What is the best treatment approach for an adult patient experiencing a gout flare-up?

Treatment of 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), with early initiation being the single most critical factor for treatment success. 1, 2

First-Line Treatment Options

All three first-line agents have equivalent efficacy—the key to success is starting treatment as soon as possible, ideally within 12 hours of symptom onset. 2, 3

Colchicine

• FDA-approved 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. 4
• Most effective when initiated within 12 hours of symptom onset. 2, 3
• Low-dose colchicine is strongly recommended over high-dose regimens due to similar efficacy with significantly fewer adverse effects. 1, 3
• Critical contraindications: Avoid in severe renal impairment (GFR <30 mL/min) and in patients taking strong CYP3A4 or P-glycoprotein inhibitors (clarithromycin, cyclosporine) due to risk of fatal toxicity. 2, 4

NSAIDs

• Use at full FDA-approved anti-inflammatory doses. 1, 2
• Contraindications: Peptic ulcer disease, renal failure (GFR <30 mL/min), uncontrolled hypertension, heart failure, and cardiovascular disease. 2, 3
• Rapid absorption and short half-life NSAIDs may help avoid accumulation in patients with subclinical renal impairment. 5

Oral Corticosteroids

• Prednisone 30-35 mg daily for 3-5 days is the preferred regimen. 2, 6
• Alternative dosing: 0.5 mg/kg/day for 5-10 days at full dose then stop, or 0.5 mg/kg/day for 2-5 days then taper over 7-10 days. 6
• Safest option for patients with: severe renal impairment, cardiovascular disease, gastrointestinal contraindications to NSAIDs, uncontrolled hypertension, and heart failure. 2, 3, 6
• No dose adjustment required for renal impairment, unlike colchicine and NSAIDs. 6

Alternative Routes for Specific Situations

Intra-articular Corticosteroid Injection

• Highly effective and preferred for monoarticular or oligoarticular flares (1-2 large joints). 2, 3
• Can be combined with any other treatment modality for severe attacks. 6

Parenteral Glucocorticoids

• Strongly recommended over IL-1 inhibitors or ACTH for patients unable to take oral medications. 1, 2
• Intramuscular route is equally effective when IV access is problematic. 6

Combination Therapy for Severe Flares

For particularly severe acute gout with multiple joint involvement, combination therapy is appropriate: 6

• Oral corticosteroids plus colchicine
• Intra-articular steroids with any other modality
• Colchicine plus NSAIDs

Second-Line Options

IL-1 Inhibitors

• Canakinumab 150 mg subcutaneously is conditionally recommended only for patients with contraindications to all first-line agents and frequent flares. 2, 3
• Absolute contraindication: Current infection. 2, 3
• Minimum 12 weeks between doses. 6

Critical Management of Urate-Lowering Therapy During Flare

Continue urate-lowering therapy (ULT) without interruption during the acute flare—stopping it worsens the flare and complicates long-term management. 2, 3, 6

• ULT can be started during an acute flare with appropriate anti-inflammatory coverage. 2, 6
• Concomitant anti-inflammatory prophylaxis for 3-6 months is strongly recommended when initiating ULT to prevent treatment-induced flares. 1, 2, 3
• First-line prophylaxis: low-dose colchicine 0.5-0.6 mg once or twice daily. 2, 3
• Second-line prophylaxis: low-dose prednisone (<10 mg/day) if colchicine or NSAIDs are contraindicated. 2, 6

Adjunctive Measures

• Topical ice application is conditionally recommended as adjuvant therapy for additional pain relief. 2, 3, 6

Treatment Selection Algorithm

Step 1: Assess renal function, cardiovascular status, and gastrointestinal risk

• Severe CKD (GFR <30 mL/min): Use oral corticosteroids (prednisone 30-35 mg daily for 3-5 days). 6
• Cardiovascular disease or heart failure: Use oral corticosteroids; avoid NSAIDs. 2, 6
• GI contraindications (peptic ulcer, bleeding risk): Use oral corticosteroids or colchicine. 2

Step 2: Consider timing and joint involvement

• Within 12 hours of onset: Colchicine is most effective. 2, 3
• Monoarticular/oligoarticular (1-2 large joints): Intra-articular corticosteroid injection is preferred. 2, 3
• Multiple joints with severe inflammation: Consider combination therapy. 6

Step 3: Check for drug interactions

• On CYP3A4/P-gp inhibitors (clarithromycin, cyclosporine): Avoid colchicine; use corticosteroids or NSAIDs. 2, 4

Step 4: If unable to take oral medications

• Use parenteral glucocorticoids (IM or IV). 2, 6

Step 5: If all first-line agents contraindicated

• Consider IL-1 inhibitor (canakinumab 150 mg SC) only if no active infection. 2, 3

Common Pitfalls to Avoid

• Delaying treatment initiation is the most critical error—early intervention is the most important determinant of success. 2, 3
• Using colchicine in severe renal impairment or with strong CYP3A4/P-gp inhibitors can result in fatal toxicity. 2, 4
• Prescribing NSAIDs in elderly patients with renal impairment, heart failure, or peptic ulcer disease significantly increases risk of adverse events. 2, 5
• Stopping urate-lowering therapy during acute flare worsens the flare and complicates long-term management. 2, 3, 6
• Using high-dose colchicine regimens increases adverse effects without improving efficacy. 1, 3
• Failing to provide prophylaxis when initiating ULT leads to treatment-induced flares and poor adherence. 1, 2, 7