From the Guidelines
I strongly recommend managing this 43-year-old male patient's bilateral foot pain with Naproxen 500 mg twice daily and topical Diclofenac cream while awaiting his scheduled Rosendahl appointment, as this approach is supported by the most recent and highest quality evidence 1.
Key Considerations
- The patient's previous response to diclofenac before incarceration suggests that NSAIDs may be effective in managing his symptoms.
- Ordering a uric acid level is appropriate to evaluate for gout, which the patient is concerned about.
- Naproxen will help reduce inflammation and pain systemically, while the topical diclofenac provides targeted relief with fewer systemic side effects.
Additional Recommendations
- If the uric acid level returns elevated, confirming gout, additional medications like allopurinol might be considered for long-term management, as recommended by the American College of Physicians guideline on management of acute and recurrent gout 1.
- In the meantime, the patient should be advised to:
- Avoid high-purine foods
- Maintain adequate hydration
- Elevate his feet when possible to help reduce pain and swelling
Evidence-Based Approach
The 2016 updated EULAR evidence-based recommendations for the management of gout support the use of NSAIDs, such as naproxen, as a first-line treatment for acute gout attacks 1. Additionally, the American College of Physicians guideline on management of acute and recurrent gout recommends choosing corticosteroids, NSAIDs, or colchicine to treat patients with acute gout, with a strong recommendation and high-quality evidence 1. This regimen should provide symptomatic relief until his specialist appointment.
From the FDA Drug Label
The recommended starting dose of naproxen is 500 mg, followed by 500 mg every 12 hours or 250 mg every 6 to 8 hours as required. Acute Gout The recommended starting dose is 750 mg of naproxen followed by 250 mg every 8 hours until the attack has subsided.
The patient is prescribed Naproxen 500 mg BID, which is a suitable dose for managing pain, but for acute gout, the recommended starting dose is 750 mg of naproxen. Considering the patient's concern about having gout, a more appropriate initial dose would be 750 mg of naproxen, followed by 250 mg every 8 hours until the attack has subsided 2.
From the Research
Patient Concerns and Treatment
- The patient is a 43-year-old male complaining of bilateral foot pain and is worried about having gout.
- The patient was previously taking diclofenac, which was effective, but is now requesting a Rosendahl appointment and has been prescribed Naproxen 500 mg BID and Diclofenac cream.
Gout Treatment and Management
- According to 3, NSAIDs, colchicine, and glucocorticoids are first-line agents for gout flares, and allopurinol is an agent of first choice for urate-lowering therapy.
- A study by 4 found that naproxen caused fewer side effects compared to low-dose colchicine for the treatment of gout flares in primary care, supporting naproxen as a first-line treatment.
- Another study by 5 suggested that low-dose colchicine can adequately prevent gout flare with fewer adverse events compared to regular-dose colchicine.
Safety and Efficacy of Prophylaxis
- Research by 6 found that adverse events were more common when allopurinol was initiated with prophylaxis, particularly diarrhea with colchicine, and angina, acute kidney injury, and myocardial infarction with NSAID prophylaxis.
- A study by 7 compared the efficacy and safety of naproxen 500 mg twice daily versus as needed for the treatment of acute ankle sprain, and found that the as-needed regimen had a better safety profile and lower total drug use.
Laboratory Tests and Monitoring
- The patient will undergo a uric acid level lab test to help diagnose and monitor gout.
- Regular monitoring of the patient's condition and adjustment of treatment as needed will be crucial in managing gout and preventing adverse events.