What is the recommended treatment for acute gouty arthritis in flare?

Treatment of Acute Gouty Arthritis Flare

For an acute gout flare, initiate treatment within 24 hours with first-line options: colchicine 1.2 mg followed by 0.6 mg one hour later, OR an NSAID at full anti-inflammatory dose (with PPI if appropriate), OR oral corticosteroids (30-35 mg prednisolone equivalent daily for 3-5 days), OR intra-articular corticosteroid injection for single joint involvement. 1, 2

Prescription Options by Clinical Scenario

For Monoarticular or Mild-Moderate Involvement

Colchicine Regimen (Most Effective Within 12 Hours of Onset):

• Day 1: Colchicine 1.2 mg (two 0.6 mg tablets) at first sign of flare, followed by 0.6 mg (one tablet) one hour later 1, 3
• Maximum dose: 1.8 mg over one hour period 3
• Do not repeat this treatment course for at least 3 days 3
• Critical contraindications: Avoid in severe renal impairment (CrCl <30 mL/min) and with strong CYP3A4/P-glycoprotein inhibitors (clarithromycin, cyclosporin) 1

NSAID Regimen:

• Naproxen: 500 mg twice daily for 5-7 days 1, 2
• Indomethacin: 50 mg three times daily for 5-7 days 2, 4
• Add PPI (omeprazole 20 mg daily or equivalent) for gastrointestinal protection 1
• Avoid in: Severe renal impairment, heart failure, active peptic ulcer disease, significant cardiovascular disease 1, 5

Corticosteroid Regimen:

• Prednisolone: 30-35 mg daily for 3-5 days, then stop (no taper needed for short course) 1, 5
• Alternative: Prednisone 0.5 mg/kg daily for 5-10 days at full dose then stop 5
• Preferred in: Patients with renal impairment, contraindications to NSAIDs/colchicine, or diabetes (though monitor glucose) 2, 5

Intra-articular Injection (Single Joint):

• Triamcinolone acetonide: 10-40 mg depending on joint size (large joints 40 mg, small joints 10-20 mg) 1, 2
• Highly effective for monoarticular involvement 1, 2

For Severe Pain (≥7/10) or Polyarticular Involvement

Combination therapy is appropriate: 1, 2, 5

• Colchicine 1.2 mg followed by 0.6 mg one hour later PLUS naproxen 500 mg twice daily 1, 2
• OR Prednisolone 30-35 mg daily PLUS colchicine 0.6 mg once or twice daily 1, 2
• OR Intra-articular corticosteroid injection PLUS any oral agent 1, 2
• Avoid combining NSAIDs with systemic corticosteroids due to synergistic gastrointestinal toxicity 1

For NPO (Nothing by Mouth) Patients

Parenteral Options: 1

• Intra-articular corticosteroid injection for 1-2 affected joints (dose based on joint size) 1, 2
• OR Intravenous/intramuscular methylprednisolone: 0.5-2.0 mg/kg initially, repeat as clinically indicated 1
• OR Subcutaneous ACTH: 25-40 IU initially, repeat doses as needed 1

Dose Adjustments for Renal Impairment

Colchicine Adjustments: 3

• Mild-moderate impairment (CrCl 30-80 mL/min): Standard dosing but monitor closely 3
• Severe impairment (CrCl <30 mL/min): Single dose 0.6 mg only; do not repeat for 2 weeks 3
• Dialysis patients: Single dose 0.6 mg; do not repeat for 2 weeks 3

NSAID Adjustments:

• Avoid entirely in severe renal impairment (CrCl <30 mL/min) 1

Corticosteroids:

• No dose adjustment needed; preferred option in renal impairment 2, 5

Dose Adjustments for Hepatic Impairment

Colchicine: 3

• Mild-moderate impairment: Standard dosing but monitor closely 3
• Severe impairment: Treatment course should not be repeated more than once every 2 weeks 3

Critical Drug Interactions with Colchicine

Absolute contraindications - do NOT prescribe colchicine with: 1, 3

• Strong CYP3A4 inhibitors: clarithromycin, ketoconazole, itraconazole, ritonavir, atazanavir 1, 3
• P-glycoprotein inhibitors: cyclosporin 1

If patient on these medications, reduce colchicine dose: 3

• For acute flare: 0.6 mg once, followed by 0.3 mg one hour later; do not repeat for 3 days 3

Management of Inadequate Response

Define inadequate response as: 1, 6

• <20% improvement in pain within 24 hours 1, 6
• OR <50% improvement in pain ≥24 hours after starting therapy 1, 6

If inadequate response: 1, 2

• First, reconsider diagnosis - confirm gout vs. other arthritis 1
• Switch to alternative monotherapy from options above 1, 2
• OR add second agent (combination therapy as outlined above) 1, 2
• For severe refractory cases: Consider IL-1 inhibitors (anakinra 100 mg subcutaneously daily for 3 days or canakinumab 150 mg subcutaneously), though these remain off-label 1, 2

Essential Principles for Optimal Outcomes

Timing is critical: 1, 2, 6

• Treatment must be initiated within 24 hours of symptom onset for maximum effectiveness 1, 2, 6
• Colchicine is most effective when started within 12 hours of flare onset 1

Patient education: 1, 2

• Educate patients to self-medicate at first warning symptoms ("pill in the pocket" approach) 1, 2
• Provide prescription in advance for early self-treatment 1

Continue urate-lowering therapy: 2, 6, 5

• Do NOT stop established allopurinol, febuxostat, or other urate-lowering therapy during acute flare 2, 6, 5
• Discontinuing urate-lowering therapy worsens and prolongs the attack 6

Common Pitfalls to Avoid

Dosing errors: 1, 2, 6

• Never use high-dose colchicine regimens (>1.8 mg in first hour) - they cause severe gastrointestinal toxicity without additional benefit 1, 2, 6
• Delaying treatment beyond 24 hours significantly reduces effectiveness of all agents 2, 6

Medication safety: 1

• Do not combine NSAIDs with systemic corticosteroids due to synergistic gastrointestinal bleeding risk 1
• Always check for colchicine drug interactions before prescribing 1, 3
• NSAIDs must be avoided in heart failure, severe renal disease, and active peptic ulcer disease 5

Treatment interruption: 2, 6

• Never discontinue urate-lowering therapy during acute flare 2, 6
• This common error worsens outcomes and prolongs attacks 6