What the guidelines say to do when a flare starts

By Nirbhay Agarwal · 19 August 2026 · 6 min read

A flare is a bad time to be figuring out what your options are. It is worth knowing beforehand what the guidelines actually say, partly so you can have the conversation with your doctor in advance, and partly because a couple of the recommendations are the opposite of what people assume.

Nothing below is a prescription, and none of it is a reason to start, stop or change a medication on your own. It is what the 2020 American College of Rheumatology guideline recommends, and how confident it is about each piece.

First: what is happening

This matters for treatment because everything below is aimed at the immune reaction, not at the urate. Nothing you take during a flare removes crystals. The drugs that work in an attack work by damping inflammation. That is why they act fast, and also why they do nothing about whether the next attack happens.

That distinction is the whole subject of why gout gets worse before it gets better, and it is worth having straight before reading on.

The three first-line options are genuinely equal

The guideline’s flare recommendation is unusual in how it is phrased:

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).

Three options, one strong recommendation, and no ranking between them. The line in brackets matters just as much: it says the choice should be based on your own circumstances, not on which drug is better in general. Your kidney function, your stomach, your heart, your diabetes and what you have tolerated before all come into it.

This is worth knowing because it means there is usually a route through for people who have been told they cannot take the obvious one. Someone who cannot take anti-inflammatories because of kidney disease or a stomach ulcer has not run out of options; they have two other first-line options. Steroids injected directly into the joint are on that list too, and for a single badly-affected joint they are a legitimate first choice rather than a last resort.

The guideline also names what should not be first: IL-1 inhibitors and ACTH. It reserves IL-1 inhibition (a conditional recommendation, moderate certainty) for people who genuinely cannot tolerate or take any of the three. That reflects its cost and how it was compared in trials, rather than any doubt that it works.

One specific case: for a patient who cannot take anything by mouth, glucocorticoids given by injection are strongly recommended over IL-1 inhibitors or ACTH.

Less colchicine, not more

This one contradicts decades of practice, and the guideline is unambiguous about it:

When colchicine is the chosen agent, we strongly recommend low-dose colchicine over high-dose colchicine given its similar efficacy and fewer adverse effects.

The evidence is a 2010 trial that compared the two head-to-head against placebo in 575 people, treating flares within the first twelve hours. One arm got a total of 1.8 mg: a 1.2 mg dose, then 0.6 mg an hour later, and that was the end of it. The other got the traditional regimen, 1.2 mg followed by 0.6 mg every hour for six hours, a total of 4.8 mg.

Pain relief was equivalent. The side effects were not:

Three-quarters of people on the old regimen got diarrhoea, for no additional benefit. The low-dose regimen’s gastrointestinal side effects were close to placebo.

The historical approach to colchicine was to keep dosing until either the pain or the patient gave way, and enough people remember that to have concluded colchicine is a miserable drug. At the dose now recommended, it mostly is not.

Ice counts

Slightly buried among the pharmacology, the guideline conditionally recommends topical ice during a flare, alongside medication rather than instead of it. The evidence behind it is low certainty, but there is no downside, and it is the only recommendation on the list you can act on at two in the morning without a prescription.

The one that surprises people: a flare is not a reason to pause your daily tablet

If you are already on allopurinol or febuxostat and a flare starts, the instinct is to assume the tablet failed or is somehow implicated, and to stop it until things settle.

The guideline points firmly the other way. It conditionally recommends that when urate-lowering therapy is indicated in someone who is currently having a flare, treatment should be started during the flare rather than waiting for it to resolve. If it is appropriate to begin the drug mid-attack, there is no case for interrupting it in someone already established on it. It separately conditionally recommends continuing urate-lowering therapy indefinitely rather than stopping.

The mechanism makes sense of this. The flare is a slab that has already come off. Stopping the drug does not put it back. All it does is let your urate rise again, which restarts the process that created the deposit in the first place. Stopping in response to a flare treats the drug as the cause of the thing it is slowly curing.

And the part that is planned for in advance

The most-missed recommendation about flares is not about flares at all. When starting urate-lowering therapy, the guideline strongly recommends giving anti-inflammatory prophylaxis at the same time: a low continuous dose of colchicine, an anti-inflammatory, or prednisone. It also strongly recommends continuing that cover for three to six months rather than stopping before three.

That is there because the early months of treatment are the most flare-prone stretch you will have, for reasons that are mechanical rather than accidental. The cover is standard practice, not an extra.

If you started urate-lowering therapy without it, that is worth raising. It is the difference between a predictable few months and a few months bad enough to make people quit, which most people do.

A short version to keep

• Three first-line options, equally recommended: colchicine, an anti-inflammatory, or steroids. The right one depends on your other conditions.
• If colchicine, the low-dose regimen gives the same relief with a fraction of the side effects.
• Ice helps, as an addition.
• Treat early. The colchicine evidence comes from flares treated within twelve hours.
• A flare is not, by itself, a reason to interrupt your daily urate-lowering tablet. The guideline is comfortable enough with the combination to recommend starting it mid-flare. If you are thinking of pausing yours, that is a question for your doctor rather than a decision to make during an attack.
• If flares keep coming, the question is not which flare drug to use. It is what your urate level has been doing, which is usually a dose question.

Have the conversation about which of the three is right for you before you need it, and know what your plan is. Working that out during an attack, at night, is how people end up with whatever is in the cupboard.

Gout Journal is written by someone who lives with gout, not by a clinician. This article is general information, not medical advice — never start, stop or change a medication without talking to your own doctor.