What are the recommended management and considerations for a pregnant patient with a possible gout flare?

Management of Gout Flare in Pregnancy

For a pregnant patient with a possible gout flare, corticosteroids (oral prednisone 30-35 mg daily for 5 days or intra-articular injection) are the safest first-line treatment, as NSAIDs are contraindicated in pregnancy and colchicine carries theoretical teratogenic concerns despite limited case reports showing successful use. 1, 2

Acute Flare Management in Pregnancy

First-Line Treatment: Corticosteroids

• Oral prednisone 30-35 mg daily for 5 days is the preferred systemic treatment for acute gout flares in pregnancy 1, 2
• Alternatively, use prednisone 0.5 mg/kg per day for 5-10 days at full dose, then stop abruptly 1, 2
• For monoarticular or oligoarticular involvement of accessible large joints, intra-articular corticosteroid injection provides targeted therapy with minimal systemic effects 2
• Intramuscular triamcinolone acetonide 60 mg is an alternative when oral administration is not feasible 2

Why Corticosteroids Are Preferred in Pregnancy

• NSAIDs are contraindicated in pregnancy, particularly in the third trimester due to risks of premature closure of the ductus arteriosus, oligohydramnios, and renal dysfunction in the fetus 1
• Colchicine has theoretical teratogenic concerns and limited safety data in pregnancy, though case reports have shown successful use 3, 4
• Corticosteroids have a well-established safety profile in pregnancy for short-term use 2

Colchicine Consideration (Second-Line)

• If corticosteroids are contraindicated or ineffective, colchicine may be considered based on individual risk-benefit assessment 3, 4
• One case report demonstrated successful management with colchicine and steroid joint injection in early pregnancy 3
• Another case report used allopurinol in the third trimester for a patient with gestational diabetes, though this is not standard practice 4
• The limited evidence suggests colchicine can be used when benefits outweigh risks, but it should not be first-line 3, 4

Diagnostic Confirmation

Clinical Assessment

• Confirm the diagnosis through clinical criteria: acute onset of severe joint pain, swelling, erythema, and warmth, typically affecting the first metatarsophalangeal joint 5
• If feasible and safe, arthrocentesis with synovial fluid analysis demonstrating monosodium urate crystals provides definitive diagnosis 5
• Evaluate for precipitating factors including dehydration, dietary triggers, or concurrent illness 3

Laboratory Evaluation

• Check serum uric acid level, though it may be normal or even low during an acute flare 5
• Assess renal function (creatinine, eGFR) as pregnancy-related changes can affect uric acid handling 4
• Screen for gestational diabetes if in second or third trimester, as insulin resistance decreases renal urate excretion and can precipitate flares 4
• Rule out septic arthritis if there are systemic signs of infection, as one case report documented H. influenzae sepsis precipitating a gout flare 3

Pregnancy-Specific Considerations

Physiologic Changes Affecting Gout Risk

• Pregnancy normally protects against gout flares due to elevated estrogen levels with uricosuric effects 3, 4
• Gout flares in pregnancy are extremely rare, with only approximately 19 pregnancies in 8 women documented in the literature as of 2015 4
• Gestational diabetes increases gout flare risk through pregnancy-induced insulin resistance that decreases renal urate excretion 4
• Hyperemesis gravidarum with dehydration can precipitate flares 3

Timing of Flares

• Of documented cases, 6 women experienced antepartum flares and 7 experienced postpartum flares 4
• Third trimester flares may be associated with gestational diabetes and metabolic changes 4

Fetal and Maternal Outcomes

• The link between gout flares and spontaneous abortion is tenuous, though one case report documented miscarriage following a gout flare complicated by sepsis 3
• Short-term corticosteroid use (5-10 days) poses minimal risk to the fetus 2
• Monitor blood glucose closely if using corticosteroids, especially in patients with gestational diabetes 2

Long-Term Management During Pregnancy

Urate-Lowering Therapy (ULT) Decisions

• Avoid initiating allopurinol or febuxostat during pregnancy unless absolutely necessary based on individualized risk-benefit assessment 4
• One case report used allopurinol in the third trimester for a patient with gestational diabetes and recurrent flares, but this is not standard practice 4
• If the patient was on ULT prior to pregnancy, discuss continuation versus discontinuation with the patient, weighing flare risk against theoretical fetal risks 4

Prophylaxis Considerations

• Do not routinely initiate flare prophylaxis during pregnancy unless the patient has severe, frequent flares 1
• If prophylaxis is deemed necessary, low-dose prednisone (<10 mg/day) is safer than colchicine or NSAIDs 2

Non-Pharmacological Management

• Emphasize dietary modifications: limit purine-rich foods (organ meats, shellfish), avoid alcohol completely, eliminate high-fructose corn syrup beverages 1, 5
• Encourage consumption of low-fat or non-fat dairy products 1, 5
• Maintain adequate hydration to prevent dehydration-induced flares 3
• Apply topical ice to affected joints as adjuvant therapy 1
• Encourage rest of the affected joint during acute flares 6

Medication Review

• Discontinue thiazide or loop diuretics if being used for hypertension, as these are the most common iatrogenic cause of gout 7
• Switch to pregnancy-safe antihypertensives such as methyldopa, labetalol, or nifedipine (calcium channel blocker) 7
• Avoid losartan during pregnancy despite its uricosuric properties, as angiotensin receptor blockers are contraindicated 7

Common Pitfalls to Avoid

• Do not use NSAIDs at any point in pregnancy, particularly avoiding them in the third trimester due to serious fetal risks 1
• Do not delay treatment waiting for definitive crystal confirmation if clinical presentation is classic, as early treatment improves outcomes 1
• Do not assume all joint pain in pregnancy is gout—rule out septic arthritis, especially if systemic symptoms are present 3
• Do not use high-dose colchicine if colchicine is chosen, as toxicity risk is substantial 1
• Do not start urate-lowering therapy during an acute flare, as this can worsen and prolong the attack 1

Postpartum Planning

• Plan for postpartum gout management, as 7 of 19 documented pregnancy-related gout cases experienced postpartum flares 4
• After delivery, initiate or resume urate-lowering therapy with allopurinol starting at 100 mg daily, titrating to achieve serum uric acid <6 mg/dL 1, 7
• Provide flare prophylaxis with colchicine 0.5-1 mg daily for 3-6 months when initiating ULT postpartum 1, 7
• Counsel that breastfeeding considerations will affect medication choices, as colchicine and allopurinol have limited safety data in lactation 4