What is the new treatment for a gout flare that has migrated from the first metatarsophalangeal joint (big toe) to the second toe after completing a course of prednisone (corticosteroid)?

From the Guidelines

For a gout flare that has moved from the big toe to the second toe after completing prednisone, you should continue anti-inflammatory treatment, as recommended by the 2020 American College of Rheumatology guideline for the management of gout 1. Options include colchicine (0.6mg once or twice daily), NSAIDs like naproxen (500mg twice daily) or indomethacin (50mg three times daily), or another course of prednisone (typically 20-40mg daily, tapered over 5-10 days) 1. Apply ice to the affected area for 20 minutes several times daily and elevate the foot when possible. Stay well-hydrated and avoid alcohol and purine-rich foods during the flare. This migration pattern is common in gout as urate crystals can deposit in multiple joints, and inflammation can shift as medication wears off. Once the acute flare resolves, discuss with your doctor about starting urate-lowering therapy like allopurinol if this is a recurrent issue, as this addresses the underlying cause by reducing uric acid levels in the blood rather than just treating symptoms 1. Some key points to consider in the management of gout include:

• The importance of continuing anti-inflammatory prophylaxis therapy for at least 3-6 months after initiating urate-lowering therapy (ULT) to prevent flares 1
• The recommendation to use allopurinol as the preferred first-line ULT, including for those with moderate-to-severe chronic kidney disease (CKD; stage >3) 1
• The need to monitor serum urate (SU) levels and maintain them at <6 mg/dL (360 mmol/L) to achieve the uricaemia target 1
• The importance of lifestyle modifications, including weight loss, avoidance of alcohol and purine-rich foods, and regular exercise, to reduce the risk of gout flares and improve overall health 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 with gout flares requiring repeated courses, consideration should be given to alternate therapy

The patient's gout flare has moved from the big toe to the second toe after finishing prednisone, indicating a need for a new treatment approach.

• Colchicine can be considered for the treatment of gout flares.
• The dose may not need to be adjusted for patients with mild to moderate renal impairment, but close monitoring for adverse effects is recommended.
• For patients with severe renal impairment, the treatment course should be repeated no more than once every two weeks, and consideration should be given to alternate therapy 2.

From the Research

Gout Flare Treatment and Management

• Gout is a common form of acute inflammatory arthritis caused by the deposition of monosodium urate crystals within synovium of joints, leading to severe pain and reduced quality of life for patients 3.
• 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, 4.
• Urate-lowering therapies aim to prevent gout flares, with an emphasis on treat-to-target strategy, and initial treatments include allopurinol and febuxostat 3, 4.

New Treatment Options

• Novel therapies, such as uricosuric agents and IL-1β antagonists, are emerging as potential treatment options for gout flares 4.
• Pegloticase is effective for patients with recalcitrant gout, but its immunogenicity can threaten sustained urate lowering responses 4.
• Verinurad and arhalofenate are novel uricosurics with future promise 4.

Prognostic Factors for Gout Flare Recurrence

• CRP levels > 30 mg/L and lack of prophylaxis when starting urate-lowering therapy are independently associated with gout flare recurrence 5.
• Intake of prophylaxis when starting urate-lowering therapy has a strong protective effect on gout flare recurrences 5.
• Gout flares are common after stopping anti-inflammatory prophylaxis, but return to levels seen during prophylaxis 6.

Management of Gout Flares After Stopping Prophylaxis

• Patients should be cautioned about the risk of gout flares and have a plan for effective gout flare management in the three months after stopping anti-inflammatory prophylaxis 6.
• The percentage of participants experiencing one or more gout flares is higher in the three-month period after ceasing prophylaxis compared to during prophylaxis 6.