What nonsteroidal anti-inflammatory drugs (NSAIDs) are used to treat acute gout?

NSAIDs for Acute Gout Management

For acute gout attacks, full-dose NSAIDs including naproxen, indomethacin, and sulindac are FDA-approved first-line treatments that should be initiated within 24 hours of symptom onset for optimal effectiveness. 1

FDA-Approved NSAIDs for Acute Gout

• Naproxen, indomethacin, and sulindac are specifically FDA-approved for the treatment of acute gout 1
• NSAIDs should be administered at full FDA-approved anti-inflammatory/analgesic doses for acute gout treatment 1
• Treatment should be continued at full dose until the gouty attack has completely resolved 1

Specific NSAID Dosing Recommendations

• Indomethacin: Initial dose of 50 mg three times daily for 2-3 days, followed by 25 mg three times daily for an additional 3-5 days until symptoms resolve 2
• Naproxen: Full anti-inflammatory dose as approved for acute pain/gout treatment 1, 3
• Treatment should be initiated as soon as possible, ideally within 24 hours of symptom onset 1

Alternative Options When NSAIDs Are Contraindicated

• Corticosteroids are recommended as first-line therapy in patients with contraindications to NSAIDs due to their safety profile and low cost 1, 4
• Low-dose colchicine (1.2 mg followed by 0.6 mg one hour later) is effective if started within 36 hours of symptom onset 1, 4
• Selective COX-2 inhibitors like celecoxib may be used in patients with GI contraindications to traditional NSAIDs, though with higher doses required 1

Combination Therapy for Severe Gout

• For severe pain in polyarticular attacks, combination therapy may be appropriate 1
• Options include combining NSAIDs with corticosteroids or colchicine, though caution is needed due to potential increased adverse effects 1, 4

NSAID Contraindications and Safety Considerations

• NSAIDs are contraindicated in patients with severe renal impairment, history of GI bleeding or ulceration, and heart failure 2, 3
• Common adverse effects include gastrointestinal issues (ulcers, bleeding), which occur more frequently than with corticosteroid alternatives 2, 3
• NSAIDs should be used with caution in elderly patients and those with cardiovascular disease 3, 5

Common Pitfalls to Avoid

• Delaying treatment beyond 24 hours of symptom onset reduces effectiveness 1, 4
• Continuing high-dose NSAIDs beyond the necessary treatment period increases risk of adverse effects 2
• Interrupting ongoing urate-lowering therapy during an acute attack (this should be continued) 1
• Inadequate dosing of NSAIDs can lead to treatment failure 1, 6

Long-Term Management Considerations

• After resolution of acute gout, prophylactic therapy should be considered when initiating urate-lowering therapy 1, 4
• Low-dose NSAIDs (e.g., naproxen 250 mg twice daily) can be used as prophylaxis when initiating urate-lowering therapy 1
• Prophylactic therapy should be continued for at least 8 weeks when starting urate-lowering therapy 1, 4

NSAIDs remain a cornerstone of acute gout management when used appropriately at full anti-inflammatory doses and initiated promptly after symptom onset. However, patient-specific factors including renal function, cardiovascular risk, and gastrointestinal risk should guide selection among the available therapeutic options.