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

From the Guidelines

The most effective treatment for acute gout flare is to start therapy as early as possible, with first-line options including colchicine, NSAIDs, or oral corticosteroids, based on the presence of contraindications and the patient's previous experience with treatments. When treating acute gout flares, it is essential to consider the patient's medical history, current medications, and potential contraindications to certain treatments.

• The choice of drug(s) should be based on several factors, including 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 1.
• Recommended first-line options for acute flares are colchicine (within 12 hours of flare onset) at a loading dose of 1 mg followed 1 hour later by 0.5 mg on day 1 and/or an NSAID (plus proton pump inhibitors if appropriate), oral corticosteroid (30–35 mg/day of equivalent prednisolone for 3–5 days) or articular aspiration and injection of corticosteroids 1.
• Colchicine and NSAIDs should be avoided in patients with severe renal impairment, and colchicine should not be given to patients receiving strong P-glycoprotein and/or CYP3A4 inhibitors such as cyclosporin or clarithromycin 1.
• In patients with frequent flares and contraindications to colchicine, NSAIDs, and corticosteroid (oral and injectable), IL-1 blockers should be considered for treating flares, with the caveat that current infection is a contraindication to the use of IL-1 blockers 1.
• It is crucial to educate patients on lifestyle modifications, including weight loss if appropriate, avoidance of alcohol (especially beer and spirits) and sugar-sweetened drinks, heavy meals, and excessive intake of meat and seafood, as well as encouraging low-fat dairy products and regular exercise 1.

From the FDA Drug Label

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. 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). For these patients, the treatment course should not be repeated more than once every two weeks

The recommended treatment guidelines for acute gout flare are as follows:

• For patients with mild to moderate renal impairment, the dose does not need to be adjusted, but monitoring for adverse effects is necessary.
• For patients with severe renal impairment, the treatment course should not be repeated more than once every two weeks.
• For patients undergoing dialysis, the total recommended dose should be reduced to a single dose of 0.6 mg, and the treatment course should not be repeated more than once every two weeks 2.

From the Research

Treatment Guidelines for Acute Gout Flare

• The treatment of acute gout flare typically involves the use of nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, or colchicine 3, 4, 5.
• NSAIDs and COX-2 inhibitors are effective agents for the treatment of acute gout attacks, with systemic corticosteroids having similar efficacy to therapeutic doses of NSAIDs 4.
• Low-dose colchicine has been demonstrated to be effective, with a comparable tolerability profile to placebo and a significantly lower side effect profile compared to high-dose colchicine 4.
• The IL-1β inhibitory antibody, canakinumab, has been shown to be effective for the treatment of acute attacks in subjects refractory to and in those with contraindications to NSAIDs and/or colchicine 4, 6.
• Prophylaxis for acute gout flares after initiation of urate-lowering therapy is an important consideration in gout management, with low-dose colchicine and low-dose NSAIDs being the recommended first-line therapies 6.

Non-Pharmacologic Measures

• Patients should limit their consumption of certain purine-rich foods (e.g., organ meats, shellfish) and avoid alcoholic drinks (especially beer) and beverages sweetened with high-fructose corn syrup 3.
• Consumption of vegetables and low-fat or nonfat dairy products should be encouraged 3.
• The use of loop and thiazide diuretics can increase uric acid levels, whereas the use of the angiotensin receptor blocker losartan increases urinary excretion of uric acid 3.

Urate-Lowering Therapy

• Allopurinol and febuxostat are first-line medications for the prevention of recurrent gout, with colchicine and/or probenecid reserved for patients who cannot tolerate first-line agents or in whom first-line agents are ineffective 3, 5.
• Patients receiving urate-lowering medications should be treated concurrently with nonsteroidal anti-inflammatory drugs, colchicine, or low-dose corticosteroids to prevent flares 3.