Treatment of Acute Gout Flares
For an acute gout flare, immediately initiate treatment with 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)—all three are equally effective first-line options, and the single most critical factor for success is early initiation, not which agent you choose. 1
First-Line Treatment Selection
The American College of Rheumatology strongly recommends three equally effective first-line agents 1:
Colchicine: Most effective when started within 12 hours of symptom onset 1, 2. The FDA-approved dosing is 1.2 mg (two tablets) at first sign of flare, followed by 0.6 mg (one tablet) one hour later, with a maximum of 1.8 mg over one hour 3. Low-dose colchicine is strongly preferred over high-dose regimens due to similar efficacy with fewer adverse effects 1.
NSAIDs: Use full FDA-approved anti-inflammatory doses (e.g., naproxen, indomethacin, sulindac) 2. These are as effective as colchicine when started promptly 2.
Oral corticosteroids: Prednisone 30-35 mg daily for 3-5 days (or 0.5 mg/kg per day for 5-10 days then stop, or taper over 7-10 days) 1, 2. Corticosteroids are the safest option for patients with renal impairment, cardiovascular disease, gastrointestinal contraindications to NSAIDs, uncontrolled hypertension, or heart failure 1.
Treatment Selection Algorithm
Early initiation is the most important determinant of success—not which agent is chosen 1, 2. Patients should be educated to self-medicate at the first warning symptoms using a "pill in the pocket" approach 2.
For Monoarticular or Oligoarticular Flares:
- Intra-articular corticosteroid injection is highly effective and preferred for flares involving 1-2 large joints 1.
For Patients Unable to Take Oral Medications:
- Parenteral glucocorticoids (intramuscular, intravenous, or intra-articular) are strongly recommended over IL-1 inhibitors or ACTH 1, 2.
For Severe or Polyarticular Attacks:
- Combination therapy (colchicine with NSAIDs, or either agent with corticosteroids) may be more effective than monotherapy 2.
Critical Contraindications and Dose Adjustments
Colchicine Contraindications:
- Avoid colchicine in patients with severe renal impairment or those on strong CYP3A4/P-glycoprotein inhibitors (e.g., clarithromycin, cyclosporine, ritonavir, ketoconazole) due to risk of fatal toxicity 1, 2, 3.
Renal Impairment Dosing for Colchicine:
- Mild-to-moderate impairment (CrCl 30-80 mL/min): No dose adjustment needed, but monitor closely 3.
- Severe impairment (CrCl <30 mL/min): Treatment course should not be repeated more than once every two weeks 3.
- Dialysis patients: Single dose of 0.6 mg only, not to be repeated more than once every two weeks 3.
NSAID Contraindications:
- Avoid NSAIDs in patients with peptic ulcer disease, renal failure, uncontrolled hypertension, cardiac failure, or severe renal impairment 1, 2. Consider adding a proton pump inhibitor for gastrointestinal protection 2.
Special Populations and Alternative Therapies
IL-1 Inhibitors:
- Canakinumab (150 mg subcutaneously) is conditionally recommended for patients with contraindications to all first-line agents and frequent flares 1.
- Current infection is an absolute contraindication to IL-1 blockers 1, 2.
Management of Urate-Lowering Therapy During Flares
Patients already on urate-lowering therapy (allopurinol, febuxostat) should continue it during the acute flare—interrupting it can worsen the flare and complicate long-term management 1, 2. The American College of Rheumatology conditionally recommends starting urate-lowering therapy during a flare with appropriate anti-inflammatory coverage 1.
Prophylaxis When Initiating Urate-Lowering Therapy:
- Concomitant anti-inflammatory prophylaxis is strongly recommended for 3-6 months when starting urate-lowering therapy to prevent treatment-induced flares 1, 2.
- Low-dose colchicine (0.5-0.6 mg once or twice daily) is the first-line prophylaxis 1, 2.
Adjunctive Measures
- Topical ice application is conditionally recommended as adjuvant therapy 1.
Critical Pitfalls to Avoid
- Delaying treatment initiation: Early intervention is the most important determinant of success 1, 2.
- Using colchicine with strong CYP3A4/P-glycoprotein inhibitors or in severe renal impairment: Can result in fatal toxicity 1, 3.
- Prescribing NSAIDs in elderly patients with renal impairment, heart failure, or peptic ulcer disease 1.
- Stopping urate-lowering therapy during acute flare: Worsens the flare and complicates long-term management 1, 2.
- Treating gout flares with colchicine in patients already receiving prophylactic colchicine and CYP3A4 inhibitors: Not recommended 3.