What is the recommended management for an acute gout flare?

Acute Gout Flare Management

For an acute gout flare, initiate treatment immediately with corticosteroids, NSAIDs, or colchicine—all three are equally effective first-line options, with corticosteroids preferred in most patients due to superior safety profile and lower cost. 1

Critical Timing Principle

• Treatment must be initiated within 12-24 hours of symptom onset for maximum efficacy—this is the single most important factor determining treatment success, more important than which specific agent you choose. 2
• Educate patients on the "pill in the pocket" approach: self-medicate at the first warning symptoms without waiting for physician contact. 2

First-Line Treatment Selection Algorithm

Step 1: Assess for Contraindications

Choose CORTICOSTEROIDS if:

• Patient has renal disease (CrCl <50 mL/min), heart failure, cirrhosis, or peptic ulcer disease 1, 3
• Patient is on anticoagulation 3
• Patient has cardiovascular disease 2, 3
• Corticosteroids are the safest and lowest-cost option when no contraindications exist 1, 3

Avoid corticosteroids if:

• Systemic fungal infection present 1
• Uncontrolled diabetes, active peptic ulcer, or immunocompromised state 3

Choose COLCHICINE if:

• Symptom onset is within 12 hours (efficacy drops significantly after this window) 2, 4
• No severe renal impairment (avoid if CrCl <30 mL/min) 2, 4
• Patient not taking strong CYP3A4 or P-glycoprotein inhibitors (clarithromycin, cyclosporine, ritonavir, ketoconazole) 2, 4

Choose NSAIDs if:

• Normal renal function (CrCl >50 mL/min) 1
• No heart failure, cirrhosis, or peptic ulcer disease 1
• Not on anticoagulation 3

Step 2: Dosing Regimens

CORTICOSTEROIDS (Preferred First-Line):

• Oral prednisone: 0.5 mg/kg/day (approximately 30-35 mg daily for average adults) 2, 3
• Duration options: 3
  • Simple approach: Full dose for 5-10 days, then stop abruptly (for monoarticular, uncomplicated cases)
  • Tapered approach: Full dose for 2-5 days, then taper over 7-10 days (for severe/polyarticular cases or patients at risk for rebound)
• Intra-articular injection: Use for 1-2 large joints involved (dose varies by joint size) 2, 3
• Intramuscular option: Triamcinolone acetonide 60 mg IM (particularly useful if patient NPO or cannot tolerate oral) 3

COLCHICINE:

• 1.2 mg (two tablets) at first sign of flare, followed by 0.6 mg (one tablet) one hour later 2, 4
• Maximum dose: 1.8 mg over one hour period—higher doses are NOT more effective and cause more GI toxicity 1, 2, 4
• Do NOT repeat treatment course for at least 3 days 4

NSAIDs:

• Use full FDA-approved anti-inflammatory doses 2
• Naproxen 500 mg twice daily, indomethacin 50 mg three times daily, or ibuprofen 800 mg three times daily 1
• Indomethacin has NO advantage over other NSAIDs despite traditional preference 1
• Add proton pump inhibitor if GI risk factors present 2

Step 3: Assess Severity for Combination Therapy

Use MONOTHERAPY for:

• Mild to moderate pain with limited joint involvement (1-2 joints) 2

Use COMBINATION THERAPY for:

• Severe pain or polyarticular involvement (≥3 joints) 2, 3
• Acceptable combinations: oral corticosteroids + colchicine, or intra-articular steroids + any oral agent 3
• NEVER combine NSAIDs + systemic corticosteroids (synergistic GI toxicity) 2

Special Population Adjustments

Renal Impairment (CrCl <50 mL/min):

• Corticosteroids are the safest choice—no dose adjustment needed 3, 4
• Colchicine: 4
  • Mild-moderate impairment (CrCl 30-80): No dose adjustment for acute treatment, but monitor closely
  • Severe impairment (CrCl <30): Single dose 0.6 mg only, repeat no more than once every 2 weeks
  • Dialysis: Single dose 0.6 mg, repeat no more than once every 2 weeks
• NSAIDs: AVOID (risk of acute kidney injury) 1, 3

Hepatic Impairment:

• Mild-moderate: No dose adjustment needed for any agent, but monitor closely 4
• Severe: Colchicine treatment course should not be repeated more than once every 2 weeks 4

Elderly Patients:

• Prefer corticosteroids over NSAIDs due to lower risk of serious adverse effects 2
• Use cautious dose selection accounting for decreased renal function 4

Critical Management Principles

• Continue established urate-lowering therapy without interruption during acute attack—do NOT stop allopurinol or febuxostat 2, 3
• Ice application to affected joints provides additional pain relief 2
• If inadequate response (defined as <20% pain improvement within 24 hours OR <50% improvement at ≥24 hours), add a second appropriate agent 2, 3
• Do NOT initiate urate-lowering therapy during an acute flare unless patient is already on prophylaxis 1, 5

Common Pitfalls to Avoid

• Waiting too long to treat—efficacy drops dramatically after 24 hours 2
• Using high-dose colchicine (the old "hourly dosing" regimen)—this causes severe diarrhea without added benefit 1, 2
• Assuming indomethacin is superior to other NSAIDs—it is not, and may have more CNS side effects 1
• Combining NSAIDs with systemic corticosteroids 2
• Stopping urate-lowering therapy during a flare 2, 3
• Using colchicine in patients on strong CYP3A4 inhibitors without dose adjustment—this can be fatal 2, 4

Prophylaxis Considerations (Not for Acute Treatment)

• If initiating urate-lowering therapy after flare resolves, provide prophylaxis with low-dose colchicine (0.5-1 mg/day) or low-dose NSAIDs for 3-6 months 2, 5
• Do NOT initiate long-term urate-lowering therapy after a first gout attack or with infrequent attacks (<2 per year) 1