What is the treatment for acute gout flare?

Treatment of Acute Gout Flare

Start treatment immediately with corticosteroids, NSAIDs, or colchicine—the single most critical factor for success is early initiation within 12-24 hours of symptom onset, not which agent you choose. 1, 2

First-Line Treatment Selection

Corticosteroids should be your first choice in most patients because they are equally effective, safer, and low-cost compared to alternatives. 3, 4 Specifically:

• Oral prednisone or prednisolone 30-35 mg daily for 3-5 days is the recommended regimen 3, 1
• Corticosteroids are particularly preferred in patients with renal impairment, cardiovascular disease, heart failure, uncontrolled hypertension, gastrointestinal contraindications to NSAIDs, or peptic ulcer disease 3, 1, 2
• Potential adverse effects include dysphoria, mood disorders, elevated blood glucose, immune suppression, and fluid retention 3, 1

Alternative First-Line Options

NSAIDs at full FDA-approved anti-inflammatory doses are equally effective when corticosteroids are contraindicated 3, 1:

• Options include naproxen, indomethacin, or other NSAIDs 1, 4
• Add a proton pump inhibitor in patients with gastrointestinal risk factors 3, 1
• Avoid NSAIDs in patients with renal disease (especially CrCl <30 mL/min), heart failure, cirrhosis, peptic ulcer disease, or uncontrolled hypertension 3, 1, 2
• Common adverse effects include dyspepsia and potential gastrointestinal perforations, ulcers, and bleeding 3

Colchicine is most effective when started within 12 hours of flare onset 3, 1:

• 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, 5
• Low-dose colchicine is as effective as high-dose with significantly fewer gastrointestinal side effects 3, 1, 2
• Fatal contraindications: severe renal impairment (CrCl <30 mL/min) and concomitant use of strong CYP3A4/P-glycoprotein inhibitors (clarithromycin, cyclosporine, ritonavir, ketoconazole, itraconazole) 3, 2, 5
• Common adverse effects include diarrhea, nausea, cramps, and vomiting 3

Treatment Algorithm Based on Clinical Scenario

For monoarticular or oligoarticular flares (1-2 large joints):

• Intra-articular corticosteroid injection is highly effective and preferred 3, 1, 2

For mild to moderate pain (≤6/10) with limited joint involvement:

• Monotherapy with any first-line agent (corticosteroids, NSAIDs, or colchicine) is appropriate 1, 4

For severe pain (≥7/10) or polyarticular involvement:

• Combination therapy is recommended 1, 4
• Effective combinations include colchicine plus NSAIDs, oral corticosteroids plus colchicine, or intra-articular steroids with any other modality 4
• Do not combine NSAIDs with systemic corticosteroids due to synergistic gastrointestinal toxicity 1

For patients unable to take oral medications:

• Parenteral glucocorticoids are strongly recommended over IL-1 inhibitors or ACTH 2

Special Populations

Renal impairment:

• Corticosteroids are the safest option 3, 1, 2, 4
• For colchicine treatment in severe renal impairment (CrCl <30 mL/min): single dose of 0.6 mg, repeat no more than once every two weeks 5
• For dialysis patients: single dose of 0.6 mg for treatment, repeat no more than once every two weeks 5
• Avoid NSAIDs in severe renal impairment 3, 1

Hepatic impairment:

• For mild to moderate impairment: no dose adjustment needed but monitor closely 5
• For severe impairment: treatment course should be repeated no more than once every two weeks 5

Elderly patients:

• Corticosteroids are preferred due to lower risk of serious adverse effects compared to NSAIDs 1

Critical Management Principles

Continue established urate-lowering therapy during the acute flare—stopping it will worsen the flare and complicate long-term management. 1, 2

If starting urate-lowering therapy during or after a flare, provide concomitant anti-inflammatory prophylaxis for 3-6 months to prevent treatment-induced flares 3, 1, 2:

• Low-dose colchicine 0.5-0.6 mg once or twice daily is first-line prophylaxis 3, 1, 2
• Alternative: low-dose NSAIDs if colchicine is contraindicated 3, 2

Adjunctive Measures

• Topical ice application to affected joints can provide additional pain relief 1, 2
• Rest the inflamed joint 6

Inadequate Response Management

If <20% pain improvement within 24 hours or <50% improvement after 24 hours:

• Switch to another monotherapy or add a second recommended agent 4
• For patients with contraindications to all first-line agents and frequent flares, consider IL-1 blockers (canakinumab 150 mg subcutaneously) 3, 2
• Current infection is an absolute contraindication to IL-1 blockers 3, 2

Common Pitfalls to Avoid

• Delaying treatment initiation is the most critical error—early intervention within 12-24 hours is the most important determinant of success 1, 2
• Never use colchicine in patients on strong CYP3A4/P-glycoprotein inhibitors—this can result in fatal toxicity 2, 5
• Never prescribe NSAIDs in elderly patients with renal impairment, heart failure, or peptic ulcer disease 2
• Never stop urate-lowering therapy during an acute flare 1, 2
• Never combine NSAIDs with systemic corticosteroids due to synergistic gastrointestinal toxicity 1