Gout Flares: Colchicine, NSAIDs, and Steroids Compared

When a gout flare hits, it doesn’t ask for permission. One minute you’re fine, the next, your big toe feels like it’s been crushed under a boot. The pain is sharp, the swelling is intense, and the redness makes it look like your joint is on fire. You need relief-fast. But with so many options-colchicine, NSAIDs, steroids-how do you pick the right one? It’s not about which drug is "best." It’s about which one works for you, given your health, your meds, and your body’s limits.

What Happens During a Gout Flare?

Gout flares happen when uric acid crystals build up in your joints. Your immune system goes into overdrive trying to clear them out, and that’s what causes the swelling, heat, and pain. These flares often start at night and can knock you out of action for days. Left untreated, they get worse over time. But treated early-within 24 hours-they usually settle down in a few days.

That’s the key: timing. Waiting even a day reduces how well any treatment works. Rheumatologists often say, "Start treatment within 24 seconds of pain onset." It’s not hyperbole. The sooner you act, the less damage the inflammation does.

NSAIDs: The Go-To for Many

Nonsteroidal anti-inflammatory drugs like naproxen, ibuprofen, and indomethacin are the most common first choice for gout flares. They work by blocking the enzymes that cause inflammation and pain. The American College of Rheumatology lists them as a first-line option, and for good reason-they’re fast, widely available, and effective.

But here’s the catch: you need high doses. For naproxen, that’s 500 mg twice daily. Ibuprofen? 800 mg three times a day. Indomethacin? 50 mg three times daily. These aren’t your typical OTC doses. You need prescription strength, and you need to take them for 3-5 days, then taper off.

Only three NSAIDs-indomethacin, naproxen, and sulindac-have FDA approval specifically for acute gout. But in practice, doctors use others like diclofenac or celecoxib if they’re safer for the patient. The problem? NSAIDs aren’t safe for everyone. If you have kidney disease, heart failure, high blood pressure, stomach ulcers, or take blood thinners, NSAIDs can make things worse. They’re especially risky for older adults, who make up most gout patients. One study found naproxen caused fewer side effects than colchicine, but still carried a high risk of GI bleeding and kidney stress.

Colchicine: The Old Favorite, Now With a New Dose

Colchicine has been used for gout for centuries. It doesn’t reduce inflammation the way NSAIDs do. Instead, it stops white blood cells from rushing to the joint where the crystals are. That cuts the immune response-and the pain.

For years, the standard dose was 4.8 mg over six hours. That meant lots of diarrhea, vomiting, and cramps. Now, we know better. A major review in 2023 showed that a lower dose-1.8 mg total, taken over one hour-works just as well. Side effects dropped by more than half.

This change is huge. It makes colchicine a real option for people who can’t take NSAIDs. But it’s still tricky. Colchicine has a narrow safety window. Too much, and you risk rhabdomyolysis (muscle breakdown), seizures, or even organ failure. That’s why dose adjustments are critical if you have kidney or liver problems. Also, it interacts with statins, certain antibiotics, and grapefruit juice. If you’re on multiple meds, your pharmacist needs to check for clashes.

One study found colchicine and naproxen gave similar pain relief over seven days. But naproxen had fewer side effects. So if you’re young and healthy, NSAIDs might be easier. If you have stomach issues or heart risks, colchicine becomes more appealing.

Steroids: The Quiet Winner

Oral corticosteroids like prednisone are often overlooked. But they’re powerful, cheap, and safer for many patients. A 2017 meta-analysis of six trials with over 800 people found steroids worked just as well as NSAIDs at reducing pain. About 73% of patients on steroids or NSAIDs had at least 50% pain relief. Only 27% did on placebo.

Here’s how it’s typically done: Start with 40-60 mg of prednisone on day one, then taper down over 10-14 days. For example: 40 mg for two days, 30 mg for two days, 20 mg for two days, then 10 mg for two days. Tapering is non-negotiable. Skip it, and you risk a rebound flare-sometimes worse than the first.

For single-joint flares, an injection right into the joint (intra-articular) is even better. No system-wide side effects. No stomach upset. No kidney stress. Just targeted relief. This is often the top choice for patients with diabetes, high blood pressure, or kidney disease. The AAFP specifically recommends it for monoarticular gout.

Steroids aren’t perfect. They can spike blood sugar, so diabetics need to monitor closely. They can cause insomnia or mood swings. But compared to NSAIDs and colchicine, they’re gentler on the gut and kidneys. And they’re inexpensive. Many primary care doctors feel more comfortable prescribing them than they do with colchicine, simply because they’ve used steroids for decades.

Which One Should You Choose?

There’s no single answer. The right drug depends on your health history.

• If you’re young, healthy, with no kidney or stomach issues: NSAIDs like naproxen are a solid first pick.
• If you have stomach ulcers, heart failure, or take blood thinners: Skip NSAIDs. Colchicine (low dose) or steroids are better.
• If you have kidney disease: Colchicine needs a lower dose. Steroids are often preferred.
• If only one joint is affected: Ask about an injection. It’s faster, safer, and just as effective.
• If you’ve had multiple flares or take urate-lowering drugs like allopurinol: You’ll need ongoing prevention. Your doctor should prescribe low-dose colchicine or NSAIDs for at least three to six months after your uric acid drops below target.

Some patients need combinations. If one drug doesn’t cut it, adding a low-dose steroid to colchicine can help. Or NSAIDs plus colchicine-though that increases side effect risk. Never mix NSAIDs and steroids unless your doctor says so. The combined gut damage risk is real.

What About Cost and Accessibility?

All three options are cheap. Generic naproxen costs less than $5 for a 10-day course. Colchicine is similarly priced. Prednisone? Often under $10. Insurance covers them all. No need for expensive new drugs. The real cost isn’t the pill-it’s the missed work, the ER visits, the long-term joint damage from delayed treatment.

What’s not cheap? The consequences of waiting. Every hour you delay treatment, the inflammation spreads. Every day you wait, the risk of a second flare increases. That’s why doctors stress: act now. Don’t wait to see if it "gets better."

What Happens After the Flare?

Getting through the flare is only half the battle. Gout is a chronic condition. If you don’t lower your uric acid long-term, flares will keep coming. That’s where allopurinol or febuxostat come in. But starting these drugs can actually trigger flares. That’s why, once you begin urate-lowering therapy, you need protection.

For at least three months (or six if you’ve had tophi), take a low daily dose of colchicine or NSAIDs-or a low-dose steroid. This prevents new flares while your body adjusts. It’s not optional. It’s part of the plan.

Final Thoughts

There’s no magic bullet. But there is a smart approach. Start early. Match the drug to your body. Don’t assume what worked for your cousin will work for you. Talk to your doctor-not just about what to take, but why. Ask: "What’s the safest option for my kidneys? My stomach? My heart?"

And if you’re unsure? Go with steroids. They’re underused, effective, and kinder to most older bodies. If you have one bad joint, ask about the injection. It’s simple, fast, and avoids the whole system.

Gout flares are brutal. But they’re treatable. And with the right choice, you can get back on your feet-without risking your health trying to get there.