Table 6.

Gout flare management^*

Recommendation	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 recommend low-dose colchicine over high-dose colchicine given its similar efficacy and fewer adverse effects.	32	High†
For patients experiencing a gout flare for whom other antiinflammatory therapies are poorly tolerated or contraindicated, we conditionally recommend using IL-1 inhibition over no therapy (beyond supportive/analgesic treatment).	33	Moderate
For patients who may receive NPO, we strongly recommend glucocorticoids (intramuscular, intravenous, or intraarticular) over IL-1 inhibitors or ACTH.	32	High†
For patients experiencing a gout flare, we conditionally recommend using topical ice as an adjuvant treatment over no adjuvant treatment.	31	Low
Strongly recommend Conditionally recommend Strongly recommend against Conditionally recommend against

^*PICO = population, intervention, comparator, outcomes; NSAIDs = nonsteroidal antiinflammatory drugs; IL-1 = interleukin-1; ACTH = adrenocorticotropic hormone; NPO = nothing by mouth (nulla per os).

^†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 cost issues significantly favor other agents.