Can Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) and colchicine be used together?

NSAIDs and Colchicine Can Be Used Together for Gout Management

NSAIDs and colchicine can be used together, particularly for acute gout management and prophylaxis during urate-lowering therapy initiation, though caution is needed regarding potential side effects. 1, 2

Evidence for Combined Use

The 2016 EULAR recommendations for gout management explicitly mention that both agents can be used together:

• For acute flares, the guidelines state that treatment options include "colchicine (within 12 hours of flare onset) at a loading dose of 1 mg followed 1 hour later by 0.5 mg on day 1 and/or an NSAID" 1
• For prophylaxis during urate-lowering therapy, the guidelines recommend "colchicine, 0.5–1 mg/day" but also note that "if colchicine is not tolerated or is contraindicated, prophylaxis with NSAIDs at low dosage, if not contraindicated, should be considered" 1

Dosing Considerations

When using these medications together:

• For colchicine:

  • Acute gout: 1 mg loading dose followed by 0.5 mg one hour later
  • Prophylaxis: 0.5-1 mg daily 1, 2

• For NSAIDs:

  • Standard anti-inflammatory doses for acute attacks (e.g., naproxen 500mg twice daily for 5 days)
  • Lower doses when used for prophylaxis 2

Safety Considerations and Precautions

While these medications can be used together, several important precautions should be observed:

Renal Function

• Both colchicine and NSAIDs should be avoided in patients with severe renal impairment 1, 2
• For patients with moderate renal impairment, dose adjustments are necessary

Gastrointestinal Risk

• Both medications can cause gastrointestinal side effects, and this risk may be additive when used together
• Consider gastroprotection with proton pump inhibitors when using NSAIDs 1

Drug Interactions

• Colchicine should not be given to patients receiving strong P-glycoprotein and/or CYP3A4 inhibitors such as cyclosporin or clarithromycin 1
• Be aware of potential drug interactions with statins that may increase risk of myopathy with colchicine 1

Case Reports of Combined Toxicity

• There are case reports of acute kidney injury when colchicine and NSAIDs are used together in high doses 3

Alternative Approaches

If combined therapy is contraindicated or poses significant risks:

• Corticosteroids (oral, intra-articular, or intramuscular) are effective alternatives 2
• For refractory cases, IL-1 inhibitors may be considered 2

Algorithm for Decision-Making

1. Assess renal function before initiating therapy

   • If eGFR < 30 ml/min: Avoid both NSAIDs and colchicine
   • If eGFR 30-60 ml/min: Consider reduced doses of colchicine; avoid NSAIDs if possible

2. Evaluate gastrointestinal risk factors

   • If history of peptic ulcer disease or GI bleeding: Avoid NSAIDs or use with PPI
   • If multiple GI risk factors: Consider alternatives to combined therapy

3. Check for drug interactions

   • Review current medications for P-glycoprotein/CYP3A4 inhibitors
   • Check for concurrent statin therapy

4. If combined therapy is appropriate:

   • Use lowest effective doses of both medications
   • Monitor for side effects, particularly GI symptoms and changes in renal function
   • Consider prophylactic PPI if using NSAIDs

The evidence supports that while NSAIDs and colchicine can be used together for gout management, careful consideration of patient factors and potential risks is essential to minimize adverse effects.