What is the recommended medication for a gout flare-up?

Treatment of Acute Gout Flare

For an acute gout flare, immediately initiate treatment with one of three equally effective first-line options: 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 single most critical factor being early initiation within 12-24 hours of symptom onset, not which agent you choose. 1, 2, 3

First-Line Treatment Options

All three first-line agents are equally effective when started early 1, 2. Your choice should be based on patient-specific contraindications and comorbidities:

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) 1, 4
• Most effective when initiated within 12 hours of symptom onset 1, 3
• Low-dose regimen is as effective as high-dose with fewer gastrointestinal side effects 1, 3
• Critical contraindications: Severe renal impairment (GFR <30 mL/min) and concomitant use of strong CYP3A4 or P-glycoprotein inhibitors (cyclosporine, clarithromycin) due to risk of fatal toxicity 1, 3, 4

NSAIDs

• Use at full FDA-approved anti-inflammatory doses (e.g., naproxen 500 mg twice daily, indomethacin 50 mg three times daily) 1, 2
• Consider adding proton pump inhibitor for gastrointestinal protection 3
• Contraindications: Peptic ulcer disease, renal failure (GFR <30 mL/min), uncontrolled hypertension, heart failure, and cardiovascular disease 1, 2, 3

Oral Corticosteroids

• Preferred dosing: Prednisone 30-35 mg daily for 5 days (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
• Safest option for patients with: Severe renal impairment, cardiovascular disease, gastrointestinal contraindications to NSAIDs, or multiple comorbidities 1, 2, 3
• Monitor for mood changes, elevated blood glucose (especially in diabetics), and fluid retention 2

Treatment Selection Algorithm

Choose corticosteroids if:

• Renal impairment (GFR <30 mL/min) 1, 2, 3
• Cardiovascular disease or heart failure 1, 2
• History of peptic ulcer disease or gastrointestinal bleeding 1, 3
• Elderly patients with multiple comorbidities 3

Choose colchicine if:

• Symptom onset <12 hours 1, 3
• No renal impairment and not on CYP3A4/P-gp inhibitors 1, 3
• Patient preference based on prior experience 3

Choose NSAIDs if:

• Normal renal function 1, 3
• No cardiovascular disease or gastrointestinal contraindications 1, 3
• Patient preference based on prior experience 3

Special Situations

Monoarticular or Oligoarticular Flares (1-2 Large Joints)

• Intra-articular corticosteroid injection is highly effective and preferred 1, 2
• Can be combined with any other modality 2

Severe Polyarticular Flares

• Consider combination therapy: oral corticosteroids plus colchicine, or colchicine plus NSAIDs 2, 3
• Avoid combining NSAIDs with systemic corticosteroids due to synergistic gastrointestinal toxicity 3

Patients Unable to Take Oral Medications

• Parenteral glucocorticoids (intramuscular, intravenous, or intra-articular) are strongly recommended over IL-1 inhibitors or ACTH 1, 2

Refractory Cases with Contraindications to All First-Line Agents

• IL-1 inhibitor (canakinumab 150 mg subcutaneously) is conditionally recommended 1, 2
• Contraindication: Current infection 1, 2

Critical Management Principles

Continue Urate-Lowering Therapy During Flare

• If patient is already on urate-lowering therapy (allopurinol, febuxostat), continue it without interruption during the acute flare 5, 1, 3
• Stopping urate-lowering therapy can worsen the flare and complicate long-term management 1

Starting Urate-Lowering Therapy During Flare

• You can conditionally start urate-lowering therapy during the flare with appropriate anti-inflammatory coverage 5, 1, 3
• When initiating urate-lowering therapy, strongly recommend concomitant anti-inflammatory prophylaxis (low-dose colchicine 0.5-0.6 mg once or twice daily, NSAIDs, or prednisone <10 mg/day) for 3-6 months to prevent treatment-induced flares 5, 1, 2

Adjunctive Measures

• Topical ice application is conditionally recommended as adjuvant therapy 1, 3
• Rest the affected joint 6

Common Pitfalls to Avoid

• Delaying treatment initiation is the most critical pitfall—early intervention within 12-24 hours is the most important determinant of success, not which drug you choose 1, 3
• Using colchicine in severe renal impairment (GFR <30 mL/min) or with strong CYP3A4/P-glycoprotein inhibitors can cause fatal toxicity 1, 3, 4
• Prescribing NSAIDs in elderly patients with renal impairment, heart failure, or peptic ulcer disease 1, 3
• Stopping urate-lowering therapy during acute flare can worsen the flare and complicate long-term management 1, 3
• Failing to provide prophylaxis when initiating urate-lowering therapy leads to increased flare frequency 5, 7
• Using high-dose colchicine (>1.8 mg over one hour) provides no additional benefit and increases adverse effects 1, 4