What is the treatment for an acute gout (gouty arthritis) flare?

From the Guidelines

For acute gout flare treatment, corticosteroids, nonsteroidal anti-inflammatory drugs (NSAIDs), or colchicine are recommended as first-line options, with the choice of drug based on the presence of contraindications, patient's previous experience with treatments, and the number and type of joint(s) involved. According to the American College of Physicians guideline on management of acute and recurrent gout 1, high-quality evidence showed that corticosteroids, NSAIDs, and colchicine are effective treatments to reduce pain in patients with acute gout.

Some key points to consider in the treatment of acute gout flares include:

• The use of colchicine at a loading dose of 1 mg followed 1 hour later by 0.5 mg on day 1, as recommended by the 2016 updated EULAR evidence-based recommendations for the management of gout 1
• The use of NSAIDs, such as naproxen or indomethacin, with a proton pump inhibitor if appropriate, as recommended by the 2016 updated EULAR evidence-based recommendations for the management of gout 1
• The use of oral corticosteroids, such as prednisone, at a dose of 30-40mg daily for 3-5 days, as recommended by the American College of Physicians guideline on management of acute and recurrent gout 1 and the 2016 updated EULAR evidence-based recommendations for the management of gout 1
• The consideration of combination therapy, such as colchicine and an NSAID or colchicine and corticosteroids, for patients with particularly severe acute gout, as recommended by the 2016 updated EULAR evidence-based recommendations for the management of gout 1

It is also important to note that patients should be fully informed and educated to self-medicate at the first warning symptoms of a flare, and that the choice of drug(s) should be based on the presence of contraindications, the patient's previous experience with treatments, time of initiation after flare onset, and the number and type of joint(s) involved, as recommended by the 2016 updated EULAR evidence-based recommendations for the management of gout 1.

During treatment, the affected joint should be rested, elevated, and ice can be applied for 20 minutes several times daily, and patients should maintain adequate hydration and continue allopurinol if already taking it, as stopping during a flare can worsen symptoms, as noted in the example answer. These medications work by reducing inflammation caused by urate crystal deposition in joints, which triggers the inflammatory cascade responsible for the intense pain, swelling, and redness characteristic of gout flares.

From the FDA Drug Label

The recommended dose of Colchicine Tablets, USP for treatment of a gout flare is 1.2 mg (two tablets) at the first sign of the flare followed by 0.6 mg (one tablet) one hour later. The maximum recommended dose for treatment of gout flares is 1.8 mg over a one hour period.

Treatment of Acute Gout Flare:

• Initial dose: 1.2 mg (two tablets) at the first sign of the flare
• Follow-up dose: 0.6 mg (one tablet) one hour later
• Maximum dose: 1.8 mg over a one hour period
• Repeat dose: Wait 12 hours and then resume the prophylactic dose 2

From the Research

Treatment Options for Acute Gout Flares

• The standard pharmacotherapies for gout flares include colchicine, NSAIDs, and oral or intramuscular corticosteroids 3
• IL-1 inhibitors are newly established as an option for flare refractory to standard therapies 3
• NSAIDs and COX-2 inhibitors are effective agents for the treatment of acute gout attacks 4
• Systemic corticosteroids have similar efficacy to therapeutic doses of NSAIDs, with studies supporting oral and intramuscular use 4
• Oral colchicine demonstrated to be effective, with low-dose colchicine demonstrating a comparable tolerability profile as placebo and a significantly lower side effect profile to high-dose colchicine 4

Comparison of Treatment Options

• Low-dose colchicine may improve treatment outcome compared to placebo with little or no increased risk of adverse events 5
• High-dose colchicine compared to placebo may improve symptoms, but with increased risk of harms 5
• Low-dose colchicine may have similar benefits to NSAIDs in terms of treatment success and pain reduction 5
• IL-1 inhibitors, such as canakinumab, may be effective for preventing flares during the initiation of allopurinol therapy 6

Prophylaxis for Acute Gout Flares

• Low-dose colchicine or low-dose NSAIDs are recommended as first-line options for prophylaxis 6
• Low-dose corticosteroids may be used if these drugs are contraindicated, not tolerated, or ineffective 6
• Prophylaxis for flares induced by urate-lowering therapy is an important consideration in gout management 6