What is the recommended management of an acute gout flare, including first‑line therapy, alternatives for contraindications, and adjunctive measures?

Managing an Acute Gout Flare

Oral corticosteroids (prednisone 30–35 mg daily for 5 days) should be your first-line treatment for most patients with acute gout because they are equally effective as NSAIDs and colchicine but safer, lower cost, and have fewer contraindications. 1, 2

First-Line Treatment Options

You have three equally effective first-line agents, but corticosteroids are preferred in most clinical scenarios 2, 3:

Oral Corticosteroids (Preferred First-Line)

• Prednisone 30–35 mg once daily for 5 days (fixed dose, no taper needed for simple cases) 1, 2
• Alternative regimen: 0.5 mg/kg/day for 2–5 days at full dose, then taper over 7–10 days for severe attacks or polyarticular involvement 1
• Methylprednisolone dose pack is also appropriate based on provider and patient preference 1

Why corticosteroids are preferred:

• Safer than NSAIDs in patients with renal impairment (eGFR <30 mL/min), cardiovascular disease, heart failure, cirrhosis, peptic ulcer disease, or anticoagulation 1, 2
• Lower cost and fewer adverse effects than colchicine 2
• No dose adjustment needed for renal impairment 1
• Only 27% adverse event rate vs. 63% with NSAIDs 1

NSAIDs (Alternative First-Line)

• Use full FDA-approved anti-inflammatory doses 2, 3
• Any potent NSAID is effective; choice matters less than early initiation 4, 5
• Contraindications: peptic ulcer disease, renal failure (eGFR <30), uncontrolled hypertension, heart failure, anticoagulation 2, 3

Colchicine (Alternative First-Line)

• FDA-approved dosing: 1.2 mg immediately, then 0.6 mg one hour later (maximum 1.8 mg over one hour) 3, 6
• Most effective when started within 12 hours of symptom onset 3, 6
• Fatal contraindications: severe renal impairment, concomitant strong CYP3A4/P-glycoprotein inhibitors (clarithromycin, cyclosporine, ritonavir, ketoconazole) 2, 6
• Requires dose reduction with moderate CYP3A4 inhibitors (diltiazem, verapamil, erythromycin) 6

Alternative Routes When Oral Therapy Impossible

Intramuscular Corticosteroids

• Triamcinolone acetonide 60 mg IM as single injection 1
• Alternative: methylprednisolone 40–140 mg IM (0.5–2.0 mg/kg) 1
• Preferred when patient is NPO, cannot tolerate oral medications, or needs rapid relief 1

Intravenous Corticosteroids

• Methylprednisolone 0.5–2.0 mg/kg IV (approximately 40–140 mg for most adults) 1
• Repeat doses as clinically indicated 1
• Use for NPO patients, active peptic ulcer disease, or recent GI bleeding 1

Intra-articular Corticosteroid Injection

• Highly effective for monoarticular or oligoarticular flares (1–2 large joints) 1, 3
• Dose varies by joint size 1
• Provides targeted therapy with minimal systemic effects 1

Treatment Selection Algorithm

Step 1: Assess contraindications

• Active systemic infection → avoid corticosteroids and IL-1 blockers 1, 3
• Severe renal impairment (eGFR <30) → avoid NSAIDs and colchicine; use corticosteroids 1, 2
• Strong CYP3A4/P-gp inhibitors → avoid colchicine 2, 6
• Cardiovascular disease, heart failure, peptic ulcer → avoid NSAIDs; use corticosteroids 1, 2

Step 2: Assess joint involvement

• 1–2 large accessible joints → consider intra-articular injection 1, 3
• Polyarticular or severe attack → oral prednisone 30–35 mg daily 1, 2

Step 3: Initiate treatment immediately

• Early initiation within 12–24 hours is the single most critical factor for success, not which agent you choose 2, 3

Step 4: Monitor response

• Inadequate response = <20% pain improvement within 24 hours OR <50% improvement at ≥24 hours 1
• If inadequate response: switch to another monotherapy or add second agent 2, 3

Combination Therapy for Severe Attacks

For severe acute gout or polyarticular involvement, use initial combination therapy: 1

• Oral corticosteroids PLUS colchicine, OR
• Intra-articular steroids PLUS any oral modality 1
• Never combine NSAIDs with systemic corticosteroids due to synergistic GI toxicity 2

Critical Management of Urate-Lowering Therapy

Continue established urate-lowering therapy during the acute flare—never stop it 2, 3

• Stopping worsens the flare and complicates long-term management 3

If starting urate-lowering therapy during or after flare:

• Provide concomitant anti-inflammatory prophylaxis for 3–6 months 2, 3
• First-line prophylaxis: low-dose colchicine 0.5–0.6 mg once or twice daily 3
• Second-line prophylaxis: low-dose prednisone <10 mg/day 1, 3

Adjunctive Measures

• Topical ice application to affected joint 3
• Rest the inflamed joint 7
• Limit alcohol (especially beer), purine-rich foods (organ meats, shellfish), and high-fructose corn syrup 3, 8
• Encourage low-fat dairy products and vegetables 8
• Weight loss program for overweight/obese patients 3

Special Populations

Elderly with Renal Impairment

• Prednisone 30–35 mg daily for 5 days is the safest option 1
• NSAIDs can cause acute kidney injury 1
• Colchicine carries fatal toxicity risk in renal impairment 1

Patients with Diabetes

• Short-term corticosteroids elevate blood glucose 1
• Monitor glucose closely and adjust diabetic medications proactively 1
• Short courses (5–10 days) are still appropriate; benefits outweigh risks 1

Patients Unable to Take Oral Medications

• Parenteral glucocorticoids strongly recommended over IL-1 inhibitors or ACTH 3
• IM triamcinolone 60 mg or IV methylprednisolone 0.5–2.0 mg/kg 1

IL-1 Inhibitors (Last Resort Only)

Canakinumab 150 mg subcutaneously is conditionally recommended only for patients with contraindications to ALL first-line agents and frequent flares 2, 3

• Current infection is absolute contraindication 3
• Much higher cost than corticosteroids 1

Critical Pitfalls to Avoid

• Delaying treatment initiation—early intervention is the most important determinant of success 2, 3
• Using colchicine with strong CYP3A4/P-gp inhibitors (clarithromycin, cyclosporine, ketoconazole)—can be fatal 2, 6
• Prescribing NSAIDs in elderly with renal impairment, heart failure, or peptic ulcer 2
• Stopping urate-lowering therapy during acute flare 2, 3
• Using high-dose prednisone (>10 mg/day) for prophylaxis 1
• Combining NSAIDs with systemic corticosteroids 2