What are the recommended medication doses and dosing schedules for treating an adult with an acute gout flare and for initiating chronic urate‑lowering therapy?

Medication Dosing and Frequency for Gout

Acute Gout Flare Treatment

Colchicine Dosing

For acute gout flares, administer colchicine 1.2 mg orally at the first sign of symptoms, followed by 0.6 mg one hour later (total 1.8 mg), then after a 12-hour pause resume 0.6 mg once or twice daily until the attack resolves—but only if treatment begins within 36 hours of symptom onset. 1, 2

• This low-dose regimen achieves ≥50% pain reduction with a number needed to treat of 3–5 and causes significantly fewer gastrointestinal adverse effects (23% diarrhea) compared to obsolete high-dose protocols (77% diarrhea). 1, 2
• Critical timing: Colchicine is most effective when started within 12 hours of symptom onset and should not be initiated after 36 hours, as efficacy declines sharply. 2, 3
• Absolute contraindications: Severe renal impairment (CrCl <30 mL/min) and concurrent use of strong CYP3A4 or P-glycoprotein inhibitors (clarithromycin, cyclosporine, ketoconazole, ritonavir, verapamil), especially with any renal or hepatic impairment—this combination can cause fatal toxicity. 1, 2, 4

NSAID Dosing

Use full FDA-approved anti-inflammatory doses throughout the entire attack without early tapering: 1, 2, 3

• Naproxen: 500 mg twice daily
• Indomethacin: 50 mg three times daily
• Sulindac: 200 mg twice daily

Continue at full dose until complete resolution of symptoms (typically 5–14 days). 3 No single NSAID has demonstrated superior efficacy; selection should be based on availability and patient tolerance. 2

Contraindications: Severe renal impairment (eGFR <30 mL/min), heart failure, cirrhosis, active peptic ulcer disease, or concurrent anticoagulation. 1, 2

Corticosteroid Dosing

Oral prednisone 0.5 mg/kg per day (approximately 30–35 mg) for 5–10 days provides Level A evidence of efficacy equivalent to NSAIDs. 1, 2 Two acceptable regimens: 2

• Give full dose for 5 days then stop abruptly, or
• Give full dose for 2–5 days followed by a 7–10 day taper

Intra-articular injection for mono- or oligoarticular involvement of large, accessible joints: 1, 2

• Knee: Triamcinolone acetonide 40 mg
• Ankle: Triamcinolone acetonide 20–30 mg

Intramuscular option: Triamcinolone acetonide 60 mg single injection for patients unable to take oral medications. 2

Combination Therapy for Severe Attacks

For polyarticular gout (≥4 joints) or severe attacks involving multiple large joints, initiate combination therapy: 1, 2, 3

• Colchicine + NSAID
• Oral corticosteroid + colchicine
• Intra-articular steroid + any oral agent

Avoid combining systemic NSAIDs with systemic corticosteroids due to synergistic gastrointestinal toxicity. 1, 2

Critical Timing for All Acute Treatments

Initiate therapy within 24 hours of symptom onset; delays beyond this window markedly reduce effectiveness of all agents. 1, 2, 3 The greatest therapeutic benefit occurs when treatment begins within 12–24 hours. 2

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Chronic Urate-Lowering Therapy (ULT)

When to Initiate ULT

Strong indications to start after first flare: 2

• Subcutaneous tophi
• Radiographic joint damage attributable to gout
• Chronic kidney disease stage ≥3

Conditional indications: 1, 2

• ≥2 gout attacks per year
• Serum urate >9 mg/dL
• Patient preference for early intervention
• Age <40 years at disease onset

Do not initiate ULT during an acute flare; wait until the attack has completely resolved. 2, 3, 4 However, do not discontinue existing ULT during an acute flare if the patient is already on therapy. 1, 2, 3

Allopurinol Dosing (First-Line ULT)

Start allopurinol at 100 mg daily (or 50 mg daily if CrCl 30–50 mL/min) and titrate upward by 100 mg every 2–4 weeks until serum urate falls below 6 mg/dL. 1, 2, 4

• Typical maintenance dose: 300–600 mg daily; maximum 800 mg daily. 2
• This "start low, go slow" approach reduces the risk of precipitating flares and allopurinol hypersensitivity syndrome. 2, 4

Febuxostat Dosing (Alternative ULT)

Start febuxostat at 40 mg daily and titrate to 80 mg (or 120 mg if needed) to achieve serum urate <6 mg/dL. 1, 2 Febuxostat does not require renal dose adjustment in mild-to-moderate chronic kidney disease. 2

Serum Urate Targets

Standard target: <6 mg/dL (360 µmol/L) for all gout patients, maintained lifelong. 2, 4

Aggressive target: <5 mg/dL (300 µmol/L) for severe gout with tophi, chronic arthropathy, or frequent attacks until crystal dissolution occurs. 2, 4

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Mandatory Prophylaxis During ULT Initiation

Colchicine Prophylaxis Dosing

When starting or adjusting ULT, prescribe colchicine 0.6 mg once or twice daily for at least 6 months to prevent acute flares triggered by urate mobilization. 1, 2, 4

Duration of prophylaxis: 2, 4

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

High-quality evidence shows colchicine prophylaxis reduces flare incidence from 77% to 33% during allopurinol initiation. 2 Stopping prophylaxis at 8 weeks leads to doubling of flare rates (from 20% to 40%). 2

Renal Dose Adjustments for Prophylaxis

• Mild-to-moderate renal impairment (CrCl 30–80 mL/min): Reduce to 0.6 mg once daily. 2
• Severe renal impairment (CrCl <30 mL/min): Start at 0.3 mg once daily or avoid entirely. 2, 4

Alternative Prophylaxis Options

If colchicine is contraindicated: 1, 2, 4

• Low-dose NSAID (e.g., naproxen 250 mg twice daily) plus proton-pump inhibitor
• Low-dose prednisone (<10 mg/day)

Continue alternative prophylaxis for the same duration (≥6 months). 2

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Common Pitfalls to Avoid

• Do not delay acute treatment beyond 24 hours—effectiveness declines sharply. 2, 3
• Do not start colchicine after 36 hours from symptom onset—efficacy drops dramatically. 2, 3
• Do not taper NSAIDs early—maintain full dose throughout the attack. 2, 3
• Do not initiate allopurinol at 300 mg daily—starting high increases flare and hypersensitivity risk. 2
• Do not stop ULT during an acute flare if already on therapy. 2, 3
• Do not omit colchicine prophylaxis when starting ULT—flare rates roughly double without it. 2
• Do not combine colchicine with strong CYP3A4/P-gp inhibitors in patients with any renal or hepatic impairment—fatal toxicity risk. 1, 2
• Do not use obsolete high-dose colchicine regimens (0.5 mg every 2 hours)—they cause severe diarrhea without added benefit. 2