What is the best treatment approach for a patient with a history of gout, currently taking allopurinol (Nonsteroidal xanthine oxidase inhibitor) for prevention, who is experiencing a gout flare-up?

Treatment of Gout Flare-Up While on Allopurinol

Continue Allopurinol Without Interruption

The most critical first step is to continue your current allopurinol without stopping, as interrupting urate-lowering therapy during an acute flare worsens the attack and complicates long-term management. 1, 2

First-Line Treatment Options for the Acute Flare

You have three equally effective first-line options to treat the acute inflammation, and early initiation within 12 hours is the single most important factor for success, not which agent you choose 2:

Option 1: Colchicine (Preferred if started early)

• Take 1.2 mg immediately, followed by 0.6 mg one hour later (maximum 1.8 mg over one hour) 2
• Most effective when started within 12 hours of symptom onset 2
• Avoid colchicine if you have severe kidney disease or are taking strong CYP3A4/P-glycoprotein inhibitors (like clarithromycin, ketoconazole) due to risk of fatal toxicity 1, 2

Option 2: Oral Corticosteroids (Best for multiple contraindications)

• Prednisone 30-35 mg daily for 3-5 days 1, 2
• This is the safest option if you have kidney disease, heart failure, uncontrolled hypertension, peptic ulcer disease, or cardiovascular disease 1, 2
• Can stop abruptly after 3-5 days or taper over 7-10 days 1

Option 3: NSAIDs (If no contraindications)

• Use full FDA-approved anti-inflammatory doses 2
• Do not use NSAIDs if you have kidney disease, heart failure, uncontrolled hypertension, active peptic ulcer disease, or gastrointestinal bleeding 1, 2

Option 4: Intra-articular Corticosteroid Injection

• Highly effective for single joint or 1-2 large joint involvement, avoiding systemic medication exposure 1, 2

Combination Therapy for Severe Flares

If you have severe polyarticular involvement (multiple large joints), combination therapy is appropriate 1:

• Acceptable combinations include colchicine + NSAIDs, oral corticosteroids + colchicine, or intra-articular steroids with any other modality 1

Adjunctive Measures

• Apply topical ice to the affected joint as additional therapy 1, 2

Why You're Having a Flare Despite Taking Allopurinol

If you recently started allopurinol or had a dose increase, flares are common during the first 3-6 months as urate crystals dissolve 3, 4. You should have been on prophylactic anti-inflammatory medication (low-dose colchicine 0.5-0.6 mg once or twice daily, or low-dose NSAIDs, or prednisone <10 mg/day) when starting allopurinol to prevent these treatment-induced flares 1, 2, 5.

Moving Forward

• Continue prophylaxis for at least 3-6 months after starting or adjusting allopurinol 1, 2, 5
• Low-dose colchicine (0.5-1 mg/day) reduces both frequency and severity of flares during allopurinol initiation 5, 3
• Your target serum uric acid should be <6 mg/dL (or <5 mg/dL if you have tophi) 5

Critical Pitfalls to Avoid

• Never stop allopurinol during a flare - this worsens the attack 1, 2
• Do not delay treatment - immediate initiation is more important than which drug you choose 2
• Avoid colchicine with certain drug interactions (CYP3A4/P-glycoprotein inhibitors) in kidney disease 1, 2
• Do not use NSAIDs if you have kidney, heart, or gastrointestinal contraindications 1, 2