Patient handout

Acute gout flare (primary-care / ED — acute monoarthritis)

PRODUCTION

1. Your condition

This handout is for acute gout flare (primary-care / ed — acute monoarthritis). Your care team identified this based on: acute hot, swollen, exquisitely painful single joint (acute monoarthritis) (acr 2020 fitzgerald pmid 32391934; margaretten jama 2007 pmid 17405973).

Other reasons your team may use this plan: classic podagra — acute 1st mtp flare (acr 2020 fitzgerald pmid 32391934); acute monoarthritis with fever / systemic illness — septic-arthritis cannot-miss (margaretten jama 2007 pmid 17405973); recurrent self-limited podagra episodes resolving in 7-14 d (acp 2017 qaseem pmid 27802508).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
colchicine	1.2 mg PO ×1, then 0.6 mg 1 h later (1.8 mg over 1 h), then 0.6 mg q12h-daily until resolution	PO	AGREE low-dose then q12h-daily	AGREE (Terkeltaub Arthritis Rheum 2010 PMID 20131255): low-dose 37.8% vs placebo 15.5% responders at 24 h (P=0.005); low-dose AE profile = placebo (OR 1.5, 95% CI 0.7-3.2), 0% severe diarrhoea/vomiting vs high-dose diarrhoea OR 21.3. ACR 2020 strong; low-dose strongly preferred (PMID 32391934)
naproxen	500 mg PO BID × 5-7 d	PO	BID	ACR 2020 equal first-line; ACP 2017 strong/high-quality. Alternative indomethacin 50 mg PO TID (PMID 32391934; PMID 27802508)
indomethacin	50 mg PO TID × 5-7 d	PO	TID	ACR 2020 equal first-line NSAID alternative for acute flare abort (PMID 32391934)
prednisone	40 mg PO daily × 5 d (or 0.5 mg/kg/d taper over 10-14 d)	PO	daily	ACR 2020 equal first-line; preferred when CKD/NSAID/colchicine-restricted; ACP 2017 strong. Counsel glycaemic monitoring in diabetes (PMID 32391934; PMID 27802508)
methylprednisolone	IM 40-80 mg single dose; or IV 40-125 mg if NPO/severe	IM/IV	single	ACR 2020 — parenteral steroid when oral route unavailable or severe flare (PMID 32391934; EULAR 2016 PMID 27457514)
triamcinolone (intra-articular)	Intra-articular 20-40 mg (large joint) / 10 mg (small joint), single	intra-articular	single	ACR 2020 — IA steroid equal/superior for accessible monoarticular flare; ONLY after septic arthritis excluded by synovial analysis (never inject an infected joint) (PMID 32391934; EULAR 2016 PMID 27457514)
anakinra	100 mg SC daily × 3-5 d	SC	daily	EULAR 2016 — IL-1 blocker when colchicine + NSAID + corticosteroids all contraindicated (PMID 27457514); ACR 2020 conditional off-label rescue (PMID 32391934)

Plan: Acute gout flare abort (≤24 h onset) — comorbidity-gated; chronic ULT routed to msk.gout-chronic.core.v1 (ACR 2020 FitzGerald; EULAR 2016 Richette; AGREE Terkeltaub)

3. Your action plan

Use these zones to know what to do based on how you feel.

GREEN — Between flares — no active joint attack

If you have:

No hot/swollen/painful joint right now
Last flare fully resolved

Do this:

If you take urate-lowering medicine (allopurinol/febuxostat), keep taking it every day — never stop it, even during a flare (ACR 2020 strong PMID 32391934)
Keep the follow-up appointment to discuss long-term urate-lowering therapy (this is decided over time, not in the ED) (ACP 2017 PMID 27802508)
Have your abort medicine on hand if your clinician prescribed a rescue plan

YELLOW — Early flare — joint pain/warmth/swelling starting

If you have:

New hot, swollen, painful joint (often the big toe)
Feels like your previous gout attacks
No fever, not systemically unwell

Do this:

Start your pre-prescribed abort regimen as early as possible (best within 24 h) (AGREE PMID 20131255; ACR 2020 PMID 32391934)
Do NOT stop your urate-lowering medicine during the flare (ACR 2020 strong PMID 32391934)
Rest, ice, and elevate the joint (EULAR 2016 PMID 28430170)
Do NOT start a new urate-lowering medicine yourself during a flare

Call your provider if:

Not improving within 48 h
More than one joint involved
You develop a fever (could be a joint infection — see red zone)

RED — Possible joint infection or severe illness — emergency

If you have:

Fever with a hot, swollen joint (a gout attack and a joint infection can happen together) (Margaretten JAMA 2007 PMID 17405973)
A single joint rapidly getting worse
Cannot move or bear weight on the joint at all
Feeling very unwell / shivering / confused

Do this:

Go to the emergency department now — the joint may need to be tapped (aspirated) urgently to check for infection
Bring your full medication list including any urate-lowering and abort medicines
Tell the ED you have gout but that this might be an infection — both can occur at once (ACR 2020 PMID 32391934)

Call your provider if:

Always seek emergency care for fever + a hot joint, or rapid severe worsening (Margaretten JAMA 2007 PMID 17405973; ACR 2020 PMID 32391934)

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Acute monoarthritis with synovial WBC >50,000/µL (LR+ 7.7, 95% CI 5.7-11.0) or >100,000 (LR+ 28.0, 12.0-66.0) or PMN ≥90% (LR+ 3.4, 2.8-4.2) or positive Gram stain — co-existence with gout possible (Margaretten JAMA 2007 PMID 17405973)(life-threatening)
Acute monoarthritis in immunosuppressed / prosthetic-or-operated joint / partially-treated host where a "low" synovial WBC LR is DOWN-WEIGHTED (conditional dependence) and fever may be absent (sens only 57%) (Margaretten JAMA 2007 PMID 17405973)
Strong CYP3A4 inhibitor (clarithromycin/ketoconazole/ritonavir) or P-gp inhibitor (cyclosporine/verapamil) or eGFR <30 / dialysis with colchicine considered (ACR 2020 FitzGerald PMID 32391934)
Flare refractory at 48 h OR colchicine + NSAID + corticosteroid all contraindicated (frequent-flare multimorbid patient) (EULAR 2016 Richette PMID 27457514; ACR 2020 PMID 32391934)

5. Follow-up

Route to msk.gout-chronic.core.v1 for the longitudinal ULT shared decision (≥2 flares/yr, tophus, CKD≥3, urolithiasis, or already on ULT). Counsel: this acute engine ABORTS and REFERS — it does not manage urate. Return precautions: fever + hot joint, rapid worsening, no improvement in 48 h (ACP 2017 Qaseem PMID 27802508; ACR 2020 PMID 32391934)

6. Sources

Guideline: 2020 ACR Guideline for the Management of Gout (FitzGerald et al, Arthritis Care Res 2020) + 2016 EULAR updated recommendations (Richette et al) + ACP 2017 (Qaseem et al); septic-arthritis cannot-miss anchored to Margaretten JAMA Rational Clinical Examination 2007