What is the first‑line treatment for an acute gout flare in an adult without contraindications?

First-Line Treatment for Acute Gout

For an adult without contraindications experiencing an acute gout flare, NSAIDs, colchicine, or oral corticosteroids are equally appropriate first-line monotherapy options, with treatment initiated within 24 hours of symptom onset for maximal efficacy. 1

Treatment Selection Algorithm

The choice among the three first-line agents should be guided by:

• Renal function: If eGFR ≥30 mL/min, all three options are appropriate; if eGFR <30 mL/min, use oral corticosteroids only and avoid NSAIDs and colchicine 1, 2
• Cardiovascular status: In patients with heart failure or established cardiovascular disease, prefer corticosteroids over NSAIDs 1, 2
• Gastrointestinal risk: In patients with active peptic ulcer disease or recent GI bleeding, avoid NSAIDs and select corticosteroids or colchicine 1, 2
• Drug interactions: If the patient is receiving strong CYP3A4 or P-glycoprotein inhibitors (clarithromycin, cyclosporine, ketoconazole, ritonavir, verapamil), colchicine is absolutely contraindicated—choose NSAIDs or corticosteroids 1
• Time from symptom onset: Colchicine should only be started within 36 hours of symptom onset; beyond this window, efficacy drops sharply 1

NSAID Regimen

• Prescribe full FDA-approved anti-inflammatory doses (naproxen 500 mg twice daily, indomethacin 50 mg three times daily, or sulindac 200 mg twice daily) and maintain the full dose throughout the entire attack until complete resolution 1
• Do not taper NSAIDs early; premature dose reduction compromises treatment success 1
• No single NSAID is superior to others for gout treatment; selection should be based on availability and individual tolerance 1

Colchicine Regimen

• Loading dose: 1.2 mg orally at the first sign of flare, followed 1 hour later by 0.6 mg (total 1.8 mg over one hour) 1, 3
• Maintenance: After a 12-hour pause, give 0.6 mg once or twice daily until the attack resolves 1, 3
• 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 regimens (77% diarrhea) 1
• Maximum efficacy is achieved when started within 12 hours of symptom onset; do not initiate after 36 hours 1

Corticosteroid Regimen

• Oral prednisone 0.5 mg/kg per day (approximately 30–35 mg daily) for 5–10 days at full dose then stop abruptly, or alternatively give for 2–5 days at full dose followed by a 7–10 day taper 1, 2
• Level A evidence supports corticosteroids as equally effective as NSAIDs with fewer adverse events (27% vs 63%) 1, 2
• For monoarticular or oligoarticular involvement of 1–2 large, accessible joints, intra-articular corticosteroid injection (triamcinolone acetonide 40 mg for knee, 20–30 mg for ankle) is an excellent alternative 1, 2

Critical Timing Considerations

• Initiate treatment within 24 hours of symptom onset; delays beyond this window markedly reduce the effectiveness of all agents 1, 4
• The optimal therapeutic window is within the first 12–24 hours for maximum benefit 1

Combination Therapy for Severe Attacks

• For polyarticular gout (≥4 joints) or severe attacks involving multiple large joints, initiate combination therapy such as colchicine + NSAID, oral corticosteroid + colchicine, or intra-articular steroid + any oral agent 1
• Avoid combining systemic NSAIDs with systemic corticosteroids due to synergistic gastrointestinal toxicity 1

Common Pitfalls to Avoid

• Do not delay treatment beyond 24 hours—effectiveness declines sharply 1, 4
• Do not start colchicine after 36 hours from symptom onset 1
• Do not use obsolete high-dose colchicine regimens (0.5 mg every 2 hours); they cause severe diarrhea without added benefit 1
• Do not combine colchicine with strong CYP3A4/P-gp inhibitors in patients with any renal or hepatic impairment due to fatal toxicity risk 1
• Do not taper NSAIDs early; maintain full dose throughout the attack 1