How should I treat an acute gouty arthritis flare, including first‑line anti‑inflammatory therapy and initiation of long‑term urate‑lowering treatment?

Acute Gouty Arthritis Flare Management

Immediate First-Line Treatment

Initiate pharmacologic therapy within 24 hours of symptom onset using NSAIDs, colchicine, or corticosteroids—the choice depends on renal function, cardiovascular risk, and drug interactions. 1, 2

NSAID Therapy

• Prescribe full FDA-approved anti-inflammatory doses: naproxen 500 mg twice daily, indomethacin 50 mg three times daily, or sulindac 200 mg twice daily 1, 2
• Continue at full dose throughout the entire attack until complete resolution—do not taper early 1, 2
• Contraindications: severe renal impairment (eGFR <30 mL/min), heart failure, cirrhosis, active peptic ulcer disease, or concurrent anticoagulation 1, 2

Colchicine Regimen

• Loading dose: 1.2 mg orally at first sign of flare, followed 1 hour later by 0.6 mg (total 1.8 mg) 2, 3
• After a 12-hour pause, resume 0.6 mg once or twice daily until the attack resolves 2, 3
• Critical timing: Must be started within 36 hours of symptom onset; efficacy drops sharply after this window 1, 2
• Absolute contraindications:
  • Severe renal impairment (CrCl <30 mL/min) 2, 4
  • Concurrent use of strong CYP3A4 or P-glycoprotein inhibitors (clarithromycin, cyclosporine, ketoconazole, ritonavir, verapamil), especially with any renal or hepatic impairment 1, 2, 3

Corticosteroid Options

• Oral prednisone: 0.5 mg/kg/day (approximately 30–35 mg) for 5–10 days, then stop or taper over 7–10 days 1, 2
• Intra-articular injection: For 1–2 large accessible joints, use triamcinolone acetonide 40 mg for knee, 20–30 mg for ankle 1, 2
• Intramuscular option: Triamcinolone acetonide 60 mg single injection for patients unable to take oral medications 1, 2
• Preferred in: severe renal impairment, heart failure, cirrhosis, or when colchicine/NSAIDs are contraindicated 2, 4

Combination Therapy for Severe Attacks

• Indications: Polyarticular gout (≥4 joints) or multiple large joints involved 1, 2
• Recommended combinations: colchicine + NSAID, oral corticosteroid + colchicine, or intra-articular steroid + any oral agent 1, 2
• Avoid: NSAIDs combined with systemic corticosteroids due to synergistic gastrointestinal toxicity 1, 2

Management of Ongoing Urate-Lowering Therapy

Continue existing allopurinol or febuxostat without interruption during an acute flare—do not stop urate-lowering therapy. 1, 2, 5

Initiation of Long-Term Urate-Lowering Treatment

When to Start ULT

• Strong indications (initiate after first flare): subcutaneous tophi, radiographic joint damage, or chronic kidney disease stage ≥3 2
• Conditional indications: patient preference, age <40 years at onset, serum urate >9 mg/dL, or ≥2 attacks per year 2
• Do not start ULT during an acute flare—wait until the attack has completely resolved 2

Allopurinol Initiation Protocol

• Starting dose: 100 mg daily (or 50 mg daily if CrCl 30–50 mL/min) 2, 6
• Titration: Increase by 100 mg every 2–4 weeks until serum urate <6 mg/dL is achieved 2, 6
• Target serum urate: <6 mg/dL for all patients; <5 mg/dL for those with tophi or chronic arthropathy 2
• Typical maintenance dose: 300–600 mg daily; maximum 800 mg daily 2, 6

Anti-Inflammatory Prophylaxis During ULT Initiation

Provide colchicine prophylaxis (0.6 mg once or twice daily) for at least 6 months when starting urate-lowering therapy to prevent recurrent flares. 1, 2

Prophylaxis Duration

• Continue for at least 6 months, or 3 months after achieving target serum urate <6 mg/dL if no tophi are present 1, 2
• If tophi are present, continue for 6 months after achieving target serum urate 1, 2

Alternative Prophylaxis Options

• Second-line: Low-dose NSAID (e.g., naproxen 250 mg twice daily) with proton pump inhibitor 1, 2
• Third-line: Low-dose prednisone (<10 mg/day) if colchicine and NSAIDs are both contraindicated 1, 2

Critical Timing Considerations

• Optimal window: Treatment initiated within 12–24 hours provides maximum benefit 2
• Colchicine-specific: Must be started within 36 hours; do not initiate after this window 1, 2
• Delays beyond 24 hours markedly reduce effectiveness of all agents 1, 2

Common Pitfalls to Avoid

• Do not delay treatment beyond 24 hours—effectiveness declines sharply 1, 2
• Do not combine colchicine with strong CYP3A4/P-gp inhibitors in patients with any renal or hepatic impairment—risk of fatal toxicity 1, 2, 3
• Do not taper NSAIDs early—maintain full dose throughout the attack 1, 2
• Do not initiate allopurinol at 300 mg daily—start low to reduce flare risk and hypersensitivity syndrome 2, 6
• Do not omit prophylaxis when starting ULT—flare rates increase from 33% to 77% without it 2
• Do not stop urate-lowering therapy during an acute flare if already established 1, 2, 5