Naproxen Dosing for Acute Gout
For acute gout attacks, the recommended dose of naproxen is 750 mg initially, followed by 250 mg every 8 hours until the attack has subsided. 1
Initial Treatment Selection
Naproxen is one of three first-line options for treating acute gout attacks, alongside colchicine and corticosteroids. The selection between these options should be based on:
- Patient comorbidities
- Timing of treatment initiation
- Joint involvement
Algorithm for Treatment Selection:
- For patients without contraindications to NSAIDs: Naproxen is an excellent choice
- For patients with renal disease, heart failure, or cirrhosis: Avoid naproxen; use corticosteroids instead
- For patients with history of GI issues or ulcers: Avoid naproxen; use corticosteroids or colchicine
- For treatment within 12-24 hours of symptom onset: Any of the three options work well
- For 1-2 large joints: Consider intra-articular corticosteroid injection
- For polyarticular involvement: Systemic therapy with naproxen, colchicine, or oral corticosteroids
Naproxen Administration Details
The FDA-approved dosing regimen for naproxen in acute gout is:
- Initial dose: 750 mg
- Subsequent doses: 250 mg every 8 hours
- Continue until the attack has subsided 1
This dosing has been shown to be effective in clinical trials. A randomized equivalence trial found that naproxen (500 mg twice daily for 5 days) was equally effective as prednisolone (35 mg once daily for 5 days) for treating acute gout 2. Another study demonstrated that naproxen 750 mg as a single dose followed by 250 mg three times daily was effective for acute gout treatment 3.
Treatment Duration
Treatment should continue until the acute attack has completely resolved. This typically takes 5-7 days, but may vary between patients.
Common Pitfalls and Caveats
Renal impairment: Naproxen is not recommended for patients with moderate to severe renal impairment (creatinine clearance <30 mL/min) 1
Elderly patients: Consider using lower doses in elderly patients due to increased unbound plasma fraction of naproxen 1
Gastrointestinal risk: NSAIDs including naproxen can cause dyspepsia and potential gastrointestinal perforations, ulcers, and bleeding 4
Cardiovascular risk: Consider cardiovascular risk factors before prescribing naproxen
Delayed treatment: Treatment should be initiated as early as possible, ideally within 24 hours of symptom onset, as delayed treatment reduces efficacy 5
Prophylaxis During Urate-Lowering Therapy
When initiating urate-lowering therapy (ULT), prophylaxis against acute flares is recommended:
- Low-dose naproxen (250 mg twice daily) can be used for prophylaxis 4, 5
- Prophylaxis should continue for at least 6 months, or 3 months after achieving target serum urate if no tophi are present 4, 5
- Alternatively, low-dose colchicine (0.6 mg once or twice daily) can be used for prophylaxis 6
Comparative Effectiveness
A recent open-label randomized pragmatic trial (CONTACT) compared naproxen (750 mg initially, then 250 mg every 8 hours for 7 days) with low-dose colchicine (500 mcg three times daily for 4 days) and found no significant difference in pain reduction over 7 days. However, naproxen caused fewer side effects, supporting its use as first-line treatment for gout flares in primary care when not contraindicated 7.
In summary, naproxen at the FDA-approved dose of 750 mg initially followed by 250 mg every 8 hours until the attack subsides is an effective and well-established treatment for acute gout attacks.