What is the recommended treatment for an acute flare-up of chronic gout?

Treatment for Acute Gout Flare

For an acute gout flare, initiate treatment immediately with one of three equally effective first-line options: oral corticosteroids (prednisone 30-35 mg daily for 3-5 days), NSAIDs at full anti-inflammatory doses, or low-dose colchicine (1.2 mg followed by 0.6 mg one hour later), with the choice based on patient comorbidities and contraindications. 1, 2

Critical Timing Principle

• Treatment must begin within 12-24 hours of symptom onset for maximum efficacy—early initiation is the single most important determinant of therapeutic success, not which agent you choose. 1, 2
• Educate patients to use the "pill in the pocket" approach, self-medicating at the first warning symptoms of a flare. 1, 2

First-Line Treatment Selection Algorithm

Option 1: Oral Corticosteroids (Preferred for Many Patients)

• Prednisone/prednisolone 30-35 mg daily for 3-5 days is the simplest and most practical regimen. 1, 3
• Alternative 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. 1
• Choose corticosteroids as first-line when:
  • Severe renal impairment (GFR <30 mL/min) is present—corticosteroids are safer than NSAIDs or colchicine. 1, 2
  • Cardiovascular disease exists—oral corticosteroids are preferred over NSAIDs due to cardiovascular risks. 1, 2
  • Multiple contraindications to NSAIDs and colchicine exist. 1, 3
• Monitor for: dysphoria, mood disorders, elevated blood glucose (check glucose more frequently in diabetics), and fluid retention. 1
• Contraindication: systemic fungal infections. 1

Option 2: NSAIDs at Full Anti-Inflammatory Doses

• Any NSAID at full FDA-approved doses is acceptable—no single NSAID is superior. 1, 2, 3
• Common options include naproxen or indomethacin at maximum anti-inflammatory doses. 2, 3
• Add a proton pump inhibitor in patients with gastrointestinal risk factors. 2
• Contraindications: renal disease, heart failure, cirrhosis, peptic ulcer disease, or significant cardiovascular disease. 2, 3

Option 3: Low-Dose 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, 2, 4
• Most effective when given within 12 hours of symptom onset. 1, 2
• Low-dose regimen is as effective as high-dose with significantly fewer gastrointestinal side effects. 2, 3
• Absolute contraindications:
  • Severe renal impairment (GFR <30 mL/min). 1, 2
  • Concomitant use of strong CYP3A4/P-glycoprotein inhibitors (cyclosporine, clarithromycin, ritonavir, ketoconazole, etc.). 1, 2, 4
• Dose adjustments required:
  • Moderate renal impairment (GFR 30-50 mL/min): monitor closely, treatment course repeated no more than once every two weeks. 4
  • Dialysis patients: single dose of 0.6 mg only, not repeated more than once every two weeks. 4
  • When taking moderate CYP3A4 inhibitors: reduce dose and frequency per FDA labeling. 4

Option 4: Intra-articular Corticosteroid Injection

• Highly effective for monoarticular gout involving 1-2 joints. 1, 2, 3
• Preferred when patient cannot take oral medications (NPO status). 3

Treatment for Severe or Polyarticular Gout

• For severe pain (≥7/10) or multiple joint involvement, use combination therapy: 1, 3
  • Oral corticosteroids + colchicine
  • Colchicine + NSAIDs
  • Intra-articular steroids + any other modality
• Combination therapy is more effective than monotherapy for severe attacks. 1, 3
• Never combine NSAIDs with systemic corticosteroids due to synergistic gastrointestinal toxicity. 2

Parenteral Options for NPO Patients

• Intravenous/intramuscular methylprednisolone (0.5-2.0 mg/kg) or intramuscular ACTH (25-40 IU) for patients unable to take oral medications with polyarticular involvement. 3
• Parenteral glucocorticoids are strongly recommended over IL-1 inhibitors when oral medications cannot be taken. 1

Treatment Duration and Monitoring

• Continue treatment until the gouty attack has completely resolved. 1
• A 5-day course at full dose is typically sufficient for oral corticosteroids. 1

Management of Inadequate Response

• Consider inadequate response if <20% improvement in pain within 24 hours or <50% improvement after 24 hours. 3
• Switch to another first-line monotherapy or add a second recommended agent. 3
• For severe refractory attacks with contraindications to all first-line agents, consider IL-1 inhibitors (canakinumab 150 mg subcutaneously), but current infection is a contraindication. 1, 2

Critical Management Principles

• Continue established urate-lowering therapy without interruption during acute flares—stopping does not improve outcomes and may worsen long-term control. 2, 3
• If initiating urate-lowering therapy during a flare, provide appropriate anti-inflammatory coverage as it does not significantly prolong flare duration. 1
• Topical ice application to affected joints provides additional pain relief as an adjunctive measure. 1, 2, 3

Common Pitfalls to Avoid

• Delaying treatment beyond 24 hours significantly reduces effectiveness—this is the most common error. 2, 3
• Using high-dose colchicine regimens causes severe gastrointestinal toxicity with no additional benefit over low-dose regimens. 2, 3
• Failing to check for drug interactions with colchicine, particularly CYP3A4/P-glycoprotein inhibitors, can result in fatal toxicity. 1, 2
• Discontinuing urate-lowering therapy during acute flares leads to poor long-term outcomes. 3
• Using NSAIDs in patients with heart failure, significant renal disease, or peptic ulcer disease. 2, 3