What is the treatment plan for a gout flare-up?

Treatment Plan for 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), full-dose NSAIDs, 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

Choose based on patient comorbidities:

• Colchicine is preferred when initiated within 12 hours of symptom onset, using FDA-approved dosing: 1.2 mg (two tablets) immediately, followed by 0.6 mg (one tablet) one hour later (maximum 1.8 mg over one hour) 1, 3

• Oral corticosteroids (prednisone 30-35 mg daily for 3-5 days) are the safest option for patients with renal impairment, cardiovascular disease, heart failure, uncontrolled hypertension, or gastrointestinal contraindications to NSAIDs 2, 4

• NSAIDs at full anti-inflammatory doses are effective but contraindicated in peptic ulcer disease, renal failure, uncontrolled hypertension, cardiac failure, and cardiovascular disease 2, 4

Alternative Routes for Specific Situations

• Intra-articular corticosteroid injection is highly effective and preferred for monoarticular or oligoarticular flares involving 1-2 large joints 2, 4

• Parenteral glucocorticoids (intramuscular, intravenous, or intra-articular) are strongly recommended over IL-1 inhibitors or ACTH for patients unable to take oral medications 1, 4

Second-Line Treatment

• IL-1 inhibitors (canakinumab 150 mg subcutaneously) are conditionally recommended only for patients with contraindications to all first-line agents and frequent flares 1, 4
• Current infection is an absolute contraindication to IL-1 blockers 2

Critical Management of Urate-Lowering Therapy During Flare

Continue urate-lowering therapy without interruption during the acute flare—stopping it worsens the flare and complicates long-term management. 2, 4

• If not already on urate-lowering therapy, you may conditionally start it during the flare with appropriate anti-inflammatory coverage 1

Prophylaxis When Initiating Urate-Lowering Therapy

Strongly recommend concomitant anti-inflammatory prophylaxis for 3-6 months when starting urate-lowering therapy to prevent treatment-induced flares. 1, 2, 4

• First-line prophylaxis: Low-dose colchicine 0.5-0.6 mg once or twice daily 2, 4
• Alternatives: Low-dose NSAIDs or prednisone <10 mg/day 2
• Continue prophylaxis for at least 3-6 months after urate-lowering therapy initiation, with ongoing evaluation and continued prophylaxis as needed if flares persist 1

Adjunctive Measures

• Topical ice application is conditionally recommended as adjuvant therapy 1, 2, 4

Critical Pitfalls to Avoid

• Delaying treatment initiation is the most critical error—early intervention within 12 hours is the most important determinant of success 2, 4

• Using colchicine in severe renal impairment (CrCl <30 mL/min): Reduce treatment dose to a single 0.6 mg dose and do not repeat more than once every two weeks; for dialysis patients, use 0.6 mg as a single dose, not repeated more than once every two weeks 3

• Using colchicine with strong CYP3A4 or P-glycoprotein inhibitors (clarithromycin, ketoconazole, ritonavir, atazanavir) can result in fatal toxicity—reduce dose to 0.6 mg × 1 followed by 0.3 mg one hour later, not repeated for at least 3 days 3

• Prescribing NSAIDs in elderly patients with renal impairment, heart failure, or peptic ulcer disease is contraindicated—use oral corticosteroids instead 2, 4

• Stopping urate-lowering therapy during acute flare worsens the flare and complicates long-term management 2, 4

Lifestyle Modifications (Conditional Recommendations)

• Limit alcohol intake, especially beer 1
• Limit purine-rich foods (organ meats, shellfish) 1
• Limit high-fructose corn syrup intake 1
• Weight loss program for overweight/obese patients 1