From the Guidelines
The best inpatient treatment for an acute gout flare typically involves NSAIDs, colchicine, or corticosteroids, with the choice depending on patient-specific factors, as recommended by the 2020 American College of Rheumatology guideline for the management of gout 1. For most patients without contraindications, oral NSAIDs like indomethacin (50mg three times daily) or naproxen (500mg twice daily) for 5-7 days are effective first-line options.
- Colchicine can be administered as 1.2mg initially, followed by 0.6mg one hour later, then 0.6mg once or twice daily until flare resolution.
- For patients with contraindications to NSAIDs or colchicine, systemic corticosteroids such as prednisone (30-40mg daily, tapered over 7-10 days) or methylprednisolone (80-120mg IV initially, followed by oral prednisone) are appropriate.
- In severe cases or polyarticular gout, intra-articular corticosteroid injections may provide targeted relief. Supportive measures include joint rest, elevation, ice application, and adequate hydration. Urate-lowering therapy should not be initiated during an acute flare but can be continued if the patient was already taking it, as supported by the 2016 updated EULAR evidence-based recommendations for the management of gout 1. These treatments work by reducing inflammation caused by monosodium urate crystal deposition in joints, with each medication targeting different inflammatory pathways. It is essential to consider patient-specific factors, such as renal function and potential drug interactions, when selecting a treatment option, as highlighted in the management of acute and recurrent gout guidelines from the American College of Physicians 1.
From the FDA Drug Label
Treatment of gout flares with Colchicine Tablets, USP is not recommended in patients receiving prophylactic dose of Colchicine Tablets, USP and CYP3A4 inhibitors. For treatment of gout flares in patients with mild (Cl cr 50 to 80 mL/min) to moderate (Cl cr 30 to 50 mL/min) renal function impairment, adjustment of the recommended dose is not required, but patients should be monitored closely for adverse effects of colchicine However, in patients with severe impairment, while the dose does not need to be adjusted for the treatment of gout flares, a treatment course should be repeated no more than once every two weeks.
The best treatment as an inpatient for acute flare of gout is not explicitly stated in the provided drug label. However, colchicine can be used for the treatment of gout flares.
- The dose for patients with mild to moderate renal impairment does not need to be adjusted, but patients should be monitored closely for adverse effects.
- For patients with severe renal impairment, the treatment course should be repeated no more than once every two weeks.
- For patients undergoing dialysis, the total recommended dose for the treatment of gout flares should be reduced to a single dose of 0.6 mg (one tablet) and the treatment course should not be repeated more than once every two weeks 2.
From the Research
Treatment Options for Acute Flare of Gout
- Standard pharmacotherapies for gout flares include colchicine, NSAIDs, and oral or intramuscular corticosteroids, with IL-1 inhibitors as an option for flare refractory to standard therapies 3
- Colchicine, NSAIDs, and systemic corticosteroids are commonly prescribed treatments for gout flares in acute care settings 4
- Low-dose colchicine (0.6 mg/day) can adequately prevent gout flare with fewer adverse events compared to regular-dose colchicine (1.2 mg/day) 5
First-Line Agents for Gout Flares
- NSAIDs, colchicine, and glucocorticoids are first-line agents for gout flares 6
- IL-1β antagonists are highly effective for arresting flares but are considered salvage therapies due to their cost-effectiveness 6
Urate-Lowering Therapy
- Allopurinol is an agent of first choice for urate-lowering therapy, but screening for HLA*B58:01 mutation is recommended in certain populations to decrease the occurrence of allopurinol hypersensitivity syndrome 6
- Febuxostat is another efficacious urate-lowering therapy, but has received a U.S. FDA black box warning for cardiovascular safety 6