What is the treatment for a gout flare in a typical adult patient?

Treatment of Acute Gout Flare

For an acute gout flare, immediately initiate treatment with one of three equally effective first-line agents: colchicine (1.2 mg followed by 0.6 mg one hour later if started within 12 hours), full-dose NSAIDs, or oral corticosteroids (prednisone 30-35 mg daily for 3-5 days), with the choice based primarily on patient contraindications rather than drug superiority. 1, 2

First-Line Treatment Selection Algorithm

The single most critical factor for treatment success is early initiation within 12-24 hours of symptom onset, not which specific agent you choose. 2, 3 All three first-line options have equivalent efficacy when started promptly. 1

Colchicine

• Dosing: 1.2 mg immediately, followed by 0.6 mg one hour later (maximum 1.8 mg over one hour) 2, 4
• Most effective when: Started within 12 hours of symptom onset 2, 4
• Strongly prefer low-dose over high-dose colchicine due to similar efficacy with significantly fewer gastrointestinal adverse effects 1, 2
• Absolute contraindications: Severe renal impairment (eGFR <30 mL/min), concurrent use of strong CYP3A4 or P-glycoprotein inhibitors (cyclosporine, clarithromycin) due to risk of fatal toxicity 2, 4, 5

NSAIDs

• Dosing: Full FDA-approved anti-inflammatory doses (e.g., naproxen 500 mg twice daily, indomethacin 50 mg three times daily) 2, 4
• Contraindications: Peptic ulcer disease, severe renal impairment (eGFR <30 mL/min), uncontrolled hypertension, heart failure, cardiovascular disease, cirrhosis 2, 4, 6
• NSAIDs can exacerbate or cause acute kidney injury in patients with chronic kidney disease 4, 6

Oral Corticosteroids

• Dosing: Prednisone 30-35 mg daily for 3-5 days (can give full dose then stop, or taper over 7-10 days for severe attacks) 2, 4, 6
• Preferred choice for: Patients with severe renal impairment, cardiovascular disease, heart failure, peptic ulcer disease, or multiple contraindications to NSAIDs and colchicine 2, 4, 6
• Advantages: No dose adjustment needed for renal impairment, safer than NSAIDs in elderly patients with comorbidities, lower cost than IL-1 inhibitors 4, 6
• Contraindications: Active systemic fungal infection (absolute), uncontrolled diabetes (relative—requires close glucose monitoring) 4, 6

Alternative Routes and Second-Line Options

Intra-articular Corticosteroid Injection

• Highly effective and preferred for monoarticular or oligoarticular flares involving 1-2 large accessible joints 2, 4
• Provides targeted therapy with minimal systemic effects 4, 6

Parenteral Glucocorticoids

• Strongly recommended over IL-1 inhibitors for patients unable to take oral medications (NPO status, active GI bleeding, severe nausea/vomiting) 2, 4, 6
• Dosing: Intramuscular triamcinolone acetonide 60 mg, or IV/IM methylprednisolone 0.5-2.0 mg/kg (40-140 mg for most adults) 4, 6

IL-1 Inhibitors (Canakinumab)

• Conditionally recommended only for patients with contraindications to ALL first-line agents and frequent flares 2, 4
• Dosing: 150 mg subcutaneously, with minimum 12-week interval between doses 4, 7
• Absolute contraindication: Current active infection 2, 4
• Significantly more expensive and less safe than corticosteroids 4, 6

Combination Therapy for Severe Attacks

For particularly severe acute gout with multiple joint involvement, initial combination therapy is appropriate: 4

• Oral corticosteroids + colchicine
• Intra-articular steroids + any oral agent
• Colchicine + NSAIDs (if no contraindications)

Critical Management Principles

Continue Urate-Lowering Therapy During Flare

Do not stop ongoing urate-lowering therapy during an acute flare—interrupting it worsens the flare and complicates long-term management. 2, 4 You can even conditionally start urate-lowering therapy during the flare with appropriate anti-inflammatory coverage. 2, 4

Prophylaxis When Initiating Urate-Lowering Therapy

When starting urate-lowering therapy, strongly recommend concomitant anti-inflammatory prophylaxis for 3-6 months to prevent treatment-induced flares: 1, 2, 4

• First-line: Low-dose colchicine 0.5-0.6 mg once or twice daily 2, 8
• Second-line: Low-dose NSAIDs or prednisone <10 mg/day (if colchicine contraindicated) 2, 4, 8

Adjunctive Measures

Topical ice application is conditionally recommended as adjuvant therapy for additional symptomatic relief. 2, 4

Common Pitfalls to Avoid

1. Delaying treatment initiation is the most critical error—early intervention within 12-24 hours is the single most important determinant of success, regardless of which agent is chosen. 2, 3

2. Using colchicine in severe renal impairment (eGFR <30 mL/min) or with strong CYP3A4/P-glycoprotein inhibitors can result in fatal toxicity. 2, 4, 5

3. Prescribing NSAIDs in elderly patients with renal impairment, heart failure, cardiovascular disease, or peptic ulcer disease—corticosteroids are safer in these populations. 2, 4, 6

4. Stopping urate-lowering therapy during acute flare worsens the flare and complicates long-term management—continue it without interruption. 2, 4

5. Using high-dose colchicine (>1.8 mg in first hour) provides no additional benefit and significantly increases gastrointestinal adverse effects. 1, 2

6. Failing to provide prophylaxis when initiating urate-lowering therapy leads to treatment-induced flares and poor adherence. 1, 2, 8