Treatment of Acute Gout Flare in Patients Without CKD
For patients without chronic kidney disease experiencing an acute gout flare, initiate treatment immediately with colchicine 1.2 mg followed by 0.6 mg one hour later (maximum 1.8 mg over one hour), NSAIDs at full anti-inflammatory doses, or oral corticosteroids (prednisone 30-35 mg daily for 3-5 days), as all three are equally effective first-line options. 1, 2
First-Line Treatment Selection Algorithm
The choice among the three first-line agents should be guided by specific patient factors:
Colchicine (Preferred if initiated early)
- Most effective when started within 12 hours of symptom onset 2
- FDA-approved dosing: 1.2 mg immediately, followed by 0.6 mg one hour later 3
- Maximum dose is 1.8 mg over one hour; higher doses provide no additional benefit 3
- Avoid in patients taking strong CYP3A4 inhibitors (clarithromycin, ketoconazole, ritonavir, diltiazem, verapamil) due to risk of fatal toxicity 1
- Well tolerated at recommended dosing with similar adverse event rates to placebo 4
NSAIDs (Preferred for patients with contraindications to colchicine)
- Use full FDA-approved anti-inflammatory doses 1
- Contraindications include peptic ulcer disease, uncontrolled hypertension, heart failure, and cardiovascular disease 2, 5
- Avoid in elderly patients with these comorbidities 2
Oral Corticosteroids (Preferred for multiple contraindications)
- Prednisone 30-35 mg daily for 3-5 days, then stop abruptly or taper over 7-10 days 5
- Safest option when NSAIDs and colchicine are contraindicated 5
- Particularly effective for flares with significant systemic inflammation 2
Alternative and Adjunctive Therapies
Intra-articular Corticosteroid Injection
- Highly effective and preferred for monoarticular or oligoarticular flares (1-2 large joints) 2, 5
- Avoids systemic drug exposure 5
Parenteral Glucocorticoids
IL-1 Inhibitors (Canakinumab)
- Conditionally recommended only for patients with contraindications to all first-line agents and frequent flares 2, 5
- Dose: 150 mg subcutaneously 2
- Current infection is an absolute contraindication 2
Topical Ice
Management of Concurrent Urate-Lowering Therapy
During Acute Flare
- Continue existing urate-lowering therapy without interruption; stopping worsens the flare and complicates long-term management 2, 5
- Urate-lowering therapy can be initiated during the acute flare rather than waiting for resolution, but must be accompanied by anti-inflammatory prophylaxis 1, 2
Prophylaxis When Starting Urate-Lowering Therapy
- Strongly recommend concomitant anti-inflammatory prophylaxis (colchicine, NSAIDs, or prednisone) for 3-6 months when initiating urate-lowering therapy 1, 2, 5
- Low-dose colchicine 0.5-0.6 mg once or twice daily is first-line prophylaxis 2, 5
- Continue prophylaxis with ongoing evaluation; extend if flares persist 1, 2
Combination Therapy for Severe Flares
For severe acute gout with multiple large joints or polyarticular involvement, combination therapy is appropriate 5:
- Acceptable combinations: colchicine + NSAIDs, oral corticosteroids + colchicine, or intra-articular steroids with any other modality 5
Critical Pitfalls to Avoid
- Delaying treatment initiation is the most critical error; early intervention within 12 hours is the most important determinant of success 2
- Never use colchicine with strong CYP3A4/P-glycoprotein inhibitors (macrolides, azole antifungals, protease inhibitors, diltiazem, verapamil, Paxlovid) due to risk of fatal toxicity 1, 2
- Do not prescribe NSAIDs to elderly patients with cardiovascular disease, heart failure, uncontrolled hypertension, or peptic ulcer disease 2, 5
- Never stop urate-lowering therapy during an acute flare 2, 5
- Do not exceed colchicine maximum dose of 1.8 mg over one hour for acute flare treatment 3