What are the treatment options for acute gout (gouty arthritis) flare?

From the Guidelines

For a gout flare, start treatment as soon as possible with colchicine at a loading dose of 1 mg followed 1 hour later by 0.5 mg on day 1, or an NSAID (plus proton pump inhibitors if appropriate), or oral corticosteroid (30–35 mg/day of equivalent prednisolone for 3–5 days) as recommended by the 2020 American College of Rheumatology guideline for the management of gout 1.

Treatment Options

• Colchicine: 1 mg initially, followed by 0.5 mg 1 hour later, then 0.5 mg once or twice daily until the flare resolves
• NSAIDs: such as naproxen (500mg twice daily) or indomethacin (50mg three times daily) for 3-5 days
• Oral corticosteroids: such as prednisone at 30-40mg daily for 3-5 days with a taper

Important Considerations

• Rest the affected joint and apply ice for 20 minutes several times daily
• Stay well-hydrated and avoid alcohol and purine-rich foods (red meat, seafood, organ meats) during the flare
• Continue any prescribed urate-lowering therapy like allopurinol during the flare, as stopping it can worsen symptoms
• The choice of drug(s) should be based on the presence of contraindications, the patient’s previous experience with treatments, time of initiation after flare onset, and the number and type of joint(s) involved, as recommended by the 2016 updated EULAR evidence-based recommendations for the management of gout 1

Lifestyle Modifications

• Weight loss, if appropriate, and avoidance of alcohol (especially beer and spirits) and sugar-sweetened drinks
• Encourage low-fat dairy products and regular exercise
• Avoid heavy meals and excessive intake of meat and seafood, as recommended by the 2016 updated EULAR evidence-based recommendations for the management of gout 1

From the FDA Drug Label

The recommended dose of Colchicine Tablets, USP for treatment of a gout flare is 1.2 mg (two tablets) at the first sign of the flare followed by 0.6 mg (one tablet) one hour later. The maximum recommended dose for treatment of gout flares is 1.8 mg over a one hour period. The treatment for gout flare is 1.2 mg of colchicine at the first sign of the flare, followed by 0.6 mg one hour later, with a maximum dose of 1.8 mg over one hour 2.

• The dose may be repeated, but no earlier than 3 days if certain interacting drugs are used, as indicated in the table for dose adjustments for coadministration with interacting drugs 2.
• Colchicine Tablets, USP may be administered for treatment of a gout flare during prophylaxis at doses not to exceed 1.2 mg (two tablets) at the first sign of the flare followed by 0.6 mg (one tablet) one hour later 2.
• After treatment of a gout flare during prophylaxis, wait 12 hours and then resume the prophylactic dose 2.

From the Research

Treatment Options for Gout Flares

• Nonsteroidal anti-inflammatory drugs (NSAIDs), colchicine, and glucocorticoids are first-line agents for treating gout flares 3, 4, 5, 6, 7
• IL-1β antagonists, such as canakinumab, are highly effective for arresting flares but are often used as salvage therapies due to their cost-effectiveness 3, 7
• Corticosteroids have similar efficacy to therapeutic doses of NSAIDs, with studies supporting oral and intramuscular use 7
• Oral colchicine is effective, with low-dose colchicine demonstrating a comparable tolerability profile as placebo and a significantly lower side effect profile to high-dose colchicine 7

Urate-Lowering Therapy

• Allopurinol is an agent of first choice for urate-lowering therapy, but screening for HLA*B58:01 mutation is recommended in Southeast Asian and Black populations to decrease the occurrence of allopurinol hypersensitivity syndrome 3
• Febuxostat is another efficacious urate-lowering therapy, but has received a U.S. FDA black box warning for cardiovascular safety 3, 4
• Novel uricosurics, such as verinurad and arhalofenate, are a class for continued drug development 3
• Pegloticase is effective for patients with recalcitrant gout, but its immunogenicity significantly threatens the achievement of sustained urate lowering responses 3, 4

Prevention and Management

• Comprehensive patient education and counseling is an important component of the treatment of patients with gout 5
• Regular laboratory follow-up is necessary to monitor serum uric acid levels and adjust treatment as needed 5
• Prophylaxis of acute gout with NSAIDs, colchicine, or corticosteroids is universally recommended when initiating any urate-lowering therapy in order to prevent acute gouty arthritis for a period of at least 6 months 6