within 12 hours of symptom onset 1, 3
• Low-dose is preferred: Low-dose colchicine has similar efficacy to high-dose with fewer adverse effects 1

Critical contraindications for colchicine:

• Severe renal impairment (GFR <30 mL/min) 1, 3
• Concurrent use of strong CYP3A4 or P-glycoprotein inhibitors (clarithromycin, cyclosporine, ritonavir, ketoconazole, etc.) due to risk of fatal toxicity 1, 2

NSAIDs

• Dosing: Full FDA-approved anti-inflammatory doses 1, 3
• Contraindications: Peptic ulcer disease, renal failure, uncontrolled hypertension, cardiac failure 1
• Avoid in: Elderly patients with renal impairment, heart failure, or peptic ulcer disease 1

Oral Corticosteroids

• Dosing: Prednisone 30-35 mg daily for 3-5 days 1, 3
• Alternative regimen: 0.5 mg/kg/day for 5-10 days at full dose then stop, or 0.5 mg/kg/day for 2-5 days then taper for 7-10 days 3
• Preferred in: Patients with renal impairment, cardiovascular disease, gastrointestinal contraindications to NSAIDs, uncontrolled hypertension, or heart failure 1, 3
• Safer profile: Generally safer than NSAIDs with fewer adverse effects in high-risk populations 3

Treatment Selection Algorithm

Step 1: Assess contraindications

• If severe renal impairment, cardiovascular disease, or GI contraindications → Choose oral corticosteroids 1, 3
• If on strong CYP3A4 inhibitors or severe renal impairment → Avoid colchicine 1, 2
• If elderly with renal impairment, heart failure, or peptic ulcer disease → Avoid NSAIDs 1

Step 2: Consider joint involvement

• If monoarticular or oligoarticular (1-2 large joints) → Intra-articular corticosteroid injection is highly effective and preferred 1, 3

Step 3: Assess severity

• If severe attack with multiple joint involvement → Consider combination therapy (oral corticosteroids + colchicine, or colchicine + NSAIDs) 3

Step 4: If unable to take oral medications

• Use parenteral glucocorticoids (intramuscular, intravenous, or intra-articular) strongly recommended over IL-1 inhibitors or ACTH 1, 3

Special Situations

Patients Already on Urate-Lowering Therapy

• Continue urate-lowering therapy during the acute flare—do not stop it, as interrupting worsens the flare and complicates long-term management 1, 4
• Can treat the flare with standard doses while continuing prophylaxis 1, 4

Refractory Cases or Multiple Contraindications

• IL-1 inhibitors (canakinumab 150 mg subcutaneously) are conditionally recommended for patients with contraindications to all first-line agents and frequent flares 1, 3
• Absolute contraindication: Current infection 1, 3

Dose Adjustments for Renal Impairment (Colchicine)

• Mild-moderate impairment (CrCl 30-80 mL/min): No dose adjustment needed, but monitor closely 2
• Severe impairment (CrCl <30 mL/min): Use 0.6 mg × 1 dose, do not repeat more than once every two weeks 2
• Dialysis patients: Single dose of 0.6 mg, do not repeat more than once every two weeks 2

Adjunctive Measures

• Topical ice application is conditionally recommended as adjuvant therapy 1, 4
• Rest the inflamed joint 5

Critical Pitfalls to Avoid

1. Delaying treatment initiation is the most critical error—early intervention is the single most important determinant of success 1, 3

2. Using colchicine with strong CYP3A4/P-glycoprotein inhibitors can result in fatal toxicity 1, 2

3. Prescribing NSAIDs in elderly patients with renal impairment, heart failure, or peptic ulcer disease is dangerous 1

4. Stopping urate-lowering therapy during acute flare worsens the flare and complicates long-term management 1, 4

5. Using high-dose colchicine provides no additional benefit and increases adverse effects 1

Prophylaxis Considerations

If initiating urate-lowering therapy during or after the flare:

• Start concomitant anti-inflammatory prophylaxis for 3-6 months 1, 4
• First-line prophylaxis: Low-dose colchicine 0.5-0.6 mg once or twice daily 1, 4
• Alternative: Low-dose prednisone (<10 mg/day) if colchicine contraindicated 3