What is the initial treatment for a gout flare?

Initial Treatment for Acute Gout Flare

Start treatment immediately with colchicine, NSAIDs, or oral corticosteroids at the first sign of symptoms—early initiation within 12 hours is the single most critical factor for success, not which specific agent you choose. 1, 2

First-Line Treatment Options (All Equally Effective)

The American College of Rheumatology recognizes three equally effective first-line agents 2:

Colchicine

• Dosing: 1.2 mg (two tablets) at first sign of flare, followed by 0.6 mg one hour later (maximum 1.8 mg over one hour) 3
• Most effective when initiated within 12 hours of symptom onset 1, 2
• Critical contraindications: Avoid in severe renal impairment (CrCl <30 mL/min) and absolutely contraindicated with strong CYP3A4/P-glycoprotein inhibitors (cyclosporine, clarithromycin, ritonavir, ketoconazole) due to risk of fatal toxicity 1, 2, 3
• For patients on dialysis, reduce to single 0.6 mg dose, not repeated more than once every two weeks 3

NSAIDs

• Use full FDA-approved anti-inflammatory doses (e.g., naproxen, indomethacin, sulindac) 1
• Contraindications: Peptic ulcer disease, renal failure (CrCl <30 mL/min), uncontrolled hypertension, cardiac failure 2
• Consider adding proton pump inhibitor for gastrointestinal protection 1

Oral Corticosteroids

• Dosing: Prednisone 30-35 mg daily for 3-5 days (can stop abruptly or taper over 7-10 days) 1, 2
• Preferred option for patients with renal impairment, cardiovascular disease, gastrointestinal contraindications to NSAIDs, or heart failure 2
• Particularly effective for flares with significant systemic inflammation 2

Treatment Selection Algorithm

For mild to moderate pain (≤6/10) affecting 1-3 small joints or 1-2 large joints:

• Use monotherapy with any first-line agent 1

For severe or polyarticular attacks:

• Consider combination therapy (colchicine + NSAIDs, or either agent + corticosteroids) 1

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

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

For patients unable to take oral medications:

• Use parenteral glucocorticoids (intramuscular, intravenous, or intra-articular) over IL-1 inhibitors or ACTH 1, 2

Special Populations and Alternative Therapies

IL-1 inhibitors (canakinumab 150 mg subcutaneously):

• Reserved for patients with contraindications to all first-line agents and frequent flares 2
• Absolute contraindication: Current infection 1, 2

Critical Management Principles

Continue established urate-lowering therapy (allopurinol, febuxostat) during the acute flare:

• Stopping ULT worsens the flare and complicates long-term management 1, 2
• Can even initiate ULT during a flare with appropriate anti-inflammatory coverage 2

Prophylaxis when starting or continuing ULT:

• Low-dose colchicine (0.5-0.6 mg once or twice daily) or low-dose NSAIDs for 3-6 months 1, 2
• This prevents treatment-induced flares from urate mobilization 1

Patient Self-Management

"Pill in the pocket" approach:

• Educate patients to self-medicate immediately at first warning symptoms 1
• Early self-initiation leads to better effectiveness than delayed treatment 1

Critical Pitfalls to Avoid

• Delaying treatment: The most common and critical error—early intervention determines success, not agent selection 1, 2
• Using colchicine with CYP3A4/P-gp inhibitors: Can result in fatal toxicity 2, 3
• Prescribing NSAIDs in elderly with renal impairment, heart failure, or peptic ulcer disease 2
• Stopping urate-lowering therapy during flare: Worsens the attack and undermines long-term control 1, 2
• Failing to adjust colchicine dose in renal impairment: Use single 0.6 mg dose for dialysis patients, repeat no more than once every two weeks 3

Adjunctive Measures

• Topical ice application is conditionally recommended as adjuvant therapy 2