Is there a role for combining colchicine and Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) for gout flare treatment?

Combining Colchicine and NSAIDs for Gout Flare

Yes, combination therapy with colchicine and NSAIDs is appropriate and recommended, particularly for severe gout attacks involving multiple large joints or polyarticular presentations. 1

When to Use Combination Therapy

Combination therapy is specifically indicated for:

• Severe acute gout flares involving multiple joints 2, 1
• Polyarticular arthritis presentations 1
• Situations where monotherapy may provide insufficient anti-inflammatory control 2

The rationale is that colchicine and NSAIDs target different inflammatory pathways, providing synergistic anti-inflammatory effects. 1

Dosing Regimen for Combination Therapy

Initial acute treatment:

• Colchicine: 1 mg loading dose followed by 0.5 mg one hour later (total 1.8 mg over first hour) 2, 1
• NSAID: Full FDA-approved dose (naproxen, indomethacin, or sulindac) 1

After initial treatment:

• Continue colchicine at prophylactic dosing (0.6 mg once or twice daily) until the acute attack resolves 1
• Continue NSAID at full dose until the gouty attack has completely resolved 1

Critical Timing

Both medications should be initiated within 12 hours of symptom onset for maximum effectiveness. 2 The "pill in the pocket" approach allows fully informed patients to self-medicate at the first warning symptoms. 2

Important Contraindications

Avoid colchicine in:

• Severe renal impairment (GFR <30 mL/min) 2, 1
• Patients taking strong P-glycoprotein and/or CYP3A4 inhibitors (cyclosporin, clarithromycin, verapamil, ketoconazole) 2, 1

Avoid NSAIDs in:

• Severe renal impairment 2
• Heart failure 1
• Cirrhosis 1
• Active gastrointestinal disorders 3

Alternative Options When Combination is Contraindicated

If either colchicine or NSAIDs cannot be used, oral corticosteroids (prednisolone 30-35 mg daily for 3-5 days) are effective alternatives. 2, 1 Intra-articular corticosteroid injection is another option for monoarticular gout. 2

Evidence Quality

The 2017 EULAR guidelines explicitly recommend considering combination therapy for severe acute gout, representing a change from their 2006 recommendations that did not prioritize combination approaches. 2 The American College of Rheumatology similarly endorses this strategy for severe attacks. 1 While direct comparative evidence between monotherapy and combination therapy is limited, the recommendation is based on the mechanistic rationale of targeting multiple inflammatory pathways and clinical experience with severe presentations. 2

Common Pitfalls to Avoid

• Do not delay treatment beyond 12-36 hours after symptom onset, as effectiveness significantly decreases. 1
• Do not use high-dose colchicine regimens (>1.8 mg in first hour), which provide no additional benefit but substantially increase gastrointestinal toxicity. 1, 4
• Be cautious about synergistic gastrointestinal toxicity when combining NSAIDs with systemic corticosteroids (avoid this combination). 1
• Do not use combination therapy indiscriminately - reserve it for severe or polyarticular presentations where monotherapy may be insufficient. 2, 1