What is the preferred anti-inflammatory treatment for a patient with gouty arthritis (gout) in acute flare?

Preferred Anti-Inflammatory for Acute Gout Flare

For acute gout flares, use colchicine, NSAIDs, or glucocorticoids as first-line therapy—all three are equally recommended and the choice depends on patient-specific contraindications rather than superiority of one agent over another. 1

First-Line Treatment Options

The 2020 American College of Rheumatology guidelines strongly recommend three equally effective first-line options for acute gout flares 1:

NSAIDs (Full Anti-Inflammatory Doses)

• Any NSAID at full dose is appropriate—no single NSAID is superior to another 2, 3
• FDA-approved options include naproxen, indomethacin, and sulindac 2, 4
• Indomethacin dosing: 50 mg three times daily for 2-3 days, then 25 mg three times daily for 3-5 days until resolution 2
• Critical timing: Initiate within 24 hours of symptom onset for optimal effectiveness 2, 3, 5
• Continue at full dose until the acute attack completely resolves 2

Colchicine (Low-Dose Regimen)

• FDA-approved dosing: 1.2 mg immediately, followed by 0.6 mg one hour later 1, 6
• Maximum dose for gout flare treatment: 1.8 mg over one hour 6
• Low-dose colchicine is strongly recommended over high-dose due to similar efficacy with significantly fewer gastrointestinal adverse effects 1
• Most effective when started within 12-24 hours of symptom onset 3, 5

Glucocorticoids

• Oral prednisone/prednisolone: 30-35 mg daily for 3-5 days 3, 5
• Intra-articular injection is highly effective for single joint involvement (e.g., triamcinolone acetonide 40 mg for large joints like the knee) 3, 5
• For patients unable to take oral medications, parenteral glucocorticoids (intramuscular, intravenous, or intra-articular) are strongly recommended over IL-1 inhibitors or ACTH 1

Treatment Selection Algorithm

Choose based on contraindications, not efficacy (all three first-line agents have similar efficacy) 1:

1. If renal impairment (CKD stage ≥3) or AKI: Use corticosteroids as first-line; avoid NSAIDs and adjust colchicine dose 3, 5

2. If GI contraindications (history of bleeding, ulceration): Avoid NSAIDs; use corticosteroids or colchicine 2

3. If heart failure: Avoid NSAIDs; use corticosteroids or colchicine 2

4. If uncontrolled diabetes or active infection: Avoid corticosteroids; use NSAIDs or colchicine 5

5. If single joint involvement: Consider intra-articular corticosteroid injection as highly effective option 3, 5

6. If severe pain (≥7/10) or polyarticular involvement: Consider combination therapy (e.g., colchicine plus NSAIDs, or oral corticosteroids plus colchicine) 3

Critical Timing Considerations

• Treatment must be initiated within 24 hours of symptom onset for optimal outcomes 2, 3, 5
• Educate patients on "pill-in-pocket" strategy to self-medicate at first warning symptoms 3
• Delayed treatment beyond 24 hours significantly reduces effectiveness 2, 3

Common Pitfalls to Avoid

• Never use high-dose colchicine regimens—they cause significant GI toxicity with no additional benefit over low-dose 1, 3
• Do not interrupt ongoing urate-lowering therapy during an acute flare—continue allopurinol or febuxostat 3, 5
• Avoid combining NSAIDs with corticosteroids due to synergistic gastrointestinal toxicity 5
• Be aware of colchicine drug interactions with strong CYP3A4 and P-glycoprotein inhibitors (e.g., clarithromycin, cyclosporine)—these require dose reduction or avoidance 3, 6
• Adjust colchicine dose in moderate to severe CKD 3, 6

Adjunctive Therapy

• Topical ice application is conditionally recommended as adjunctive treatment 1, 3

Second-Line Options

• IL-1 inhibitors (anakinra or canakinumab) are conditionally recommended only when first-line therapies are ineffective, poorly tolerated, or contraindicated 1
• These remain expensive with access concerns 1