Nonpharmacologic measures
›Nonpharmacologic measures
›Local care
›Rest of affected joint
›Ice application intervals
›Mobility support
›Assistive device for weight-bearing joints
›Splinting for severe pain
›Medication continuity
›Continue existing urate-lowering therapy during flare
›Avoid abrupt allopurinol discontinuation
First-line anti-inflammatory options
›First-line anti-inflammatory options
›NSAIDs (avoid if contraindicated)
›Naproxen
›500 mg PO twice daily
›Typical duration 3 to 7 days with stop when flare resolves
›Indomethacin
›50 mg PO three times daily
›Step-down to 25 mg PO three times daily as improving
›Ibuprofen
›600 to 800 mg PO three to four times daily
›Maximum 3200 mg per day
›Celecoxib
›800 mg PO once then 400 mg PO later day 1
›400 mg PO twice daily thereafter for short course
›Safety checks
›Avoid in eGFR reduction or acute kidney injury
›Avoid in active GI bleed or high bleeding risk without protection plan
›Avoid in decompensated heart failure
›Colchicine (most effective if early)
›Low-dose regimen
›1.2 mg PO once then 0.6 mg PO 1 hour later
›0.6 mg PO once or twice daily starting day 2 until flare resolves
›Renal impairment adjustments
›If eGFR < 30 mL/min/1.73 m2, avoid repeat loading within 14 days
›If dialysis, avoid routine use unless specialist guidance
›Drug interaction screen
›Strong CYP3A4 inhibitors
›P-gp inhibitors
›Macrolide antibiotics
›Adverse effects
›Diarrhea
›Myopathy risk with statins
›Systemic corticosteroids
›Prednisone or prednisolone
›30 to 40 mg PO daily for 5 to 10 days
›Alternative taper 30 to 40 mg PO daily then taper over 7 to 10 days
›IV methylprednisolone
›40 to 125 mg IV once for severe flare with oral intolerance
›Transition to oral regimen when feasible
›IM triamcinolone acetonide
›40 to 60 mg IM once
›Useful when oral adherence is concern
›Safety checks
›Hyperglycemia risk
›Mood and sleep disturbance risk
Intra-articular therapy and procedures
›Intra-articular therapy and procedures
›Arthrocentesis
›Diagnostic aspiration when septic arthritis in differential
›Therapeutic aspiration for tense effusion
›Intra-articular corticosteroid (after infection excluded)
›Triamcinolone acetonide small joint
›10 mg intra-articular once
›Ultrasound guidance if needed
›Triamcinolone acetonide large joint
›20 to 40 mg intra-articular once
›Post-injection rest 24 hours
Combination therapy and escalation
›Combination therapy and escalation
›Indications for combination anti-inflammatory therapy
›Polyarticular flare
›Severe pain with functional impairment
›Combination options
›NSAID plus colchicine
›Avoid if renal impairment and dehydration
›Monitor GI intolerance
›Oral steroid plus colchicine
›Monitor glucose
›Interaction review
›Refractory flare options
›Interleukin-1 blockade specialist pathway
›Consider when NSAIDs colchicine and steroids contraindicated
›Infection exclusion required before initiation
›Analgesia adjuncts
›Acetaminophen
›650 to 1000 mg PO every 6 to 8 hours as needed
›Maximum 3000 mg per day in most adults
›Short-term opioid pathway
›Consider only for severe pain with contraindications to anti-inflammatories
›Avoid co-prescribing sedatives