How should I manage an acute gout flare?

Management of Acute Gout Flare

Initiate treatment within 12 hours of symptom onset with colchicine, NSAIDs, or oral corticosteroids—these three agents are equally effective, and early timing matters far more than which drug you choose. 1

Immediate Treatment Selection Algorithm

Base your first-line agent on renal function, cardiovascular status, and drug interactions:

Choose Oral Corticosteroids When:

• Severe renal impairment (eGFR < 30 mL/min) exists—both NSAIDs and colchicine are contraindicated 1, 2
• Heart failure or uncontrolled hypertension is present—NSAIDs worsen both conditions 1, 2
• Active peptic ulcer disease or recent GI bleeding exists—NSAIDs carry unacceptable bleeding risk 1, 2
• Patient is on anticoagulation—corticosteroids avoid the synergistic bleeding risk of NSAIDs 2
• Cirrhosis or significant hepatic disease is present—NSAIDs are contraindicated 1, 2

Dosing: Prednisone 30–35 mg orally once daily for 5 days, then stop abruptly (no taper needed for short courses). 1, 2 Alternative: 0.5 mg/kg/day for 5–10 days. 1

Choose Colchicine When:

• Symptom onset is ≤ 12 hours (efficacy drops sharply after 36 hours) 1, 3
• No severe renal impairment (CrCl ≥ 30 mL/min) 1, 4
• Patient is NOT taking strong CYP3A4 or P-glycoprotein inhibitors (clarithromycin, erythromycin, cyclosporine, ketoconazole, ritonavir, verapamil)—combination causes fatal toxicity 1, 4

Dosing: 1.2 mg immediately, then 0.6 mg one hour later (total 1.8 mg). After a 12-hour pause, give 0.6 mg once or twice daily until the flare resolves. 1, 2 This low-dose regimen achieves 50% pain reduction with far fewer GI side effects (23% diarrhea) than obsolete high-dose protocols (77% diarrhea). 1

Choose NSAIDs When:

• Normal renal function (eGFR ≥ 50 mL/min) 1, 2
• No cardiovascular disease, heart failure, or uncontrolled hypertension 1, 2
• No GI contraindications (no active ulcer, no recent bleeding) 1, 2
• Not on anticoagulation 2

Dosing: Use full FDA-approved anti-inflammatory doses for the entire attack—naproxen 500 mg twice daily, indomethacin 50 mg three times daily, or sulindac 200 mg twice daily. 1, 2 Do not taper early. 1 Add a proton-pump inhibitor if any GI risk factors exist. 1

Special Population Adjustments

Moderate Renal Impairment (CrCl 30–50 mL/min):

• Colchicine: Use standard acute dosing (1.2 mg then 0.6 mg) but monitor closely; reduce prophylactic dose to 0.6 mg once daily 4
• NSAIDs: Use with extreme caution and close monitoring 1, 4
• Corticosteroids: No dose adjustment needed—safest choice 2, 4

Severe Renal Impairment (CrCl < 30 mL/min):

• Colchicine: For acute flare, use standard dose but repeat course no more than once every 2 weeks; for dialysis patients, give single 0.6 mg dose only, repeat no more than once every 2 weeks 4
• NSAIDs: Absolutely contraindicated 1, 2
• Corticosteroids: Preferred option, no adjustment needed 2, 4

Hepatic Impairment:

• Mild-to-moderate: No colchicine dose adjustment for acute flare, but monitor closely 4
• Severe: Repeat colchicine courses no more than once every 2 weeks; consider dose reduction for prophylaxis 4

Management of Existing Urate-Lowering Therapy

Do NOT stop allopurinol or febuxostat during an acute flare—continuing ULT does not worsen the attack and maintains long-term control. 1, 3, 2 Treat the flare separately while keeping ULT unchanged. 1, 3

When to Add a Second Agent

For severe or polyarticular attacks (≥ 4 joints), initiate combination therapy: 1, 3

• Colchicine + NSAID 1
• Oral corticosteroid + colchicine 1
• Intra-articular steroid + any oral agent 1

Never combine systemic NSAIDs with systemic corticosteroids—synergistic GI toxicity. 1, 2

Alternative Options

Intra-articular Corticosteroid Injection:

For monoarticular gout in one or two large, accessible joints (knee, ankle), inject triamcinolone acetonide 40 mg (knee) or 20–30 mg (ankle). 1, 3 This avoids systemic drug exposure. 1

Parenteral Corticosteroids:

For patients unable to take oral medication, give intramuscular triamcinolone acetonide 60 mg as a single injection. 1, 3

Adjunctive Measures

Apply topical ice to the affected joint—provides additional pain relief. 3, 2

Critical Pitfalls to Avoid

• Delaying treatment beyond 12–24 hours—efficacy drops dramatically 1, 2
• Starting colchicine after 36 hours from symptom onset—ineffective 1, 3
• Using colchicine with CYP3A4/P-gp inhibitors in any patient with renal or hepatic impairment—fatal toxicity risk 1, 4
• Prescribing NSAIDs in severe renal impairment, heart failure, or active GI disease—unacceptable adverse event risk 1, 2
• Tapering NSAIDs early—maintain full dose throughout the attack 1, 2
• Using obsolete high-dose colchicine regimens (0.5 mg every 2 hours)—severe diarrhea without added benefit 1
• Stopping allopurinol or febuxostat during the flare—worsens the attack and complicates long-term management 1, 3, 2