Initial Treatment for Gout Flares

First-Line Treatment Options

The European League Against Rheumatism recommends colchicine as the first-line treatment for an acute gout flare, most effective when given within 12 hours of symptom onset 1
Colchicine should be avoided in patients with severe renal impairment, and should not be given to patients receiving strong P-glycoprotein and/or CYP3A4 inhibitors such as cyclosporin or clarithromycin 2
NSAIDs are as effective as colchicine when started promptly, but should be avoided in patients with severe renal impairment, and consider adding a proton pump inhibitor for gastrointestinal protection if appropriate 1
The American College of Rheumatology recommends oral corticosteroids, such as prednisolone (30-35 mg/day for 3-5 days), as an effective option, particularly useful when colchicine and NSAIDs are contraindicated 2

For patients unable to take oral medications, treatment with glucocorticoids (intramuscular, intravenous, or intraarticular) is strongly recommended over IL-1 inhibitors or ACTH 3
For patients with contraindications to first-line therapies, IL-1 blockers should be considered for treating flares in patients with frequent flares and contraindications to colchicine, NSAIDs, and corticosteroids, but current infection is a contraindication to the use of IL-1 blockers 2

Patients should be educated to self-medicate at the first warning symptoms ("pill in the pocket" approach), and early initiation of any treatment for flare leads to better effectiveness 2, 1
Fully informed patients should be involved in the choice of drug(s) based on presence of contraindications, previous experience with treatments, time of initiation after flare onset, and number and type of joint(s) involved 2

Delaying treatment is a common pitfall, as early intervention is critical for effective management, and failing to adjust medication for patients with renal impairment, such as avoiding colchicine and NSAIDs in severe renal impairment, is also a common mistake 2, 1

The American College of Rheumatology recommends using full FDA-approved anti-inflammatory/analgesic doses of NSAIDs, such as naproxen, indomethacin, and sulindac, for the treatment of acute gout flare-ups 4, 5
Oral prednisone (0.5 mg/kg per day for 5-10 days then stop, or for 2-5 days then taper for 7-10 days) is a recommended treatment option for acute gout flare-ups, particularly when colchicine and NSAIDs are contraindicated 4
The use of colchicine, NSAIDs, or corticosteroids as monotherapy is recommended for mild to moderate pain (≤6/10) affecting 1-3 small joints or 1-2 large joints 5
Combination therapy, such as combining colchicine with NSAIDs, or either agent with corticosteroids, may be more effective for severe or polyarticular attacks 4, 5

The American College of Rheumatology recommends continuing established urate-lowering therapy (e.g., allopurinol, febuxostat) during acute flares, as interrupting ULT can worsen the flare and complicate long-term management 4, 6
Prophylaxis with low-dose colchicine (0.6 mg once or twice daily) or low-dose NSAIDs should be continued for up to 6 months after starting urate-lowering therapy 6