What is the recommended initial treatment for an acute flare of gouty arthritis?

Management of Acute Gouty Arthritis Flare

Immediate Treatment Initiation

Start pharmacologic therapy within 24 hours of symptom onset using NSAIDs, colchicine, or corticosteroids as first-line monotherapy, and continue treatment at full dose until complete symptom resolution. 1, 2, 3

Treatment effectiveness is directly tied to how quickly therapy begins—delays beyond 24 hours significantly reduce efficacy. 2, 3 Colchicine specifically loses effectiveness if not started within 36 hours of flare onset. 1, 2

First-Line Treatment Options

For Mild-to-Moderate Attacks (Monoarticular or Limited Joint Involvement)

Choose one of the following based on contraindications and patient-specific factors:

NSAIDs (Preferred for most patients):

• Use full FDA-approved doses until complete resolution 1, 2
• Indomethacin 50 mg three times daily until pain is tolerable, then rapidly taper 4
• Naproxen or sulindac are also FDA-approved options 1
• Add proton pump inhibitor if gastrointestinal risk factors present 1
• Avoid in severe renal impairment 1

Colchicine (Only if started within 36 hours):

• Loading dose: 1.2 mg (two 0.6 mg tablets) at first sign of flare 1, 2, 5
• Follow with 0.6 mg one hour later 1, 2, 5
• Maximum dose: 1.8 mg over one hour period 5
• Critical contraindications: Do not use with strong CYP3A4 or P-glycoprotein inhibitors (clarithromycin, cyclosporine, ritonavir, ketoconazole) due to fatal toxicity risk 1, 5
• Avoid in severe renal impairment 1

Corticosteroids:

• Oral prednisone 30-35 mg daily for 3-5 days, then stop (no taper needed for short course) 1, 2
• Alternative: Prednisone 0.5 mg/kg daily for 5-10 days 1
• For 1-2 large joints: Intra-articular triamcinolone acetonide 40-60 mg after arthrocentesis 1, 6
• Intramuscular option: Triamcinolone acetonide 60 mg 1

For Severe or Polyarticular Attacks

Use combination therapy with two agents at full doses: 2

• Recommended combinations: Colchicine + NSAIDs, or Oral corticosteroids + Colchicine 2
• Never combine NSAIDs with systemic corticosteroids due to synergistic gastrointestinal toxicity risk 6, 3

Critical Management Principles

Do not stop ongoing urate-lowering therapy (allopurinol, febuxostat) during the acute attack—continue without interruption. 1, 2, 3 Stopping urate-lowering therapy worsens and prolongs the attack. 3

Educate patients to self-initiate treatment at the first warning symptoms without waiting for physician consultation. 1, 2 This patient empowerment strategy ensures treatment begins within the critical 24-hour window. 2

Special Populations

Renal Impairment:

• First-line: Corticosteroids (oral prednisone 30-35 mg daily or intra-articular injection) 6
• Avoid NSAIDs and colchicine in severe renal impairment 1
• If colchicine must be used with moderate renal impairment, reduce dose appropriately 1, 5

Patients on Strong CYP3A4 Inhibitors:

• If taking clarithromycin, cyclosporine, or other strong inhibitors within past 14 days, reduce colchicine dose to 0.6 mg × 1 dose, followed by 0.3 mg one hour later, with no repeat for 3 days 5
• Better option: Choose NSAID or corticosteroid instead 1

Treatment Duration

Continue therapy at full dose until complete resolution of symptoms, typically 5-14 days depending on agent and severity. 2 For indomethacin specifically, definite pain relief occurs within 2-4 hours, tenderness/heat subside in 24-36 hours, and swelling resolves in 3-5 days. 4

Prophylaxis When Initiating Urate-Lowering Therapy

Start prophylaxis with or just prior to initiating urate-lowering therapy: 1, 2

• First-line: Colchicine 0.6 mg once or twice daily 1, 2, 3
• Alternative: Low-dose NSAID (naproxen 250 mg twice daily) with PPI if indicated 1, 3
• Duration: Continue for at least 6 months, or 3 months after achieving target uric acid with no tophi 1, 2
• This prevents the increased flare frequency that occurs when mobilizing urate from tissue deposits 1, 7, 8

Common Pitfalls to Avoid

• Delaying treatment beyond 24 hours reduces effectiveness dramatically 2, 3
• Stopping urate-lowering therapy during acute attack worsens outcomes 1, 3
• Using colchicine with strong CYP3A4 inhibitors can cause fatal toxicity 1, 5
• Failing to provide prophylaxis when starting urate-lowering therapy leads to increased flare frequency 2, 3
• Combining NSAIDs with systemic corticosteroids increases GI bleeding risk 6, 3
• Using colchicine or NSAIDs in severe renal impairment risks toxicity 1