What is the best treatment for a gout flare?

Treatment of Acute Gout Flare

For an acute gout flare, initiate treatment immediately 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 and contraindications. 1, 2

Critical Principle: Early Treatment is Key

• The single most important factor for treatment success is immediate initiation—not which specific agent you choose. 1
• Treatment should begin within 12 hours of symptom onset for optimal effectiveness, particularly with colchicine. 1, 2
• Consider providing patients with a "pill in the pocket" approach to self-medicate at the first warning symptoms. 2

First-Line Treatment Selection Algorithm

Option 1: Colchicine

• Dosing: 1.2 mg (two tablets) at first sign of flare, followed by 0.6 mg (one tablet) one hour later (total 1.8 mg over one hour). 1, 2, 3
• Low-dose colchicine (1.8 mg total) is strongly recommended over high-dose regimens due to similar efficacy with significantly fewer adverse effects. 1, 3
• Most effective when started within 12 hours of symptom onset. 1, 2

Absolute contraindications to colchicine:

• 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
• Current colchicine prophylaxis in patients with renal impairment. 3

Option 2: NSAIDs

• Use full FDA-approved anti-inflammatory doses. 1, 2
• All NSAIDs are equally effective when dosed appropriately. 1

Contraindications to NSAIDs:

• Peptic ulcer disease or active gastrointestinal bleeding. 1
• Severe renal failure (GFR <30 mL/min). 1, 2
• Uncontrolled hypertension. 1
• Heart failure. 1
• Cardiovascular disease (corticosteroids are safer). 2

Option 3: Oral Corticosteroids (Often the Safest Choice)

• Prednisone 30-35 mg daily for 3-5 days (fixed-dose regimen, no taper needed for short courses). 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 preferred first-line option when:

• Severe renal impairment (GFR <30 mL/min) is present—colchicine and NSAIDs must be avoided. 1, 2
• Cardiovascular disease exists—safer than NSAIDs. 2
• Gastrointestinal contraindications to NSAIDs are present. 1, 2
• Uncontrolled hypertension or heart failure exists. 1, 2
• Multiple comorbidities make other options unsafe. 2

Monitor for: mood changes, hyperglycemia (especially in diabetics), fluid retention, and immune suppression. 2

Special Situations

Monoarticular or Oligoarticular Flares (1-2 Large Joints)

• Intra-articular corticosteroid injection is highly effective and preferred for isolated joint involvement. 1, 2
• Can be combined with any other systemic therapy for severe flares. 2

Severe Flares with Multiple Joint Involvement

• Combination therapy is appropriate: oral corticosteroids plus colchicine, intra-articular steroids with any systemic agent, or colchicine plus NSAIDs. 2

Patients Unable to Take Oral Medications

• Parenteral glucocorticoids (intramuscular, intravenous, or intra-articular) are strongly recommended over IL-1 inhibitors or ACTH due to safety and cost advantages. 1, 2

Refractory Cases or Multiple Contraindications

• IL-1 inhibitors (canakinumab 150 mg subcutaneously) are conditionally recommended when colchicine, NSAIDs, and corticosteroids are all contraindicated, ineffective, or poorly tolerated. 1, 2
• Current infection is an absolute contraindication to IL-1 blockers. 1, 2
• Allow at least 12 weeks between canakinumab doses. 2

Management of Urate-Lowering Therapy During Flare

• Continue urate-lowering therapy (allopurinol, febuxostat) during the acute flare—do not stop it. 1, 2
• Stopping urate-lowering therapy can worsen the flare and complicate long-term management. 1
• You may conditionally start urate-lowering therapy during a flare with appropriate anti-inflammatory coverage. 1, 2

Adjunctive Measures

• Topical ice application is conditionally recommended as adjuvant therapy for additional pain relief. 1, 2
• Rest the affected joint. 4

Critical Pitfalls to Avoid

• Delaying treatment initiation—this is the most critical error, as early intervention determines success more than agent selection. 1
• Using colchicine in severe renal impairment (GFR <30 mL/min) or with strong CYP3A4/P-glycoprotein inhibitors—can cause fatal toxicity. 1, 2
• Prescribing NSAIDs in elderly patients with renal impairment, heart failure, or peptic ulcer disease. 1
• Stopping urate-lowering therapy during acute flare. 1
• Using high-dose colchicine (>1.8 mg over one hour)—no additional benefit with significantly more adverse effects. 1, 3
• Treating gout flares with colchicine in patients already on prophylactic colchicine who have renal impairment. 3