What is the treatment for a gout flare?

Treatment of Acute Gout Flare

Start treatment 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)—early initiation within 12 hours is the single most critical factor for success, not which agent you choose. 1, 2, 3

First-Line Treatment Selection Algorithm

The choice among the three first-line agents depends primarily on patient comorbidities and contraindications, as all are equally effective when started early 1, 2:

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, 4
• Optimal timing: Most effective when initiated within 12 hours of symptom onset 1, 2
• Low-dose is strongly preferred over historical high-dose regimens due to similar efficacy with significantly fewer adverse effects 1, 3
• Absolute contraindications:
  • Severe renal impairment (GFR <30 mL/min) 1, 2, 4
  • Concurrent use of strong CYP3A4 or P-glycoprotein inhibitors (cyclosporine, clarithromycin, ritonavir, ketoconazole, itraconazole) due to risk of fatal toxicity 1, 2, 4
  • Patients on dialysis should receive only 0.6 mg as a single dose, not repeated more than once every two weeks 4

NSAIDs

• Dosing: Full FDA-approved anti-inflammatory doses 1, 2
• Contraindications:
  • Peptic ulcer disease 1, 3
  • Renal failure or severe renal impairment 1, 2
  • Uncontrolled hypertension 1, 3
  • Cardiac failure or cardiovascular disease 1, 2
  • Elderly patients with renal impairment 1

Oral Corticosteroids (Preferred for High-Risk Patients)

• Dosing: Prednisone 30-35 mg daily for 3-5 days (fixed-dose regimen is simpler and equally effective) 1, 2
• Alternative regimen: 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:
  • Severe renal impairment (GFR <30 mL/min) 1, 2
  • Cardiovascular disease 1, 2
  • Gastrointestinal contraindications to NSAIDs 1, 2
  • Uncontrolled hypertension 1, 2
  • Heart failure 1, 2
• No dose adjustment needed for renal impairment 2
• Monitor for: Dysphoria, mood disorders, elevated blood glucose (especially in diabetics), fluid retention 2
• Contraindication: Systemic fungal infections 2

Alternative Routes for Specific Scenarios

Intra-articular Corticosteroid Injection

• Highly effective and preferred for monoarticular or oligoarticular flares involving 1-2 large joints 1, 2, 3
• Can be combined with any other modality for severe attacks 2

Parenteral Glucocorticoids

• Strongly recommended over IL-1 inhibitors or ACTH for patients unable to take oral medications 1, 2, 3
• Intramuscular route is equally effective when IV access is problematic 2

Combination Therapy for Severe Flares

• Consider initial combination therapy for severe acute gout with multiple joint involvement 2
• Acceptable combinations:
  • Oral corticosteroids + colchicine 2
  • Intra-articular steroids + any other modality 2
  • Colchicine + NSAIDs 2

Second-Line Option: IL-1 Inhibitors

• Canakinumab 150 mg subcutaneously is conditionally recommended for patients with contraindications to all first-line agents and frequent flares 1, 2, 3
• Absolute contraindication: Current infection 1, 2, 3
• Minimum 12 weeks between doses 2

Critical Management Principles

Continue Urate-Lowering Therapy During Flares

• Do not stop urate-lowering therapy during acute flares—interrupting it worsens the flare and complicates long-term management 1, 3
• Urate-lowering therapy can be started during an acute flare with appropriate anti-inflammatory coverage 1, 2, 3

Prophylaxis When Starting Urate-Lowering Therapy

• Strongly recommended: Concomitant anti-inflammatory prophylaxis for 3-6 months when initiating urate-lowering therapy to prevent treatment-induced flares 1, 2, 3
• First-line prophylaxis: Low-dose colchicine 0.5-0.6 mg once or twice daily 1, 3
• Second-line prophylaxis: Low-dose prednisone (<10 mg/day) if colchicine and NSAIDs are contraindicated 2

Adjunctive Measures

• Topical ice application is conditionally recommended as adjuvant therapy for additional pain relief 1, 2, 3

Critical Pitfalls to Avoid

• Delaying treatment initiation is the most critical error—early intervention is the most important determinant of success 1, 2
• Using colchicine in severe renal impairment or with CYP3A4/P-gp inhibitors can result in fatal toxicity 1, 2, 4
• Prescribing NSAIDs in elderly patients with renal impairment, heart failure, or peptic ulcer disease significantly increases risk 1
• Stopping urate-lowering therapy during acute flare worsens the flare and complicates long-term management 1, 3
• Using high-dose colchicine provides no additional benefit and significantly increases adverse effects 1, 3