What is the recommended management of an acute gout flare in an adult, including immediate anti‑inflammatory therapy and subsequent urate‑lowering treatment?

Management of Acute Gout Flares

Corticosteroids should be your first-line treatment for acute gout flares in patients without contraindications, as they are equally effective as NSAIDs and colchicine but safer and less expensive. 1

Immediate Anti-Inflammatory Therapy

First-Line Treatment Selection

The American College of Physicians strongly recommends three equally effective options—corticosteroids, NSAIDs, or colchicine—but prioritizes corticosteroids first due to superior safety profile and cost-effectiveness. 1, 2

Corticosteroids (Preferred First-Line):

• Prednisolone 35 mg daily for 5 days is the evidence-based regimen 1, 2
• Alternative dosing: Prednisone 0.5 mg/kg/day for 5-10 days at full dose then stop, or 2-5 days at full dose followed by 7-10 day taper 2
• Safer than NSAIDs in patients with renal disease, heart failure, cirrhosis, or gastrointestinal bleeding risk 1, 3
• Avoid in patients with diabetes (worsens glycemic control), systemic fungal infections, or those requiring immune suppression avoidance 1, 2

NSAIDs (Alternative First-Line):

• Use full FDA-approved anti-inflammatory doses: naproxen, indomethacin, or sulindac 2, 3
• Indomethacin has no superiority over other NSAIDs despite traditional preference 1, 2
• Contraindicated in renal disease, heart failure, cirrhosis, active peptic ulcer disease, or anticoagulation 1, 3
• Preferred over corticosteroids in diabetic patients 1

Colchicine (Alternative First-Line):

• Low-dose regimen: 1.2 mg loading dose, then 0.6 mg one hour later 1, 2, 3
• This low-dose regimen is equally effective as high-dose colchicine with significantly fewer gastrointestinal adverse effects 1
• Reduce dose to 0.5 mg daily or every other day if creatinine clearance 30-50 mL/min 4
• Contraindicated in severe renal insufficiency or combined hepatic-renal insufficiency 5
• Preferred over corticosteroids in diabetic patients and over NSAIDs in patients with gastrointestinal risk factors 1, 2

Treatment Algorithm Based on Severity

Mild to Moderate Pain (≤6/10) with Limited Joint Involvement:

• Monotherapy with any first-line agent is appropriate 2, 3

Severe Pain (≥7/10) or Polyarticular Involvement:

• Combination therapy is required 2, 3
• Effective combinations: colchicine plus NSAIDs, oral corticosteroids plus colchicine, or intra-articular steroids with any other modality 2, 3

Critical Timing Principle

Initiate treatment within 24 hours of symptom onset for optimal outcomes—the most important determinant of therapeutic success is how soon therapy begins, not which specific agent is chosen. 2, 6

Subsequent Urate-Lowering Therapy

Indications for Long-Term Urate-Lowering Therapy (ULT)

Do NOT initiate ULT for single or infrequent gout attacks (<2 per year). 2

Initiate ULT in patients with:

• Recurrent gout flares (≥2 per year) 3
• Tophi (visible or radiographic) 3
• Radiographic joint damage 3
• Renal stones 3
• Multiple high-risk comorbidities (hypertension, diabetes, renal impairment) 4

Urate-Lowering Therapy Protocol

Allopurinol (First-Line ULT):

• Start at 100 mg daily, increase by 100 mg every 2-4 weeks until serum uric acid <6 mg/dL (360 μmol/L) 4, 3
• Target serum uric acid <6 mg/dL lifelong (or <5 mg/dL for severe gout with tophi or frequent attacks) 4
• Adjust dose based on creatinine clearance in renal impairment 3

Febuxostat (Alternative ULT):

• Clinically equivalent to allopurinol but significantly more expensive 3
• Consider in allopurinol-allergic patients 6

Mandatory Flare Prophylaxis During ULT Initiation

This is the most commonly missed step in gout management and leads to treatment failure.

All patients initiating ULT must receive prophylactic anti-inflammatory therapy for at least 6 months to prevent mobilization flares that occur when urate crystals dissolve. 1, 2, 4, 7

Prophylaxis Options:

• Colchicine 0.5-1 mg daily (first-line) 2, 4, 7
• Low-dose NSAIDs (naproxen 250 mg twice daily) if colchicine contraindicated 2, 7
• Low-dose corticosteroids (prednisone or prednisolone) if both colchicine and NSAIDs contraindicated 2, 7

Duration: Continue prophylaxis for minimum 6 months, with moderate-strength evidence supporting duration longer than 8 weeks 1

Critical Management Principle During Acute Flares

Never stop established urate-lowering therapy during an acute gout attack—this perpetuates the cycle of recurrent flares. Continue ULT without interruption. 2, 4

Special Populations and Comorbidity Management

Renal Impairment

• Corticosteroids are safest option for acute flares 1, 3
• Avoid or reduce colchicine dose based on creatinine clearance 4, 5
• Avoid NSAIDs 1, 3

Diabetes

• Prefer NSAIDs or colchicine over corticosteroids for acute flares 1
• Optimize glycemic control as hyperglycemia worsens hyperuricemia 4

Diuretic Use (Most Common Iatrogenic Cause)

• Substitute thiazide or loop diuretics if possible 4
• Switch to losartan (modest uricosuric effects) or calcium channel blockers for hypertension management 4
• Do not stop low-dose aspirin for cardiovascular indications despite mild uric acid elevation 4

Hyperlipidemia

• Consider fenofibrate which has uricosuric properties 4

Patient Education and Non-Pharmacologic Measures

Educate patients to self-initiate treatment at first signs of acute attack to optimize outcomes. 2

Mandatory lifestyle modifications:

• Weight loss if obese 4, 3
• Avoid alcohol, especially beer and spirits 4, 3
• Eliminate sugar-sweetened drinks and high-fructose foods 4, 3
• Reduce red meat and seafood intake 4, 3
• Encourage low-fat dairy products, particularly skim milk 4
• Regular exercise 4

Common Pitfalls to Avoid

1. Starting ULT during an acute flare without prophylaxis—this triggers more severe flares and treatment abandonment 7
2. Stopping ULT during acute attacks—this perpetuates the flare cycle 2, 4
3. Inadequate prophylaxis duration (<6 months)—flares continue during crystal dissolution phase 1, 7
4. Prescribing NSAIDs in renal impairment—use corticosteroids instead 1, 3
5. Using high-dose colchicine—low-dose is equally effective with fewer adverse effects 1
6. Failing to address medication-induced hyperuricemia (diuretics)—substitute causative agents when possible 4