Optimizing Gout Flare Management: Key Approaches for Pharmacists

Learn effective gout flare management strategies, including NSAIDs, colchicine, and corticosteroids.

Overview

As a clinical pharmacist, aim to optimize gouty flare management to relieve pain and control inflammation swiftly. Gout flares can last from days to over a week, so rapid intervention is essential. Non-pharmacologic methods like rest and ice may offer some relief, but pharmacologic treatment is generally required.

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Stepwise approach

Begin with NSAIDs, if appropriate

Use NSAIDs as a first-line choice for their rapid pain relief, unless contraindications exist (avoid NSAIDs in patients with renal impairment, peptic ulcers, or chronic anticoagulant use). Continue NSAID therapy for 5–7 days until symptoms improve, then discontinue.

Diclofenac: Administer 50 mg every 8 to 12 hours, with a daily maximum of 150 mg. U.S. guidelines allow up to 200 mg daily, while the approved maximum in Canada is 100 mg.

Note that dosing differs for free-acid forms compared to sodium or potassium salt preparations.

Etodolac: Prescribe 200 to 400 mg every 6 to 8 hours, with a maximum daily dose of 1000 mg. This NSAID exhibits relative COX-2 selectivity and has minimal effect on platelet function at lower daily doses (600 to 800 mg), making it a safer option for some patients.
Indomethacin: Typically dosed at 25 to 50 mg every 8 to 12 hours, with a maximum of 150 mg daily. For certain rheumatologic conditions, U.S. labeling permits up to 200 mg daily.

This NSAID is effective for acute gout and some types of headaches, but has potent inhibitory effects on kidney prostaglandin synthesis and is more likely to cause CNS side effects, such as headache or altered mental status, compared to other NSAIDs.

Meloxicam: Dosage is 7.5 to 15 mg once daily for conventional tablets or oral suspension, with a maximum of 15 mg daily. Meloxicam has a long duration of effect and a relatively slow onset, with COX-2 selectivity at lower doses (7.5 mg daily).
Mefenamic Acid: Recommended dosing is 250 mg every 6 hours or 500 mg three times daily, with a maximum of 1000 mg per day and up to 1500 mg for dysmenorrhea.

Mefenamic acid is intended for short-term use only, typically 3 days for dysmenorrhea or up to 7 days for acute pain, and is not indicated for chronic pain or inflammation due to its limited anti-inflammatory effect.

Piroxicam: Typically prescribed at 10 to 20 mg once daily, with a maximum daily dose of 20 mg. This long-acting NSAID is often reserved for chronic pain and inflammation that is unresponsive to other NSAIDs, and its prescribing is generally limited to specialists experienced in managing these conditions.

Figure (1)

Management of gout flare for adults with established gout, from Am Fam Physician. 2020;102(9):533-538.

Transition to colchicine for patients unable to use NSAIDs

Start with 1.2 mg at flare onset, followed by 0.6 mg an hour later. Maintain colchicine at 0.6 mg once or twice daily for 7–10 days, adjusting for renal function to minimize toxicity risk. Avoid in patients already on colchicine prophylaxis, and consider corticosteroids if colchicine is not tolerated or is contraindicated.

Use corticosteroids if NSAIDs and colchicine are unsuitable

Administer oral prednisolone (30-40 mg daily) or consider intramuscular or intra-articular injections. Continue for 5–10 days, then taper as needed. Transition to canakinumab if corticosteroids are not effective or suitable.

Use corticosteroids if NSAIDs and colchicine are unsuitable

For patients contraindicated for NSAIDs, colchicine, and corticosteroids, use canakinumab (150 mg subcutaneously) for its anti-inflammatory effects on interleukin-1β. Reassess after each dose, especially in patients with frequent flares.

Key considerations

Initiate treatment early to reduce flare severity and duration.
Maintain anti-inflammatory therapy for 6–10 days until symptoms fully resolve.
Continue urate-lowering therapy without interruption. If initiating urate-lowering therapy during a flare, ensure anti-inflammatory treatment continues for several months to prevent rebound flares.

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References

Gaffo AL. Gout: Treatment of flares. UpToDate 2024. https://www.uptodate.com/contents/gout-treatment-of-flares.
Qaseem A, Harris RP, Forciea MA, et al. Management of Acute and Recurrent Gout: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017;166(1):58-68.
Clebak KT, Morrison A, Croad JR. Gout: Rapid Evidence Review. Am Fam Physician. 2020;102(9):533-538.