What is the best course of action for a 43-year-old male patient with suspected gout, currently being managed with Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)?

From the Guidelines

The patient should continue taking Naproxen 500 mg twice daily and apply Diclofenac cream to the affected areas for pain relief, as this treatment plan is in line with the current guidelines for managing acute gout symptoms, as recommended by the American College of Physicians 1. The patient's current treatment plan is appropriate, given that high-quality evidence shows that NSAIDs, such as Naproxen, are effective in reducing pain in patients with acute gout 1. Additionally, the use of topical Diclofenac cream provides localized pain relief with fewer systemic side effects than oral NSAIDs alone. It is also important to note that the patient is already scheduled for a Rosendahl appointment, and a uric acid level test has been ordered to evaluate for gout, which will help guide further management decisions. According to the 2016 updated EULAR evidence-based recommendations for the management of gout, acute flares of gout should be treated as early as possible, and fully informed patients should be educated to self-medicate at the first warning symptoms 1. The choice of drug(s) should be based on the presence of contraindications, the patient’s previous experience with treatments, time of initiation after flare onset, and the number and type of joint(s) involved. In this case, the patient's current treatment plan with Naproxen and Diclofenac cream is a reasonable approach, and further management decisions can be made after reviewing the lab results and during the upcoming appointment. It is also important to consider lifestyle modifications, such as weight loss, avoidance of alcohol and sugar-sweetened drinks, and regular exercise, as these can help reduce the risk of gout attacks and improve overall health 1.

From the FDA Drug Label

NSAIDs, including diclofenac, can cause serious skin adverse reactions such as exfoliative dermatitis, Stevens-Johnson Syndrome (SJS), and toxic epidermal necrolysis (TEN), which can be fatal. The concomitant use of diclofenac with other NSAIDs or salicylates (e.g., diflunisal, salsalate) increases the risk of GI toxicity, with little or no increase in efficacy [ seeWarnings and Precautions ( 5. 2) ]. Concomitant use of oral NSAIDs with diclofenac sodium topical solution has been evaluated in one Phase 3 controlled trial and in combination with oral diclofenac, compared to oral diclofenac alone, resulted in a higher rate of rectal hemorrhage (3% vs. less than 1%), and more frequent abnormal creatinine (12% vs. 7%), urea (20% vs. 12%) and hemoglobin (13% vs. 9%) Upper GI ulcers, gross bleeding, or perforation caused by NSAIDs occur in approximately 1% of patients treated for 3-6 months, and in about 2-4% of patients treated for one year.

The patient is already taking Diclofenac and is now being prescribed Naproxen.

• The use of Naproxen and Diclofenac together is not recommended due to the increased risk of GI toxicity and other adverse effects.
• The patient should be monitored for signs of bleeding, GI adverse reactions, and renal dysfunction.
• It is recommended to use the lowest effective dose for the shortest possible duration to minimize the risk of adverse events.
• The patient should be informed about the signs and symptoms of serious skin reactions and GI adverse events and should seek medical attention immediately if they occur 2, 2, 3.

From the Research

Patient Treatment Options

• The patient is currently taking diclofenac and reports it is working well, but is asking for an alternative treatment option, Naproxen 500 mg BID, which is a common treatment for acute gout 4, 5.
• Diclofenac cream has also been prescribed for the patient, which can be used in conjunction with oral NSAIDs for the treatment of acute gout 4.
• The patient's uric acid level lab has been ordered to confirm the diagnosis of gout and to monitor the effectiveness of treatment 6.

Efficacy of Naproxen

• Naproxen has been shown to be effective in reducing pain intensity in patients with acute gout, with no significant difference in pain reduction compared to low-dose colchicine 5.
• Naproxen is also recommended as a first-line treatment option for acute mild to moderate pain, including musculoskeletal injuries 7, 8.
• The use of naproxen has been associated with fewer side effects compared to colchicine, including less diarrhea and headache 5.

Safety Considerations

• Nonsteroidal anti-inflammatory drugs (NSAIDs), including naproxen, should be used with caution in patients with a history of gastrointestinal bleeding, cardiovascular disease, or chronic renal disease 4, 7.
• The patient's medical history and current medications should be reviewed to minimize the risk of adverse effects associated with naproxen use 7.