How are gout flares treated
Treatment options for gout flares
Medications most often used to treat gout flares include: nonsteroidal antiinflammatory drugs (NSAIDs, full dose), oral colchicine, or glucocorticoids. Patients experiencing a severe flare (polyarticular or severe pain) may require combination therapy, understanding that the concomitant use of NSAIDs and oral glucocorticoids may be less desirable due to heightened potential for gastrointestinal toxicity. Topical ice can also be used as an adjuvant. Short-acting NSAIDs (e.g., ibuprofen, naproxen) all demonstrate similar efficacy when given in antiinflammatory doses. For flares, oral colchicine is dosed at 1.2 mg followed by 0.6 mg 1 hour later; this can be followed by prophylaxis dosing of 0.6 mg once or twice daily. Glucocorticoids can be administered by oral, intravenous, intramuscular, or intraarticular routes. Second-line options for the treatment of gout flare include IL-1 inhibition (anakinra or canakinumab) or ACTH. ULT is typically deferred to intercritical periods once the acute flare has resolved, although there is emerging evidence that ULT can be initiated safely during a flare in the background of appropriate anti-inflammatory treatment. Medications used in the treatment of gout flare:
| Treatment Options | Dosage | Comments |
|---|---|---|
| NSAIDs (Indomethacin) | 50 mg po qid × 24–48 hours, then 50 mg po tid × 48 hours. Taper and discontinue after the attack subsides. | Other NSAIDs with short half-lives are probably as effective; contraindicated in patients with moderate/severe CKD. |
| Oral colchicine | 1.2 mg po followed by 0.6 mg po 1 hour later | Most effective within the first 36 hours of an attack. Contraindicated in the elderly or significant renal or hepatic insufficiency. Avoid use with concomitant P450 3A4 and P-glycoprotein inhibitors including cyclosporine, clarithromycin/erythromycin, keto- and itraconazole, disulfiram, HIV protease inhibitors, diltiazem, verapamil, and grapefruit juice. |
| Intraarticular steroids (triamcinolone or methylprednisolone) | 40 mg intraarticularly for large joints, 10–20 mg for small joints or bursae | Useful in the treatment of 1 or 2 involved joints or bursae. Effective within the first 24 hours of an attack in 90% of patients. |
| Systemic corticosteroids | Prednisone 0.5 mg/kg per day for 5–10 days or for 2–5 days, then taper for 7–10 days or triamcinolone acetonide 60 mg IM, can repeat once. | Rebound arthropathy may occur. May be used in patients with CKD. |
CKD, Chronic kidney disease; HIV, human immunodeficiency virus; NSAID, nonsteroidal antiinflammatory drug.
