What is the recommended management of an adult with an acute gout flare?

Treatment of Acute Gouty Arthritis

For an acute gout flare, immediately initiate monotherapy with corticosteroids, NSAIDs, or low-dose colchicine—all three are equally appropriate first-line options with strong evidence supporting their use. 1

Immediate Treatment Algorithm

Step 1: Initiate Anti-Inflammatory Therapy Within 24 Hours

Treatment should begin within 24 hours of symptom onset for optimal pain relief and resolution. 1 The choice among the three first-line agents depends on patient-specific contraindications and comorbidities, not on superiority of one class over another. 1

Step 2: Select First-Line Agent Based on Patient Factors

NSAIDs (Full Anti-Inflammatory Dose):

• Use FDA-approved doses for acute gout (naproxen, indomethacin, sulindac) or any NSAID at full anti-inflammatory dosing. 1
• Continue at full dose until the attack has completely resolved. 1
• Avoid in patients with: significant renal impairment (CrCl <30 mL/min), active peptic ulcer disease, heart failure, cirrhosis, or recent cardiovascular events. 2, 3

Low-Dose Colchicine:

• Dosing: 1.2 mg orally immediately, then 0.6 mg one hour later (total 1.8 mg). 1
• This low-dose regimen is equally effective as high-dose colchicine but produces significantly fewer gastrointestinal adverse events. 1, 2
• Must be started within 36 hours of symptom onset for optimal efficacy. 1, 2
• Avoid in patients with: severe renal impairment (CrCl <30 mL/min), severe hepatic impairment, or those on strong CYP3A4 or P-glycoprotein inhibitors. 1, 2

Corticosteroids:

• Oral prednisone: 0.5 mg/kg per day (typically 30–40 mg daily) for 5–10 days at full dose, then stop; OR 2–5 days at full dose followed by 7–10 day taper. 1, 2
• Intramuscular: Triamcinolone acetonide 60 mg IM, optionally followed by oral prednisone taper. 1
• Intra-articular: Dose varies by joint size; particularly valuable for monoarticular attacks. 1, 2, 3
• Corticosteroids are the preferred option in patients with renal disease, heart failure, cirrhosis, or contraindications to both NSAIDs and colchicine. 2, 3

Step 3: Continue Until Complete Resolution

Maintain the chosen anti-inflammatory agent at full therapeutic dose until the acute attack has completely resolved—typically 5–14 days depending on severity. 1, 2

Critical Management Principles

Do NOT Stop Urate-Lowering Therapy

If the patient is already on allopurinol, febuxostat, or another urate-lowering drug, continue it without interruption during the acute flare. 1 Stopping urate-lowering therapy during an attack can prolong symptoms and undermine long-term disease control. 2, 4

Do NOT Initiate Urate-Lowering Therapy During First Attack

Urate-lowering therapy should not be started during an acute gout attack in most patients, especially after a first attack or in those with infrequent attacks. 1 However, if already established on urate-lowering therapy, it should be continued. 1, 4

Adjunctive Non-Pharmacologic Measures

• Apply topical ice to the affected joint. 2, 5
• Rest the inflamed joint. 2, 5

Combination Therapy for Severe Polyarticular Attacks

For severe pain (>6/10 on visual analog scale) involving multiple large joints or polyarticular distribution, combination therapy with two anti-inflammatory agents from different classes is appropriate. 1 Common combinations include corticosteroids plus colchicine, or corticosteroids plus NSAIDs. 1

Alternative Therapy for Refractory Cases

Canakinumab (IL-1β inhibitor):

• FDA-approved for symptomatic treatment of adult patients with gout flares when NSAIDs and colchicine are contraindicated, not tolerated, or ineffective, and repeated corticosteroid courses are inappropriate. 6
• Dosing: 150 mg subcutaneously as a single dose. 6
• Minimum 12-week interval required before re-treatment. 6
• This biologic option is reserved for patients who have failed or cannot use all three conventional first-line therapies. 1, 6

Common Pitfalls to Avoid

Using high-dose colchicine: The traditional high-dose colchicine regimen (1.2 mg followed by 0.6 mg every hour) causes significantly more gastrointestinal toxicity without additional efficacy compared to low-dose (1.8 mg total). 1, 2

Delaying treatment initiation: Waiting beyond 24 hours from symptom onset reduces treatment effectiveness regardless of which agent is chosen. 1, 2

Stopping established urate-lowering therapy: Discontinuing allopurinol or febuxostat during an acute flare prolongs the attack and destabilizes long-term urate control. 1, 2

Inadequate treatment duration: Stopping anti-inflammatory therapy before complete resolution of symptoms leads to rebound flares. 1

Starting urate-lowering therapy during the acute attack: Initiating allopurinol or febuxostat during an acute flare can paradoxically worsen or prolong symptoms. 1 Wait until the attack has fully resolved before starting urate-lowering therapy in treatment-naïve patients.