Management of Acute Gout Flare
For patients with potential kidney disease or cardiovascular conditions, oral corticosteroids (prednisone 30-35 mg daily for 3-5 days) are the safest and most effective first-line treatment, as NSAIDs carry significant cardiovascular and renal risks, and colchicine requires dose adjustment or avoidance in renal impairment. 1, 2, 3
First-Line Treatment Options
The American College of Rheumatology identifies three equally effective first-line agents for acute gout flares: NSAIDs, corticosteroids, and colchicine—but the choice must be guided by comorbidities rather than treating them as truly interchangeable. 4
Treatment Selection Algorithm Based on Comorbidities
For patients with renal impairment (CKD stage ≥3 or eGFR <60 mL/min):
- Oral corticosteroids are the preferred choice (prednisone 30-35 mg daily for 3-5 days), as they require no dose adjustment and avoid the toxicity risks of colchicine and NSAIDs in this population. 1, 2, 3
- Colchicine must be dose-reduced in moderate renal impairment and is contraindicated when eGFR <30 mL/min due to risk of fatal toxicity. 1, 5
- NSAIDs should be avoided entirely in moderate-to-severe CKD due to risk of acute kidney injury and fluid retention. 1, 2
For patients with cardiovascular disease (heart failure, uncontrolled hypertension, coronary artery disease):
- Oral corticosteroids are safer than NSAIDs, which carry significant cardiovascular risks including myocardial infarction, stroke, and heart failure exacerbation. 1, 2
- If only 1-2 joints are involved, intra-articular corticosteroid injection is highly effective and avoids systemic exposure entirely. 1, 2
For patients with gastrointestinal contraindications (peptic ulcer disease, GI bleeding history):
- Oral corticosteroids or colchicine are preferred over NSAIDs. 1, 2
- Colchicine dosing: 1.2 mg immediately, followed by 0.6 mg one hour later (total 1.8 mg), most effective when started within 12 hours of symptom onset. 1, 2, 5
Critical Timing Principle
The single most important factor for treatment success is initiating therapy within 24 hours of symptom onset—preferably within 12 hours for colchicine—not which specific agent is chosen. 4, 1
Specific Corticosteroid Dosing Regimens
- Fixed-dose regimen (simplest): Prednisone 30-35 mg daily for 5 days, then stop. 2, 3
- Weight-based regimen: Prednisone 0.5 mg/kg/day for 5-10 days at full dose, then stop. 2
- Taper regimen: Prednisone 0.5 mg/kg/day for 2-5 days, then taper over 7-10 days. 2
Alternative Routes When Oral Medications Cannot Be Taken
Parenteral glucocorticoids are strongly recommended over IL-1 inhibitors or ACTH when patients cannot take oral medications, due to superior safety profile and lower cost. 1, 2
Colchicine-Specific Contraindications and Dose Adjustments
Absolute contraindications to colchicine:
- Severe renal impairment (eGFR <30 mL/min or on dialysis). 1, 5
- Concurrent use of strong CYP3A4 or P-glycoprotein inhibitors (clarithromycin, cyclosporine, ritonavir, indinavir) in patients with any degree of renal or hepatic impairment—fatal toxicity can occur. 1, 5
Dose adjustments for moderate renal impairment (eGFR 30-50 mL/min):
- Treatment dose does not require adjustment, but monitor closely for adverse effects. 5
- Treatment courses should not be repeated more than once every two weeks. 5
For dialysis patients:
- Maximum single dose of 0.6 mg for acute flare treatment. 5
- Treatment course should not be repeated more than once every two weeks. 5
Management of Urate-Lowering Therapy During Acute Flare
Do not stop existing urate-lowering therapy during an acute flare—interrupting it can worsen the flare and complicate long-term management. 4, 1
Urate-lowering therapy can be started during an acute flare with appropriate anti-inflammatory coverage, as it does not significantly prolong flare duration. 4, 1, 2
When initiating urate-lowering therapy, concomitant anti-inflammatory prophylaxis is mandatory for 3-6 months to prevent treatment-induced flares. 4, 1
- First-line prophylaxis: Low-dose colchicine (0.5-0.6 mg once or twice daily). 1, 2
- Second-line prophylaxis (if colchicine contraindicated): Low-dose prednisone (<10 mg/day) or low-dose NSAIDs. 1, 2
Combination Therapy for Severe or Polyarticular Flares
For severe acute gout involving multiple joints, combination therapy is more effective than monotherapy. 2
Acceptable combinations:
- Oral corticosteroids plus colchicine. 2
- Intra-articular corticosteroids with any other modality. 2
- Colchicine plus NSAIDs (if no contraindications). 2
Second-Line Options for Refractory Cases
IL-1 inhibitors (canakinumab 150 mg subcutaneously) are conditionally recommended only for patients with contraindications to all first-line agents (colchicine, NSAIDs, and corticosteroids) and frequent flares. 1, 2
- Current infection is an absolute contraindication to IL-1 blocker use. 1, 2
- Minimum 12 weeks between doses. 2
Adjunctive Non-Pharmacologic Measures
Topical ice application is conditionally recommended as adjuvant therapy for additional pain relief. 1, 2
Critical Pitfalls to Avoid
- Delaying treatment initiation beyond 24 hours significantly reduces effectiveness—early intervention is paramount. 4, 1
- Using colchicine in severe renal impairment or with strong CYP3A4/P-glycoprotein inhibitors can cause fatal toxicity. 1, 5
- Prescribing NSAIDs in patients with CKD, heart failure, uncontrolled hypertension, or peptic ulcer disease increases risk of acute kidney injury, cardiovascular events, and GI bleeding. 1, 2
- Stopping urate-lowering therapy during acute flare worsens the flare and complicates long-term management. 4, 1
- Failing to provide prophylaxis when initiating urate-lowering therapy leads to treatment-induced flares and poor adherence. 4, 1
Monitoring for Corticosteroid Adverse Effects
Patients on corticosteroid therapy should be monitored for: