What nonsteroidal anti-inflammatory drug (NSAID) would be the best choice for a 60-year-old male patient with gout, who is taking Losartan (losartan) and has normal renal function?

From the Guidelines

For a 60-year-old male patient with gout who is taking losartan and has normal renal function, I would recommend naproxen as the NSAID of choice. The typical regimen would be naproxen 500 mg twice daily for acute gout flares, continuing until the flare resolves (usually 5-7 days), then tapering off. While all NSAIDs carry some risk of interaction with losartan (an angiotensin receptor blocker), naproxen tends to have a moderate risk profile compared to other options, as noted in studies such as 1 and 1. The combination requires monitoring but can be used with caution in patients with normal renal function, as indicated by the American College of Physicians guidelines 1. The patient should be advised to stay well-hydrated and report any signs of decreased urine output, swelling, or unexplained weight gain. Naproxen works by inhibiting cyclooxygenase enzymes, reducing prostaglandin synthesis and thereby decreasing inflammation in the affected joint. The patient should take naproxen with food to minimize gastrointestinal side effects, and colchicine could be considered as an alternative if NSAIDs are not tolerated or contraindicated, as suggested by the 2016 updated EULAR evidence-based recommendations for the management of gout 1. Some key points to consider when prescribing naproxen for gout include:

• Monitoring for potential interactions with losartan
• Advising the patient to stay well-hydrated
• Reporting any signs of decreased urine output, swelling, or unexplained weight gain
• Taking naproxen with food to minimize gastrointestinal side effects
• Considering colchicine as an alternative if NSAIDs are not tolerated or contraindicated. It's also important to note that lifestyle modifications, such as weight loss, avoidance of alcohol and sugar-sweetened drinks, and regular exercise, can help reduce the frequency of gout attacks, as recommended by the EULAR guidelines 1.

From the FDA Drug Label

7.3 Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) Including Selective Cyclooxygenase-2 Inhibitors (COX-2 Inhibitors) In patients who are elderly, volume-depleted (including those on diuretic therapy), or with compromised renal function, coadministration of NSAIDs, including selective COX-2 inhibitors, with angiotensin II receptor antagonists (including losartan) may result in deterioration of renal function, including possible acute renal failure. These effects are usually reversible. Monitor renal function periodically in patients receiving losartan and NSAID therapy. The antihypertensive effect of angiotensin II receptor antagonists, including losartan, may be attenuated by NSAIDs, including selective COX-2 inhibitors.

Given the patient has normal renal function and is on losartan, the choice of NSAID should be based on the potential risks of renal function deterioration and hyperkalemia.

• The patient's age (60) and gout should also be considered when selecting an NSAID.
• Since the patient has normal renal function, the risk of renal function deterioration is lower.
• However, it is still important to monitor renal function periodically when coadministering NSAIDs with losartan.
• Considering the available information, a conservative approach would be to choose an NSAID with a lower risk of renal toxicity, such as naproxen or ibuprofen, but the label does not provide enough information to make a specific recommendation 2.

From the Research

NSAID Selection for a 60-Year-Old Male Patient with Gout and Normal Renal Function

• The patient is on losartan, which has uricosuric properties and can help lower uric acid levels 3.
• NSAIDs are the preferred treatment for acute gout, and the choice of NSAID is not as important as initiating therapy promptly 4.
• Considering the patient's normal renal function and use of losartan, any NSAID can be chosen, but it is essential to consider potential interactions and side effects.
• Studies have shown that losartan can reduce uric acid levels and may be beneficial in patients with gout 3, 5.
• There is no specific NSAID recommended over others for patients with gout and normal renal function, but it is crucial to monitor for potential side effects and interactions with other medications 4, 6.

Considerations for NSAID Use in Patients with Gout

• NSAIDs can be effective in reducing pain and inflammation in acute gout, but they may have adverse effects, such as gastrointestinal problems and renal impairment 4, 6.
• The patient's age and use of losartan should be considered when selecting an NSAID, as older adults may be more susceptible to side effects 6.
• It is essential to weigh the benefits and risks of NSAID use in patients with gout and to monitor for potential side effects and interactions with other medications 4, 6.