What is the recommended management of an acute gout flare, including first‑line NSAIDs, colchicine dosing, and alternative glucocorticoid options?

Acute Gout Flare Treatment

For an acute gout flare, initiate treatment within 24 hours using NSAIDs, colchicine, or oral corticosteroids as equally effective first-line monotherapy options, with selection based on renal function, cardiovascular risk, and gastrointestinal comorbidities. 1

First-Line Treatment Selection Algorithm

Step 1: Assess contraindications and comorbidities

• Severe renal impairment (eGFR <30 mL/min): Use oral corticosteroids (prednisone 30-35 mg daily for 5 days); avoid NSAIDs and colchicine 1, 2
• Cardiovascular disease or heart failure: Prefer corticosteroids over NSAIDs 2
• Active peptic ulcer disease or recent GI bleeding: Use corticosteroids or intra-articular injection; avoid NSAIDs 2
• Concurrent strong CYP3A4/P-glycoprotein inhibitors (clarithromycin, cyclosporine, ketoconazole, ritonavir, verapamil): Absolutely contraindicate colchicine; use corticosteroids or NSAIDs 1, 3
• Symptom onset >36 hours: Do not use colchicine; select NSAID or corticosteroid 3

Step 2: Choose first-line agent based on patient profile

NSAIDs (if no contraindications)

• Dosing: Naproxen 500 mg twice daily, indomethacin 50 mg three times daily, or sulindac 200 mg twice daily 3
• Duration: Continue full dose throughout entire attack until complete resolution; do not taper early 1, 3
• Efficacy: All NSAIDs demonstrate equivalent effectiveness; no single agent is superior 3

Colchicine (if presenting ≤36 hours from onset)

• Loading dose: 1.2 mg orally at first sign of flare, followed 1 hour later by 0.6 mg (total 1.8 mg) 1, 3
• Maintenance: After 12-hour pause, resume 0.6 mg once or twice daily until attack resolves 1, 3
• Efficacy: Achieves ≥50% pain reduction with NNT of 3-5, equivalent to high-dose regimens but with 23% vs 77% diarrhea rate 3
• Renal adjustment: In moderate impairment (CrCl 30-80 mL/min), use standard loading dose with close monitoring; reduce maintenance to 0.6 mg once daily 3

Oral Corticosteroids (preferred in renal/cardiac/GI disease)

• Dosing: Prednisone 0.5 mg/kg/day (approximately 30-35 mg) for 5-10 days at full dose then stop, OR 2-5 days at full dose followed by 7-10 day taper 1, 2
• Evidence: Level A evidence for equivalent efficacy to NSAIDs with fewer adverse events (27% vs 63% with indomethacin) 2
• No dose adjustment required for renal impairment 2

Intra-articular Corticosteroid Injection (for monoarticular involvement)

• Indication: 1-2 large, accessible joints 1, 2
• Dosing: Triamcinolone acetonide 40 mg for knee, 20-30 mg for ankle 2
• Advantage: Minimal systemic effects with targeted local control 2

Combination Therapy for Severe Attacks

Initiate combination therapy when:

• Polyarticular involvement (≥4 joints) 3
• Multiple large joints affected 1, 3
• Severe pain requiring rapid control 2

Recommended combinations:

• Colchicine + NSAID (synergistic anti-inflammatory effects) 3
• Oral corticosteroid + colchicine 1, 3
• Intra-articular steroid + any oral agent 1, 3

Avoid: NSAID + systemic corticosteroid (synergistic GI toxicity) 1, 3

Parenteral Options (when oral route unavailable)

• Intramuscular triamcinolone acetonide 60 mg as single injection 1, 2
• Intravenous methylprednisolone 0.5-2.0 mg/kg (40-140 mg for most adults), repeat as needed 2
• Strongly recommended over IL-1 inhibitors or ACTH for NPO patients 1, 2

Management of Ongoing Urate-Lowering Therapy

Do not discontinue allopurinol or febuxostat during an acute flare if already prescribed 1, 3

Do not initiate new urate-lowering therapy until flare completely resolves 3

Prophylaxis When Starting Urate-Lowering Therapy

• Colchicine 0.6 mg once or twice daily for at least 6 months when initiating allopurinol or febuxostat 1, 3
• Continue until serum urate <6 mg/dL achieved AND no clinical gout activity 3
• Alternative: Low-dose NSAID with PPI, or low-dose prednisone (<10 mg/day) as second-line 1, 3

Adjunctive Therapy

• Topical ice conditionally recommended as adjuvant treatment 1

Critical Timing Considerations

• Optimal window: Initiate treatment within 12-24 hours of symptom onset 1, 3
• Maximum efficacy for colchicine: Within 36 hours; do not start beyond this window 1, 3
• Delays beyond 24 hours markedly reduce effectiveness of all agents 3

Common Pitfalls to Avoid

• Never use obsolete high-dose colchicine regimen (0.5 mg every 2 hours); causes severe diarrhea in most patients with no additional benefit 3
• Never combine colchicine with strong CYP3A4/P-gp inhibitors in any patient with renal or hepatic impairment; risk of fatal toxicity 1, 3
• Never taper NSAIDs early; maintain full dose throughout entire attack 3
• Never use high-dose prednisone (>10 mg/day) for prophylaxis; increases adverse effects without proportional benefit 2
• Never prescribe colchicine to patients on verapamil; life-threatening interaction with 93-103% increase in colchicine levels 3

Monitoring for Inadequate Response

Define treatment failure as:

• <20% pain improvement within 24 hours, OR
• <50% improvement at ≥24 hours after initiating therapy 2

If inadequate response: Consider alternative diagnosis, switch to different monotherapy, or add second agent 2