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

Treatment for Gout Flare-Up

For an acute gout flare, start 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)—the single most critical factor for success is early initiation, not which agent you choose. 1, 2

First-Line Treatment Selection Algorithm

The choice among the three first-line agents depends entirely on patient-specific contraindications and comorbidities:

Colchicine

• Most effective when initiated within 12 hours of symptom onset 1
• Dosing: 1.2 mg (two 0.6 mg tablets) at first sign of flare, followed by 0.6 mg one hour later—maximum 1.8 mg over one hour 3
• Low-dose colchicine is strongly recommended over high-dose regimens due to similar efficacy with significantly fewer adverse effects 1
• Absolute contraindications: Severe renal impairment (GFR <30 mL/min) and concurrent use of strong CYP3A4 or P-glycoprotein inhibitors (cyclosporine, clarithromycin) due to risk of fatal toxicity 1, 2, 3

NSAIDs

• Use full FDA-approved anti-inflammatory doses 1, 2
• Contraindications: Peptic ulcer disease, renal failure, uncontrolled hypertension, cardiac failure, and cardiovascular disease 1, 2
• Not recommended in elderly patients with renal impairment or heart failure 1

Oral Corticosteroids (Preferred in Multiple Clinical Scenarios)

• Prednisone 30-35 mg daily for 3-5 days is the most practical fixed-dose regimen 2
• Alternative weight-based dosing: 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: renal impairment, cardiovascular disease, gastrointestinal contraindications to NSAIDs, uncontrolled hypertension, and heart failure 1, 2
• No dose adjustment required for renal impairment, unlike colchicine and NSAIDs 2
• Generally safer than NSAIDs with fewer adverse effects and lower cost 2

Alternative Routes and Severe Cases

Intra-articular Corticosteroid Injection

• Highly effective and preferred for monoarticular or oligoarticular flares (1-2 large joints) 1, 2

Parenteral Glucocorticoids

• Strongly recommended over IL-1 inhibitors or ACTH for patients unable to take oral medications 1, 2
• Intramuscular route equally effective when IV access is problematic 2

Combination Therapy

• Appropriate for severe acute gout with multiple joint involvement 2
• Acceptable combinations: oral corticosteroids plus colchicine, intra-articular steroids with any other modality, or colchicine plus NSAIDs 2

Second-Line Options

IL-1 Inhibitors

• Canakinumab 150 mg subcutaneously conditionally recommended for patients with contraindications to all first-line agents and frequent flares 1, 2
• Absolute contraindication: Current infection 1, 2
• At least 12 weeks required between doses 2

Critical Management Principles

Continue Urate-Lowering Therapy During Flares

• Patients already on urate-lowering therapy should continue it during acute flare—interrupting it worsens the flare and complicates long-term management 1, 2
• Urate-lowering therapy can be conditionally started during the flare with appropriate anti-inflammatory coverage 1, 2

Prophylaxis When Initiating Urate-Lowering Therapy

• Strongly recommend concomitant anti-inflammatory prophylaxis for 3-6 months when starting urate-lowering therapy to prevent treatment-induced flares 4, 1, 2
• First-line prophylaxis: low-dose colchicine 0.5-0.6 mg once or twice daily 1, 2
• Second-line prophylaxis: low-dose NSAIDs or prednisone <10 mg/day 1, 2

Adjunctive Measures

• Topical ice application conditionally recommended as adjuvant therapy 1, 2
• Rest of the inflamed joint 5

Critical Pitfalls to Avoid

• Delaying treatment initiation is the most critical error—early intervention is the most important determinant of success, regardless of agent chosen 1, 2
• Using colchicine in severe renal impairment or with strong CYP3A4/P-glycoprotein inhibitors can result in fatal toxicity 1, 2, 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
• Using prolonged high-dose corticosteroids (>10 mg/day) for prophylaxis carries significant long-term risks 2