What are the recommended treatments for an acute gout flare?

Treatment of Acute Gout Flare

For an acute gout flare, start treatment immediately—within 12 hours of symptom onset—with oral prednisone 30–35 mg daily for 5 days, colchicine 1.2 mg followed by 0.6 mg one hour later, or a full-dose NSAID; all three are equally effective, but early initiation matters far more than which drug you choose. 1, 2, 3

First-Line Treatment Selection Algorithm

Step 1: Assess contraindications and comorbidities

• Choose oral corticosteroids (prednisone 30–35 mg daily for 5 days) if the patient has: 1, 2

  • Severe renal impairment (eGFR <30 mL/min) 1, 2
  • Cardiovascular disease or heart failure 2, 3
  • Peptic ulcer disease or GI bleeding risk 2
  • Uncontrolled hypertension 3
  • Cirrhosis or hepatic impairment 2

• Choose colchicine (1.2 mg then 0.6 mg one hour later, max 1.8 mg) if: 1, 4

  • Treatment can start within 12 hours of symptom onset 1, 3
  • No severe renal impairment 1
  • Patient is NOT on strong CYP3A4 or P-glycoprotein inhibitors (clarithromycin, cyclosporine, ritonavir, ketoconazole) 1, 4

• Choose NSAIDs (full anti-inflammatory dose) only if: 1, 3

  • No renal impairment 3
  • No cardiovascular disease 3
  • No GI contraindications 3
  • No heart failure or uncontrolled hypertension 3
  • Add a proton pump inhibitor if any GI risk factors exist 1, 5

Step 2: Consider route of administration based on joint involvement

• Intra-articular corticosteroid injection for monoarticular or oligoarticular involvement (1–2 large accessible joints) 1, 2, 3
• Intramuscular triamcinolone acetonide 60 mg if patient is NPO, cannot tolerate oral medications, or needs rapid relief 2
• Intravenous methylprednisolone 0.5–2.0 mg/kg for patients unable to take oral medications due to surgical or medical conditions 2

Step 3: Escalate for severe or polyarticular flares

• For severe attacks or polyarticular involvement, use combination therapy: oral corticosteroids plus colchicine, or intra-articular steroids with any oral agent 2, 3

Critical Dosing Details

Oral Corticosteroids

• Prednisone 0.5 mg/kg/day (approximately 30–35 mg for average adults) 1, 2
• Two acceptable regimens: 2
  • 5–10 days at full dose, then stop abruptly (for straightforward monoarticular cases)
  • 2–5 days at full dose, then taper over 7–10 days (for severe attacks, polyarticular involvement, or patients at risk for rebound)

Colchicine

• 1.2 mg (two 0.6 mg tablets) immediately, followed by 0.6 mg one hour later 1, 4
• Maximum dose: 1.8 mg over one hour 4
• Do NOT use high-dose hourly regimens—they cause dangerous toxicity without added benefit 3, 4
• If patient is already on prophylactic colchicine, give the flare dose then wait 12 hours before resuming prophylaxis 4

NSAIDs

• Use full FDA-approved anti-inflammatory doses (e.g., naproxen 500 mg twice daily, indomethacin 50 mg three times daily) 3, 5

Management of Urate-Lowering Therapy During Flare

Do NOT stop existing urate-lowering therapy (allopurinol, febuxostat) during an acute flare—stopping worsens the flare and complicates long-term control. 3, 5

You may start urate-lowering therapy during an acute flare if adequate anti-inflammatory coverage is provided, though this is a conditional recommendation. 3, 5

When initiating urate-lowering therapy (whether during or after a flare), provide concomitant anti-inflammatory prophylaxis for 3–6 months: 1, 3

• First-line prophylaxis: low-dose colchicine 0.5–0.6 mg once or twice daily 1, 3
• Second-line alternatives: low-dose NSAIDs or prednisone <10 mg/day 1, 3
• Never use prednisone >10 mg/day for prophylaxis—it increases adverse effects without proportional benefit 2

Special Populations and Dose Adjustments

Renal Impairment

• Corticosteroids are the safest choice—no dose adjustment required 2
• Avoid NSAIDs entirely in severe renal impairment (eGFR <30 mL/min)—they can precipitate acute kidney injury 1, 2
• Colchicine requires dose reduction in renal impairment and is contraindicated in severe renal failure 1, 4

Drug Interactions with Colchicine

If patient is on strong CYP3A4 or P-glycoprotein inhibitors (clarithromycin, cyclosporine, ritonavir, ketoconazole, itraconazole): 1, 4

• For gout flare treatment: reduce to 0.6 mg × 1 dose, then 0.3 mg one hour later; do not repeat for 3 days 4
• For prophylaxis: reduce to 0.3 mg once daily 4
• Absolute contraindication: do not give colchicine with these drugs if severe renal or hepatic impairment coexists 1

Diabetes

• Short-term corticosteroids (5–10 days) are safe but cause transient hyperglycemia 2
• Increase prandial insulin proactively—morning prednisone causes disproportionate daytime hyperglycemia 2
• Monitor blood glucose closely and adjust diabetic medications before starting steroids 2

Adjunctive Measures

• Apply topical ice to the affected joint for additional pain relief 3, 5
• Rest the inflamed joint 6

Monitoring Response and Inadequate Response

Define inadequate response as: 2, 3

• <20% improvement in pain within 24 hours, OR
• <50% improvement at ≥24 hours after starting therapy

If inadequate response occurs: 2, 3

• Consider alternative diagnoses (septic arthritis, pseudogout)
• Switch to another first-line monotherapy
• Add a second agent (combination therapy)

Critical Pitfalls to Avoid

• Delaying treatment beyond 12–24 hours—early initiation is the single most important determinant of success 3, 5
• Using colchicine in severe renal impairment or with strong CYP3A4/P-gp inhibitors—can cause fatal toxicity 1, 3, 4
• Prescribing NSAIDs in elderly patients with renal impairment, heart failure, or peptic ulcer disease 2, 3
• Stopping urate-lowering therapy during a flare—worsens the attack and complicates long-term management 3, 5
• Using high-dose colchicine regimens (hourly dosing)—causes severe GI toxicity without added efficacy 3, 4
• Using prednisone >10 mg/day for prophylaxis—increases adverse effects without benefit 2

When to Consider IL-1 Inhibitors

IL-1 blockers (canakinumab 150 mg subcutaneously) are reserved for patients with: 1, 3

• Contraindications to ALL first-line agents (colchicine, NSAIDs, corticosteroids)
• Frequent flares despite optimal management
• Absolute contraindication: current active infection 1