What is the recommended acute treatment for a gout flare, including first‑line medication choices, dosing, and contraindications?

Acute Gout Flare Treatment

First-Line Medication Choices

For most patients with an acute gout flare, oral prednisone 30–35 mg once daily for 5 days is the preferred first-line treatment because it provides efficacy equal to NSAIDs and colchicine while offering superior safety, lower cost, and no need for dose tapering in uncomplicated attacks. 1, 2, 3

The three equally effective first-line options are:

• NSAIDs at full FDA-approved anti-inflammatory doses (naproxen 500 mg twice daily, indomethacin 50 mg three times daily, or sulindac 200 mg twice daily) continued until complete resolution 4, 1, 5
• Colchicine 1.2 mg immediately followed by 0.6 mg one hour later (total 1.8 mg), then 0.6 mg once or twice daily until attack resolves 4, 1, 5
• Oral corticosteroids (prednisone 30–35 mg daily for 5 days, or 0.5 mg/kg/day for 5–10 days) 4, 1, 2, 3

Critical Timing Considerations

Initiate treatment within 12–24 hours of symptom onset; delays beyond 24 hours markedly reduce effectiveness of all agents. 4, 1, 3

• Colchicine is most effective when started within 12 hours and should not be initiated after 36 hours from symptom onset 4, 1
• Early treatment is more important than which specific agent is chosen 1, 6

Dosing Regimens

Colchicine Dosing

• Acute flare: 1.2 mg (two 0.6 mg tablets) at first sign, followed by 0.6 mg one hour later 4, 1, 5
• Maintenance: After 12-hour pause, resume 0.6 mg once or twice daily until attack resolves 4, 1, 5
• Maximum dose: 1.8 mg over one hour period 4, 5
• The low-dose regimen (1.8 mg total) is as effective as high-dose colchicine (4.8 mg) but causes significantly fewer gastrointestinal side effects (23% vs 77% diarrhea rate) 1

NSAID Dosing

• Use full FDA-approved doses throughout the entire attack; do not taper early 4, 1, 3
• Naproxen 500 mg twice daily, indomethacin 50 mg three times daily, or sulindac 200 mg twice daily 4, 1
• No single NSAID has demonstrated superior efficacy 1

Corticosteroid Dosing

• Oral prednisone: 30–35 mg daily for 5 days (no taper needed), OR 0.5 mg/kg/day for 5–10 days then stop, OR 2–5 days at full dose followed by 7–10 day taper 4, 1, 2, 3
• Intramuscular: Triamcinolone acetonide 60 mg as single injection 1, 2, 3
• Intravenous: Methylprednisolone 0.5–2.0 mg/kg (40–140 mg) when oral route unavailable 1, 2, 3
• Intra-articular: For 1–2 large accessible joints (40 mg for knee, 20–30 mg for ankle) 4, 1, 2, 3

Absolute Contraindications

Colchicine Contraindications

• Severe renal impairment (eGFR <30 mL/min or CrCl <30 mL/min) – risk of fatal toxicity 4, 1, 3, 5
• Concurrent use of strong CYP3A4 or P-glycoprotein inhibitors (clarithromycin, erythromycin, cyclosporine, ketoconazole, ritonavir, verapamil), especially with any degree of renal or hepatic impairment – can cause fatal toxicity 4, 1, 3, 5

NSAID Contraindications

• Severe renal impairment (eGFR <30 mL/min) – risk of acute kidney injury 4, 1, 2, 3
• Active or recent gastrointestinal bleeding 1, 3
• Heart failure or significant cardiovascular disease 4, 1, 3
• Cirrhosis or hepatic impairment 4, 1, 3
• Anticoagulation therapy 1, 2, 3
• Active peptic ulcer disease 1, 2, 3

Corticosteroid Contraindications

• Active systemic fungal infection 1, 2, 3
• Current active infection (relative contraindication) 2, 3

Treatment Selection Algorithm

Step 1: Assess contraindications

• If eGFR <30 mL/min → use corticosteroids, avoid NSAIDs and colchicine 4, 1, 3
• If on strong CYP3A4/P-gp inhibitors → avoid colchicine 4, 1, 3
• If cardiovascular disease, heart failure, or peptic ulcer disease → avoid NSAIDs, prefer corticosteroids 1, 2, 3
• If active infection → avoid corticosteroids 2, 3

Step 2: Assess joint involvement

• If 1–2 accessible large joints → consider intra-articular corticosteroid injection 4, 1, 2, 3
• If polyarticular or severe attack → use oral prednisone 30–35 mg daily or consider combination therapy 1, 2, 3

Step 3: Assess timing

• If >36 hours since symptom onset → do not use colchicine; choose NSAID or corticosteroid 4, 1
• If within 12 hours → colchicine is most effective 4, 1

Step 4: Monitor response

• Inadequate response = <20% pain reduction within 24 hours OR <50% reduction after ≥24 hours 1, 2, 3
• If inadequate response → switch to alternative monotherapy or add second agent 1, 3

Combination Therapy for Severe Attacks

For polyarticular gout (≥4 joints) or severe attacks involving multiple large joints, initiate combination therapy with colchicine plus NSAID, oral corticosteroid plus colchicine, or intra-articular steroid plus any oral agent. 4, 1, 3

• Avoid combining NSAIDs with systemic corticosteroids due to synergistic gastrointestinal toxicity 1, 3
• Combination therapy provides synergistic anti-inflammatory effects targeting different pathways 1

Management of Ongoing Urate-Lowering Therapy

If the patient is already on allopurinol or febuxostat, continue the urate-lowering therapy throughout the acute flare; do not discontinue. 4, 1, 3

• Stopping urate-lowering therapy during a flare worsens outcomes and hampers long-term control 1, 3
• Treat the acute flare separately while maintaining the established urate-lowering regimen 1, 3

Prophylaxis When Initiating Urate-Lowering Therapy

When starting allopurinol or febuxostat, prescribe colchicine 0.6 mg once or twice daily for at least 6 months to prevent acute flares triggered by urate mobilization. 4, 1, 3

• Continue prophylaxis for 3 months after achieving serum urate <6 mg/dL if no tophi present, or 6 months if tophi present 1, 3
• If colchicine contraindicated, use low-dose NSAID with proton pump inhibitor or low-dose prednisone (<10 mg/day) as second-line prophylaxis 1, 2, 3

Special Populations

Elderly with Renal Impairment

• Prednisone 30–35 mg daily for 5 days is the safest option 1, 2, 3
• NSAIDs risk acute kidney injury 1, 2, 3
• Colchicine carries fatal toxicity risk in severe renal impairment 4, 1, 3

Patients with Diabetes

• Short-course corticosteroids (5–10 days) may raise blood glucose transiently 2
• Close glucose monitoring and proactive adjustment of diabetic medications are required 2
• Morning prednisone dosing produces disproportionate daytime hyperglycemia; increase prandial insulin during the day 2

Patients Unable to Take Oral Medications

• Intramuscular triamcinolone acetonide 60 mg is preferred over IL-1 inhibitors or ACTH 1, 2, 3
• Intravenous methylprednisolone 0.5–2.0 mg/kg (40–140 mg) can be repeated as needed 1, 2, 3

Patients with NSAID Allergies

• Colchicine can be safely used – it works through a different mechanism (inhibits microtubule polymerization) with no cross-reactivity with NSAIDs 1
• Oral corticosteroids are an excellent alternative 1, 2

Common Pitfalls to Avoid

• Do not delay treatment initiation – delays beyond 24 hours markedly reduce effectiveness 4, 1, 3
• Do not co-administer colchicine with strong CYP3A4/P-gp inhibitors – can be fatal 4, 1, 3, 5
• Do not taper NSAIDs early – maintain full dose throughout entire attack 4, 1, 3
• Do not stop urate-lowering therapy during a flare – continue allopurinol or febuxostat 4, 1, 3
• Do not use high-dose prednisone (>10 mg/day) for prophylaxis – increases adverse effects without proportional benefit 1, 2, 3
• Do not combine NSAIDs with systemic corticosteroids – synergistic gastrointestinal toxicity 1, 3
• Do not use the obsolete high-dose colchicine regimen (0.5 mg every 2 hours) – causes severe diarrhea in most patients with no additional benefit 1
• Do not initiate colchicine after 36 hours from symptom onset – efficacy drops sharply 4, 1

Adjunctive Measures

• Topical ice applied to the affected joint provides symptomatic relief 3, 6
• Rest the inflamed joint during acute attack 6