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

Treatment of Acute Gout Flare

For an acute gout flare, initiate treatment with corticosteroids, NSAIDs, or colchicine within 12-24 hours of symptom onset, with corticosteroids being the preferred first-line option due to superior safety profile and lower cost in most patients. 1, 2, 3

Critical Timing Principle

• Treatment must begin within 12-24 hours of symptom onset—this is the single most important factor determining treatment success, regardless of which agent is chosen. 1, 2, 3
• Educate patients to self-medicate at the first warning symptoms using the "pill in the pocket" approach. 1

First-Line Treatment Selection Algorithm

Corticosteroids (Preferred in Most Scenarios)

• Corticosteroids are the recommended first-line treatment for patients with renal disease, heart failure, cirrhosis, peptic ulcer disease, or cardiovascular disease. 2, 3
• Corticosteroids are the safest and lowest-cost option when no contraindications exist. 2, 3
• Dosing: Oral prednisone 30-35 mg daily (or 0.5 mg/kg/day) for 3-5 days. 1, 2
• Alternative regimen: Full dose for 5-10 days then stop, or 2-5 days at full dose followed by 7-10 day taper. 2
• For monoarticular gout, intra-articular corticosteroid injection is an effective option. 1
• Potential adverse effects include dysphoria, mood disorders, elevated blood glucose, and fluid retention. 1
• For patients with diabetes, NSAIDs or colchicine may be preferred over corticosteroids. 2

Colchicine

• Colchicine is most effective when given within 12 hours of symptom onset. 1
• Dosing: 1.2 mg (two tablets) at first sign of flare, followed by 0.6 mg (one tablet) one hour later, for a maximum of 1.8 mg over one hour. 1, 2, 4
• This low-dose regimen is as effective as higher doses with significantly fewer gastrointestinal side effects. 1, 2
• Contraindications: Severe renal impairment (GFR <30 mL/min) and concomitant use of strong P-glycoprotein and/or CYP3A4 inhibitors (cyclosporin, clarithromycin). 1, 4
• For patients on dialysis, reduce to single dose of 0.6 mg, not to be repeated more than once every two weeks. 4

NSAIDs

• NSAIDs should be used at full FDA-approved anti-inflammatory doses: naproxen 500 mg twice daily, indomethacin 50 mg three times daily, or ibuprofen 800 mg three times daily. 1, 2, 3
• Indomethacin is not more efficacious than other NSAIDs—this is a common misconception. 2, 3
• Add a proton pump inhibitor in patients with gastrointestinal risk factors. 1
• Contraindications: Renal disease, heart failure, cirrhosis, and peptic ulcer disease. 1, 2, 3
• For patients on anticoagulation, corticosteroids are preferred over NSAIDs. 3

Treatment Based on Severity

• For mild to moderate pain (≤6/10) with limited joint involvement, monotherapy with any first-line agent is appropriate. 1, 2
• For severe pain or polyarticular involvement, combination therapy is recommended: colchicine plus NSAIDs, oral corticosteroids plus colchicine, or intra-articular steroids with any other modality. 2
• If inadequate response to monotherapy, add a second appropriate agent. 1, 3

Special Population Adjustments

Renal Impairment

• For mild to moderate renal impairment (CrCl 30-80 mL/min), no dose adjustment needed for any agent, but monitor closely. 4
• For severe renal impairment (CrCl <30 mL/min): Corticosteroids are the safest choice with no dose adjustment needed. 2, 3, 4
• For colchicine in severe renal impairment: Reduce prophylaxis dose to 0.3 mg/day; for acute treatment, use standard dose but repeat no more than once every two weeks. 4
• For patients on dialysis: Colchicine 0.6 mg single dose for acute flare, not to be repeated more than once every two weeks. 4

Hepatic Impairment

• For mild to moderate hepatic impairment, no dose adjustment needed but monitor closely. 3, 4
• For severe hepatic impairment, reduce prophylaxis dose; for acute treatment, use standard dose but repeat no more than once every two weeks. 4

Elderly Patients

• Corticosteroids are preferred over NSAIDs due to lower risk of serious adverse effects. 1, 3

Drug Interactions

• For patients on strong CYP3A4 inhibitors (clarithromycin, ritonavir, ketoconazole): Reduce colchicine dose to 0.6 mg × 1 dose, followed by 0.3 mg one hour later, not to be repeated for at least 3 days. 4
• Treatment of gout flares with colchicine is not recommended in patients receiving prophylactic colchicine and CYP3A4 inhibitors. 4

Critical Management Principles

• Continue established urate-lowering therapy without interruption during an acute attack—stopping it can worsen the condition. 1, 2, 3
• Ice application to affected joints provides additional pain relief. 1, 3
• Do not initiate urate-lowering therapy during an acute flare unless the patient is already on prophylaxis. 3

Common Pitfalls to Avoid

• Do not wait beyond 24 hours to treat—efficacy drops dramatically after this window. 3
• Do not use high-dose colchicine—it causes severe diarrhea without added benefit. 3
• Do not assume indomethacin is superior to other NSAIDs—all NSAIDs at appropriate doses are equally effective. 2, 3
• Do not combine NSAIDs with systemic corticosteroids—this increases gastrointestinal toxicity risk. 1, 3
• Do not stop urate-lowering therapy during a flare—this can precipitate further attacks. 1, 3

Adjunctive Measures

• Rest and ice application to the affected joint. 1, 3
• Colchicine is not an analgesic and should not be used to treat pain from other causes. 4