» Treatment guidelines

Role of colchicine for acute gout flare & prevention gout treatment

2020 American College of Rheumatology Guideline for the Management of Gout strongly recommend to use colchicine for gout flares management and for gout flares prophylaxis¹⁴

Gout flare management

Using colchicine, NSAIDs, or glucocorticoids (oral, intraarticular, or intramuscular) as appropriate first- line therapy for gout flares over IL-1 inhibitors or adrenocorticotropic hormone (ACTH) is strongly recommended for patients experiencing a gout flare.

Given similar efficacy and a lower risk of adverse effects, low-dose colchicine over high-dose colchicine is strongly recommended when colchicine is the chosen agent.
For colchicine specifically, the FDA-approved dosing should be followed (1.2 mg immediately followed by 0.6 mg an hour later with ongoing anti-inflammatory therapy until the flare resolves).

Gout flare management¹⁴

Recommendations for choice of initial urate-lowering therapy (ULT) in patients with gout*

Strongly recommend:	PICO question	Certainty of evidence
For patients experiencing a gout flare, we strongly recommend using oral colchicine, NSAIDs, or glucocorticoids (oral, intraarticular, or intramuscular) as appropriate first-line therapy for gout flares over IL-1 inhibitors or ACTH (the choice of colchicine, NSAIDs, or glucocorticoids should be made based on patient factors and preferences. When colchicine is the chosen agent, we strongly recommended low-dose colchicine over high-dose colchicine given is similar efficacy and fewer adverse effects.	32	High

^*PICO = population, intervetion, comparator, outcomes

NSAIDs = nonsteroidal antiimflammatory drugs

IL-1 = interleukin-1

ACTH = adrenocorticotropic hormone

High quality of evidence from network meta-analyses supporting canakinumab, which has superior mean pain score reduction and mean day-2 joint tenderness reduction. However, the Voting Panel raised concern that the comparator was weak (triamcinolone 40 mg) and that costissues significantly favor other agents.

Gout prophylaxis therapy

Administering concomitant anti-inflammatory prophylaxis therapy (e.g., colchicine, nonsteroidal anti-inflammatory drugs NSAIDs, prednisone/ prednisolone) over no anti-inflammatory prophylaxis therapy is strongly recommended.

Based on 8 RCTs and 2 observational studies, there is moderate certainty of evidence to support the strong recommendations to use anti-inflammatory prophylaxis therapy when initiating urate-lowering therapy (ULT). Continuation of prophylaxis for at least 3–6 months after ULT initiation was recommended because shorter durations were associated with flares upon cessation of prophylaxis. After cessation, monitoring for flare activity and continuation of anti-inflammatory treatment as needed if the patient continues to experience flares was recommended.

Recommendations for choice of initial urate-lowering therapy ULT in patients with gout¹⁴

Strongly recommended:	PICO question	Certainty of evidence
We strongly recommend initiating concomitant antiinflammatory prophylaxis therapy (e.g. colchicine, NSAIDs, prednisone/prednisolone) over no antiinflammatory prophylaxis. The choice of specific antiinflammatory prophylaxis should be based upon patient factors.	9	Moderate
We strongly recommend continuing prophylaxis for 3-6 month rather than <3 months, with ongoing evaluation and continued prophylaxis as needed if the patient continues to experience flares.	9	Moderate

^*PICO = population, intervetion, comparator, outcomes

CKD = chronic kidney disease

NSAIDs = nonsteroidal antiinflammantory drugs

Moderate evidence is in support of the efficacy of pegoticase, but due to cost, safety concerns, and favorable benefit-to-harm ratios of other untried treatment options, the recommendation is against using pegloticase as first-line agent.