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

Management of Acute Gout Flare

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), with the choice based on patient comorbidities and contraindications. 1

Critical Principle: Early Treatment is Key

• The single most important factor for treatment success is early initiation, not which specific agent you choose. 1
• Treatment should begin at the first sign of flare symptoms—the "pill in the pocket" approach is recommended for informed patients to self-medicate immediately. 2
• Delaying treatment significantly reduces effectiveness regardless of the agent selected. 1

First-Line Treatment Options

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, 3
• Most effective when started within 12 hours of symptom onset. 1, 2
• Low-dose colchicine is strongly preferred over high-dose regimens due to similar efficacy with fewer adverse effects. 1
• Critical contraindications: Avoid in severe renal impairment (GFR <30 mL/min) and patients on strong CYP3A4/P-glycoprotein inhibitors (clarithromycin, cyclosporine, ritonavir) due to risk of fatal toxicity. 1, 3
• For patients on these interacting drugs, reduce dose to 0.6 mg × 1 followed by 0.3 mg one hour later, not to be repeated for at least 3 days. 3

NSAIDs

• Use full FDA-approved anti-inflammatory doses (e.g., naproxen 500 mg twice daily, indomethacin 50 mg three times daily). 1
• Contraindications: Peptic ulcer disease, renal failure (GFR <30 mL/min), uncontrolled hypertension, heart failure, and cardiovascular disease. 1
• Avoid in elderly patients with renal impairment or cardiovascular risk factors. 1

Oral Corticosteroids

• Dosing: Prednisone 30-35 mg daily for 3-5 days (fixed-dose regimen) or 0.5 mg/kg/day for 5-10 days then stop. 2
• Preferred choice for: Patients with severe renal impairment (GFR <30 mL/min), cardiovascular disease, gastrointestinal contraindications to NSAIDs, uncontrolled hypertension, or heart failure. 1, 2
• Particularly effective for flares with significant systemic inflammation (elevated CRP, leukocytosis). 4
• Safer than NSAIDs with fewer adverse effects in high-risk populations. 2
• No dose adjustment needed for renal impairment, unlike colchicine and NSAIDs. 2

Intra-articular Corticosteroid Injection

• Highly effective and preferred for monoarticular or oligoarticular flares (1-2 large joints). 1, 2
• Can be combined with any other treatment modality for severe attacks. 2

Treatment Selection Algorithm

Step 1: Assess renal function and comorbidities

• GFR <30 mL/min → Oral corticosteroids (prednisone 30-35 mg daily × 3-5 days). 2
• Cardiovascular disease, heart failure, or uncontrolled hypertension → Oral corticosteroids. 1
• Peptic ulcer disease or GI bleeding history → Oral corticosteroids or colchicine. 1

Step 2: Check for drug interactions

• Patient on CYP3A4/P-gp inhibitors (clarithromycin, cyclosporine, ritonavir) → Avoid standard-dose colchicine; use corticosteroids or NSAIDs instead. 1, 3

Step 3: Consider joint involvement

• Monoarticular (1-2 large joints) → Intra-articular corticosteroid injection is highly effective. 1, 2
• Polyarticular or severe systemic inflammation → Oral corticosteroids or consider combination therapy. 2, 4

Step 4: If patient cannot take oral medications

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

Combination Therapy for Severe Flares

• For severe acute gout with multiple joint involvement, combination therapy is appropriate: oral corticosteroids plus colchicine, intra-articular steroids with any other modality, or colchicine plus NSAIDs. 2
• Combination therapy is more effective than monotherapy for severe attacks. 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
• Current infection is an absolute contraindication to IL-1 blockers. 1
• At least 12 weeks should elapse between doses. 2

Management of Urate-Lowering Therapy During Flare

• Continue urate-lowering therapy (ULT) during acute flare—do not stop it, as interrupting worsens the flare and complicates long-term management. 1
• ULT can be started during an acute flare with appropriate anti-inflammatory coverage without significantly prolonging flare duration. 1, 2
• When initiating ULT, provide concomitant anti-inflammatory prophylaxis for 3-6 months to prevent treatment-induced flares. 1
• Prophylaxis options: Low-dose colchicine (0.5-0.6 mg once or twice daily) is first-line; low-dose prednisone (<10 mg/day) is second-line if colchicine/NSAIDs contraindicated. 1, 2

Adjunctive Measures

• Topical ice application is conditionally recommended as adjuvant therapy for additional pain relief. 1, 2
• Rest the inflamed joint. 5

Critical Pitfalls to Avoid

• Delaying treatment initiation—this is the most critical error; start treatment immediately at first symptom. 1, 2
• Using colchicine in severe renal impairment or with CYP3A4/P-gp inhibitors—can result in fatal toxicity. 1, 3
• Prescribing NSAIDs in elderly patients with renal impairment, heart failure, or peptic ulcer disease—use corticosteroids instead. 1
• Stopping urate-lowering therapy during acute flare—continue it to avoid worsening the flare. 1
• Inadequate prophylaxis duration when starting ULT—must continue for 3-6 months, not just a few weeks. 1
• Failing to rule out septic arthritis in patients with significant leukocytosis and elevated inflammatory markers—perform arthrocentesis if infection suspected. 4

Monitoring

• Continue treatment until the gouty attack has completely resolved. 2
• Monitor for corticosteroid adverse effects: dysphoria, mood changes, elevated blood glucose (especially in diabetics), and fluid retention. 2
• Corticosteroids are contraindicated in patients with systemic fungal infections. 2