What is the recommended management for a gout flare?

Management of Acute Gout Flare

For an acute gout flare, immediately initiate treatment with one of three equally effective first-line agents: colchicine (1.2 mg followed by 0.6 mg one hour later), NSAIDs at full anti-inflammatory doses, or oral corticosteroids (prednisone 30-35 mg daily for 3-5 days), with the choice determined by patient comorbidities rather than agent superiority. 1, 2

Critical Principle: Early Treatment Initiation

• The single most important factor for treatment success is early initiation, not which agent is chosen 1
• Treatment should begin within 12 hours of symptom onset for optimal effectiveness 1, 2
• Consider a "pill in the pocket" approach for informed patients to self-medicate at first warning symptoms 2

First-Line Treatment Selection Algorithm

Colchicine

• Dosing: 1.2 mg (two tablets) at first sign of flare, followed by 0.6 mg (one tablet) one hour later; maximum 1.8 mg over one hour 3
• Most effective when initiated within 12 hours of symptom onset 1, 2
• Low-dose colchicine is strongly recommended over high-dose due to similar efficacy with fewer adverse effects 1, 2
• Absolute contraindications:
  • Severe renal impairment (GFR <30 mL/min) 1, 2
  • Concurrent use of strong CYP3A4 or P-glycoprotein inhibitors (clarithromycin, cyclosporine, ritonavir, ketoconazole, itraconazole) due to risk of fatal toxicity 1, 2, 3

NSAIDs

• Use full FDA-approved anti-inflammatory doses 1, 2
• Contraindications: peptic ulcer disease, renal failure, uncontrolled hypertension, cardiac failure, elderly patients with renal impairment 1
• NSAIDs carry cardiovascular risks and should be avoided in patients with cardiovascular disease 2

Oral Corticosteroids (Preferred in Many Clinical Scenarios)

• Prednisone 30-35 mg daily for 5 days (fixed-dose regimen, no taper needed for short course) 1, 2
• 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 over 7-10 days 2
• Corticosteroids are the safest first-line option for patients with:
  • Renal impairment (GFR <30 mL/min) 1, 2
  • Cardiovascular disease 1, 2
  • Gastrointestinal contraindications to NSAIDs 1
  • Uncontrolled hypertension 1
  • Heart failure 1
• Corticosteroids are as effective as NSAIDs with generally fewer adverse effects and lower cost 2
• Monitor for dysphoria, mood disorders, elevated blood glucose, and fluid retention 2
• Contraindicated in systemic fungal infections 2

Alternative Routes and Special Situations

Intra-articular Corticosteroid Injection

• Highly effective and preferred for monoarticular or oligoarticular flares (1-2 large joints) 1, 2
• Can be combined with any other treatment modality 2

Parenteral Glucocorticoids

• Strongly recommended over IL-1 inhibitors or ACTH for patients unable to take oral medications 1
• Intramuscular corticosteroids are equally effective when IV access is problematic 2

Combination Therapy for Severe Flares

• For severe acute gout with multiple joint involvement, combination therapy is appropriate 2
• Acceptable combinations: oral corticosteroids + colchicine, intra-articular steroids + any other modality, colchicine + NSAIDs 2

IL-1 Inhibitors (Canakinumab)

• Conditionally recommended only for patients with contraindications to all first-line agents and frequent flares 1, 2
• Dosing: 150 mg subcutaneously, with at least 12 weeks between doses 2
• Current infection is an absolute contraindication 1, 2

Management of Urate-Lowering Therapy During Acute Flare

• Continue urate-lowering therapy during acute flare; do not interrupt it 1, 2
• Stopping urate-lowering therapy can worsen the flare and complicate long-term management 1
• Starting urate-lowering therapy during a flare (with appropriate anti-inflammatory coverage) is conditionally recommended and does not significantly prolong flare duration 1, 2
• When initiating urate-lowering therapy, provide concomitant anti-inflammatory prophylaxis for 3-6 months to prevent treatment-induced flares 1, 2
• First-line prophylaxis: low-dose colchicine 0.5-0.6 mg once or twice daily 1
• Second-line prophylaxis: low-dose prednisone <10 mg/day if colchicine/NSAIDs contraindicated 2

Adjunctive Measures

• Topical ice application is conditionally recommended as adjuvant therapy 1, 2
• Rest of the inflamed joint 4

Critical Pitfalls to Avoid

• Delaying treatment initiation is the most critical error—early intervention is the most important determinant of success 1
• Never use colchicine in severe renal impairment (GFR <30 mL/min) or with strong CYP3A4/P-glycoprotein inhibitors—this can result in fatal toxicity 1, 2
• Avoid NSAIDs in elderly patients with renal impairment, heart failure, or peptic ulcer disease 1
• Do not stop urate-lowering therapy during acute flare—this worsens the flare and complicates long-term management 1
• Do not use colchicine as an analgesic for non-gout pain 3
• The safety and efficacy of repeat colchicine treatment for gout flares has not been established; wait at least 3 days before repeating treatment dose 3