Can I give diclofenac (Nonsteroidal Anti-Inflammatory Drug (NSAID)) to a patient with impaired renal function (dialysis) for gout?

No, Do Not Give Diclofenac to a Dialysis Patient for Gout

NSAIDs including diclofenac should be avoided in patients with severe renal impairment (dialysis) for treatment of acute gout flares. 1, 2

Why NSAIDs Are Contraindicated in Dialysis Patients

The 2016 EULAR guidelines explicitly state that "colchicine and NSAIDs should be avoided in patients with severe renal impairment." 1 This is a Grade A recommendation based on the risk of:

• Acute kidney injury and worsening renal function - NSAIDs reduce prostaglandin-mediated renal perfusion, which is critical in patients with compromised kidneys 3, 4
• Fluid retention and edema - NSAIDs cause sodium and water retention, worsening heart failure risk 3
• Hyperkalemia - NSAIDs can cause dangerous potassium elevation, particularly problematic in dialysis patients 3
• Cardiovascular complications - NSAIDs increase risk of MI and heart failure hospitalization 3

The FDA label for diclofenac specifically warns to "avoid the use of diclofenac potassium tablets in patients with advanced renal disease unless the benefits are expected to outweigh the risk of worsening renal function." 3

Recommended Alternatives for Acute Gout in Dialysis Patients

First-Line Treatment: Oral Corticosteroids

Use oral corticosteroids (30-35 mg/day prednisolone equivalent for 3-5 days) as first-line therapy. 1, 2 This is the safest and most effective option for dialysis patients with acute gout flares.

Second-Line: Intra-articular Corticosteroids

For monoarticular gout, perform joint aspiration and inject corticosteroids. 1, 2 This approach:

• Minimizes systemic effects 2
• Provides rapid local relief 1
• Avoids renal toxicity concerns 1

Third-Line: IL-1 Blockers

Consider IL-1 blockers (anakinra, canakinumab) if corticosteroids are contraindicated. 1, 2 However, these are expensive and carry infection risks. 2

Colchicine: Generally Avoid

Colchicine should also be avoided in severe renal impairment (dialysis). 1 While low-dose colchicine (0.5 mg/day) can be used with extreme caution in less severe CKD with dose reduction 1, it poses significant risks of neurotoxicity and muscular toxicity in dialysis patients. 1

Long-Term Management Considerations

Once the acute flare is controlled:

• Initiate urate-lowering therapy (ULT) - Allopurinol remains first-line even in dialysis patients, starting at very low doses (50-100 mg/day) with slow titration 1, 2
• Provide flare prophylaxis - Use low-dose prednisone (5-10 mg daily) for 3-6 months when starting ULT, as colchicine and NSAIDs are contraindicated 1, 2
• Target serum uric acid <6 mg/dL (or <5 mg/dL in severe gout) 1, 2

Critical Pitfalls to Avoid

• Never use standard NSAID dosing in dialysis patients - the risk of acute kidney injury, fluid overload, and cardiovascular events far outweighs any anti-inflammatory benefit 3, 5, 4
• Do not combine NSAIDs with ACE inhibitors or diuretics - this "triple whammy" dramatically increases acute kidney injury risk 3, 4
• Avoid the temptation to use "just one dose" - even short-term NSAID use can precipitate acute decompensation in dialysis patients 3, 6