Management of Acute Gout Attack
For an acute gout flare in the Philippines, initiate treatment immediately with one of three equally effective first-line agents: NSAIDs at full anti-inflammatory doses, oral corticosteroids (prednisone 30-35 mg daily for 3-5 days), or colchicine (1.2 mg followed by 0.6 mg one hour later, maximum 1.8 mg over one hour), with the single most critical factor being early initiation within 12-24 hours of symptom onset, not which specific agent is chosen. 1, 2
First-Line Treatment Selection Algorithm
The choice among the three first-line agents should be guided by patient-specific contraindications rather than perceived superiority of one agent over another:
Choose Oral Corticosteroids (Prednisone 30-35 mg daily for 3-5 days) if patient has: 2, 3
- Chronic kidney disease (CKD stage ≥3) where NSAIDs are contraindicated 3
- Heart failure or uncontrolled hypertension 1, 3
- History of peptic ulcer disease or gastrointestinal bleeding 3
- Cirrhosis 3
- Severe renal or hepatic impairment making colchicine unsafe 3
- Cardiovascular disease 2
Corticosteroids are generally the safest and lowest-cost option for most patients with comorbidities. 3
Choose NSAIDs (at full FDA-approved anti-inflammatory doses) if patient has: 1, 2
- No renal impairment 1
- No cardiovascular disease 1
- No gastrointestinal contraindications 1
- No uncontrolled hypertension 1
Choose Colchicine (1.2 mg immediately, then 0.6 mg one hour later) if: 2, 4
- Treatment can be initiated within 12 hours of symptom onset (most effective window) 2
- Patient has no severe renal impairment 4
- Patient is not taking strong CYP3A4 or P-glycoprotein inhibitors (clarithromycin, ketoconazole, ritonavir, etc.) 4
- Maximum dose is 1.8 mg over one hour period 4
Alternative Routes for Specific Situations
For Monoarticular or Oligoarticular Flares (1-2 large joints):
- Intra-articular corticosteroid injection is highly effective and preferred 2
- Triamcinolone acetonide 40 mg intramuscularly is validated as effective 3
For Patients Unable to Take Oral Medications:
- Parenteral glucocorticoids (intramuscular, intravenous, or intra-articular) are strongly recommended over IL-1 inhibitors or ACTH 2
For Polyarticular Flares (≥4 joints):
- Systemic corticosteroids are particularly effective for flares with significant systemic inflammation 2, 5
Critical Management Principles During Acute Flare
Continue Urate-Lowering Therapy Without Interruption
If the patient is already on allopurinol or other urate-lowering therapy, continue it without interruption during the acute flare—stopping it will worsen the flare and complicate long-term management. 1, 2, 6
Starting Urate-Lowering Therapy During a Flare
- Urate-lowering therapy can be conditionally started during the acute flare with appropriate anti-inflammatory coverage, rather than waiting for resolution 1, 2
- If initiating allopurinol during a flare, start at low dose (≤100 mg/day, lower in CKD) 1, 6
Anti-Inflammatory Prophylaxis When Initiating Urate-Lowering Therapy
When starting any urate-lowering therapy, concomitant anti-inflammatory prophylaxis must be initiated and continued for 3-6 months to prevent treatment-induced flares. 1, 2
Prophylaxis Options: 1, 2
- Low-dose colchicine (0.5-0.6 mg once or twice daily) as first-line 2
- Low-dose NSAIDs as alternative 1
- Low-dose prednisone (<10 mg/day) 2
Adjunctive Non-Pharmacologic Measures
- Topical ice application to the affected joint is conditionally recommended as adjuvant therapy 2
- Rest of the inflamed joint 7
Critical Pitfalls to Avoid
Timing Errors:
- Delaying treatment initiation beyond 12-24 hours is the single most critical error—early intervention determines success more than drug choice. 1, 2
Colchicine Toxicity:
- Never use colchicine in patients with severe renal impairment or those on strong CYP3A4/P-glycoprotein inhibitors (clarithromycin, ketoconazole, ritonavir)—this can result in fatal toxicity. 2, 4
- Do not use high-dose colchicine regimens (dosing every hour)—they cause dangerous toxicity without greater efficacy 2
NSAID Contraindications:
- Never prescribe NSAIDs in elderly patients with renal impairment, heart failure, peptic ulcer disease, or cirrhosis—corticosteroids are safer. 2, 3
Urate-Lowering Therapy Errors:
- Never stop established urate-lowering therapy during an acute flare—this worsens the flare and complicates long-term management. 1, 2, 6
Special Populations
For Patients with Contraindications to All First-Line Agents:
- IL-1 inhibitors (canakinumab 150 mg subcutaneously) are conditionally recommended only for patients with frequent flares and contraindications to all first-line agents 2
- Current infection is an absolute contraindication to IL-1 blockers 2
Dose Adjustments in Chronic Kidney Disease:
- Colchicine requires dose adjustment in CKD 1, 4
- Allopurinol should start at ≤100 mg/day (or lower) in CKD stage ≥3 1, 6