Is hydration beneficial for patients experiencing gout flares?

Hydration for Gout Flares: Limited Evidence but Reasonable Supportive Measure

While hydration is not formally recommended as a primary treatment for acute gout flares in current guidelines, it represents reasonable supportive care, particularly for patients receiving uricosuric therapy, though it should never substitute for evidence-based anti-inflammatory treatment.

Primary Treatment Remains Anti-Inflammatory Therapy

The 2020 American College of Rheumatology guidelines make no specific recommendation for hydration as a treatment modality during acute gout flares 1. The strongly recommended first-line therapies are:

• Colchicine, NSAIDs, or glucocorticoids as appropriate first-line therapy over IL-1 inhibitors or ACTH 1
• Topical ice as adjuvant treatment is the only conditionally recommended non-pharmacologic intervention specifically mentioned 1

The most important determinant of therapeutic success is how soon anti-inflammatory therapy is initiated, not which specific agent is chosen 2, 3.

Context Where Hydration Has Supporting Evidence

For patients receiving uricosuric medications, adequate hydration is specifically mentioned as standard best practice counseling 1. The guideline notes that:

• Patients with known renal calculi or moderate-to-severe CKD (stage >3) should not be treated with uricosurics 1
• For those who are treated with uricosurics, patients should receive counseling about adequate hydration 1
• However, they need not be prescribed alkalinizing agents given the lack of evidence for efficacy 1

Physiologic Rationale Without Strong Clinical Evidence

Dehydration is recognized as a known precipitant of gout flares 4. The theoretical mechanism involves:

• Increased serum uric acid concentration through volume contraction 4
• Potential promotion of urate crystal formation in joints 4

However, no high-quality studies directly evaluate hydration as an intervention during acute flares to improve pain, inflammation, or flare duration 1.

Practical Clinical Approach

Hydration should be positioned as supportive care, not primary treatment:

1. During acute flares: Ensure patients are not dehydrated, but prioritize immediate anti-inflammatory therapy (colchicine, NSAIDs, or glucocorticoids) 1, 5, 2

2. For chronic management: Counsel patients on adequate hydration as part of general lifestyle modifications, particularly if considering or using uricosuric therapy 1

3. Avoid overemphasis: Dietary modifications, including hydration, likely yield only small changes in serum urate concentration, and their impact on long-term clinical course is uncertain 1, 6

Important Caveats

• Never delay evidence-based anti-inflammatory treatment to focus on hydration alone 1, 2
• The ACR guidelines emphasize that providers should be mindful not to engage in "patient-blaming" when discussing lifestyle factors, as patients frequently feel stigmatized 1
• Weight loss, limiting alcohol, limiting purine intake, and limiting high-fructose corn syrup all have conditional recommendations with low to very low certainty of evidence 1
• Hydration has even less formal evidence than these other lifestyle factors 1

Bottom line: Hydration is reasonable general advice but lacks the evidence base to be considered a meaningful intervention for acute gout flares. Focus counseling on proven anti-inflammatory therapies and long-term urate-lowering strategies 1, 5, 2.