Acute Gout Flare Management

Introduction

Acute gout flares require prompt treatment to alleviate symptoms and prevent long-term damage, as recommended by the European League Against Rheumatism and the American College of Rheumatology 1, 2

The European League Against Rheumatism and the American College of Rheumatology recommend corticosteroids, including intra-articular injections, as a first-line treatment option for acute gout flares, particularly for monoarticular gout 1, 2
Systemic corticosteroids, such as 30-35 mg/day of prednisolone equivalent for 3-5 days, are an effective first-line option for acute gout flares 1
Colchicine is a recommended first-line treatment option for acute gout flares, with a low-dose regimen of 1 mg loading dose followed 1 hour later by 0.5 mg on day 1, and should be given within 12 hours of symptom onset 1, 2
NSAIDs are also a recommended first-line option for acute gout flares, although patients with severe renal impairment or significant cardiovascular disease should avoid them 1, 2

For patients with renal impairment (GFR <30 mL/min), the European League Against Rheumatism recommends avoiding colchicine and NSAIDs, and using corticosteroids (oral, intra-articular, or intramuscular) instead 1
For patients with moderate renal impairment, the colchicine dose should be reduced, although the exact reduction is not specified 1
For patients with significant cardiovascular disease, NSAIDs should be avoided, and colchicine (if renal function is normal) or oral corticosteroids should be used instead 1
For patients with diabetes, monitoring of blood glucose is recommended when using prednisone 3
For patients unable to take oral medications, intramuscular or intravenous glucocorticoids are strongly recommended over IL-1 inhibitors, according to the American College of Rheumatology 2

Intra-articular corticosteroid injections provide targeted relief directly to the affected joint, avoiding systemic side effects associated with oral medications, and are particularly useful when oral medications are contraindicated 1
Short-term use of corticosteroids is generally safe, but extended use increases the risk of adverse effects 1, 3
Colchicine is most effective when given within 12 hours of symptom onset, and a low-dose regimen is preferred over high-dose due to similar efficacy with fewer side effects 1, 2
Topical ice is conditionally recommended as an adjuvant treatment for acute gout flares, according to the American College of Rheumatology 2

Combination therapy (e.g., oral corticosteroids plus colchicine) can be considered for severe, multiarticular flares, and intra-articular corticosteroid injection may be added for specific affected joints 3, 1
If first-line agents are contraindicated, not tolerated, or ineffective, IL-1 inhibitors (e.g., anakinra, canakinumab) can be used, as recommended by the European League Against Rheumatism 1, 2
Methylprednisolone dose pack and intramuscular corticosteroids (e.g., triamcinolone acetonide 60 mg) are alternative options for treating acute gout flares 3, 2

Prophylactic anti-inflammatory therapy (colchicine, NSAIDs, or prednisone/prednisolone) should be continued for 3-6 months when initiating urate-lowering therapy, as recommended by the American College of Rheumatology and the European League Against Rheumatism 3, 2
Low-dose colchicine (0.5-0.6 mg once or twice daily) or low-dose NSAIDs are recommended first-line options for prophylaxis 2
Urate-lowering therapy should not be stopped during an acute gout attack, as recommended by the American College of Rheumatology 3

Limiting alcohol intake, particularly beer, can reduce the risk of acute gout flares, as recommended by the American College of Rheumatology 2
Limiting purine-rich foods (e.g., organ meats, shellfish) and high-fructose corn syrup intake can also reduce the risk of acute gout flares, according to the American College of Rheumatology 2
A weight loss program for overweight/obese patients is recommended to reduce the risk of acute gout flares, according to the American College of Rheumatology 2

Extended use of steroids beyond the recommended duration increases the risk of adverse effects 3
Failing to consider renal function, cardiovascular disease, or diabetes when selecting therapy can lead to adverse outcomes 3, 1
Neglecting prophylaxis when initiating urate-lowering therapy can lead to flares, and prophylaxis should be continued for 3-6 months, as recommended by the American College of Rheumatology and the European League Against Rheumatism 3, 2