What is the treatment for an acute gout flare in a relatively healthy adult with no significant comorbidities and normal renal function?

Treatment for Acute Gout Flare

For a relatively healthy adult with normal renal function experiencing an acute gout flare, start with oral colchicine (1 mg loading dose followed by 0.5 mg one hour later) within 12 hours of symptom onset, OR an NSAID at full dose, OR oral prednisone 30-35 mg daily for 5 days—all are equally effective first-line options. 1

First-Line Treatment Options

You have three equally effective choices for initial therapy, and the selection depends on timing of presentation and patient-specific factors 1:

Colchicine (Preferred if within 12 hours of onset)

• Loading dose: 1 mg followed by 0.5 mg one hour later 1
• Most effective when started within 12 hours of symptom onset 1
• FDA-approved dosing: 1.2 mg total on day 1 (1 mg, then 0.5 mg one hour later), then can resume prophylactic dosing 12 hours later 2
• Critical contraindications: Do NOT use in patients taking strong P-glycoprotein or CYP3A4 inhibitors (cyclosporin, clarithromycin) 1
• Avoid in severe renal impairment (CrCl <30 mL/min) 1, 2

NSAIDs (Convenient and well-accepted)

• Use full FDA-approved doses for acute pain/gout 1
• Naproxen, indomethacin, and sulindac are FDA-approved specifically for acute gout 1
• Continue at full dose until the attack completely resolves 1
• Add proton pump inhibitor if gastrointestinal risk factors present 1
• Avoid in patients with: severe renal impairment, cardiovascular disease, heart failure, active peptic ulcer disease, or on anticoagulation 1, 3

Oral Corticosteroids (Safest option for many patients)

• Prednisone 0.5 mg/kg/day (approximately 30-35 mg daily) for 5 days, then stop 1, 4
• Alternative: Give full dose for 2-5 days, then taper over 7-10 days 1, 4
• Methylprednisolone dose pack is also appropriate 1, 4
• Level A evidence shows equivalency to NSAIDs with fewer adverse effects 1, 4
• Generally safer and lower cost than colchicine 4

Alternative Routes for Specific Situations

Intra-articular Corticosteroid Injection

• Highly effective for monoarticular or oligoarticular involvement of accessible large joints 1, 4
• Dose varies by joint size 1
• Can be combined with oral therapy for severe attacks 1, 4

Intramuscular Corticosteroids

• Triamcinolone acetonide 60 mg IM is the specifically recommended dose 1, 4
• Alternative: Methylprednisolone 0.5-2.0 mg/kg IM (40-140 mg for most adults) 4
• Particularly useful when patient is NPO or cannot tolerate oral medications 4

Combination Therapy for Severe Attacks

For severe acute gout or polyarticular involvement, use combination therapy from the start 1:

• Colchicine PLUS oral corticosteroids 1
• Colchicine PLUS NSAID 1
• Intra-articular steroids PLUS any oral modality 1

Critical Timing Considerations

• Treat as early as possible—ideally within 24 hours of symptom onset 1
• Educate patients on "pill in the pocket" approach to self-medicate at first warning symptoms 1
• Early treatment leads to better effectiveness regardless of agent chosen 1

Monitoring Response and Inadequate Response

Define inadequate response as: 1, 4

• <20% improvement in pain within 24 hours, OR
• <50% improvement at ≥24 hours after initiating therapy

If inadequate response occurs: 1

• Consider alternative diagnosis
• Switch to another monotherapy, OR
• Add a second agent (combination therapy)

Common Pitfalls to Avoid

• Never use colchicine for acute flare in patients already on prophylactic colchicine 2
• Do not interrupt ongoing urate-lowering therapy during an acute attack 1
• Avoid NSAIDs in patients with CrCl <30 mL/min—use corticosteroids instead 1, 4
• Do not use high-dose colchicine regimens (hourly dosing)—they cause excessive toxicity without added benefit 1, 2
• Avoid starting urate-lowering therapy during the acute flare unless already decided and patient is on prophylaxis 1

Special Considerations for Your Healthy Patient

Since your patient has normal renal function and no significant comorbidities 1:

• All three first-line options are appropriate
• If presenting within 12 hours: Colchicine offers excellent efficacy with the FDA-approved low-dose regimen 1, 2
• If presenting after 12 hours: NSAIDs or corticosteroids are preferred 1
• For monoarticular large joint involvement: Consider intra-articular injection for rapid relief with minimal systemic effects 1, 4

Prophylaxis During Urate-Lowering Therapy Initiation

Once the acute flare resolves and you decide to start urate-lowering therapy 1:

• Strongly recommended: Start prophylaxis with colchicine 0.5-0.6 mg once or twice daily 1
• Alternative: Low-dose NSAID with PPI 1
• Duration: Continue for 3-6 months minimum, with ongoing evaluation 1
• Continue longer if patient continues experiencing flares 1