Prevention of gout flares when starting or changing urate-lowering therapy

Graf, 2015Seth, 2014Sivera, Andres, Carmona, 2014

Starting or increasing urate-lowering therapy is associated with a high risk of gout flare, so flare prophylaxis is recommended.

Colchicine has the strongest evidence as a prophylactic drug for gout flares and is well tolerated at a daily dose of 500 micrograms.

Nonsteroidal anti-inflammatory drugs (NSAIDs) may be considered for patients in whom colchicine is contraindicated or ineffective. When using an NSAID, consider the benefit-harm ratio, particularly in patients at high risk of harms (see Principles of NSAID use for musculoskeletal pain for more information).

Low-dose oral corticosteroids should be used with caution because long-term use is associated with adverse effects (see Principles of immunomodulatory drug use).

If a patient has had recurrent flares of gout despite prophylaxis, a specialist may consider combination therapy with colchicine plus either an NSAID or prednisolone (or prednisone). Avoid concurrent use of NSAIDs and oral corticosteroids because of the significantly increased risk of gastrointestinal toxicity, and because NSAIDs are not likely to have additional benefit in patients taking oral corticosteroids. See Drug regimens for chronic gout for flare prophylaxis regimens.

Patients may be reluctant to take urate-lowering therapy because of a previous acute attack precipitated by starting or increasing therapy. Starting on a low dose of urate-lowering therapy minimises the risk of flares; the dose is then gradually increased until the target serum uric acid concentration is achieved. Flare prophylaxis is recommended for all patients starting or changing urate-lowering therapy. Advise patients of the high risk of gout flare and the recommended management as for an acute attack (see Management of acute gout).

The optimal duration of flare prophylaxis with colchicine is unclear, but the frequency of flares, the duration of gout and the presence and size of tophi should be taken into account. In general, flare prophylaxis with colchicine should be continued until the patient has no further attacks and the target serum uric acid concentration has been achieved. Typically, this takes at least 6 months, but the presence of tophi may warrant prolonged flare prophylaxis with colchicine.

The duration of flare prophylaxis with an NSAID or corticosteroid should be individualised because long-term use can be associated with unacceptable adverse effects. Limit treatment to the lowest dose and shortest duration of treatment.

If the patient has a gout flare, the recommended management is as for an acute attack (see Pharmacological management for acute gout); urate-lowering therapy should be continued. If the patient has a gout flare after prophylaxis has been stopped, restart prophylaxis and reassure patients that the urate-lowering therapy is working.