What is the recommended dosage and duration of naproxen (nonsteroidal anti-inflammatory drug (NSAID)) for a 44-year-old female patient with gout?

Naproxen Prescribing for Acute Gout in a 44-Year-Old Female

For acute gout in a 44-year-old female, prescribe naproxen 750 mg immediately as a loading dose, followed by 250 mg every 8 hours until the attack has completely resolved, typically 5-10 days. 1

Dosing Strategy

Initial Loading Dose

• Start with naproxen 750 mg as a single loading dose 1, 2
• This FDA-approved regimen provides rapid onset of pain relief, typically within 1 hour 1

Maintenance Dosing

• Follow with 250 mg every 8 hours until the acute attack has completely subsided 1
• Alternative dosing: 500 mg every 12 hours can be used, though the every-8-hour regimen is specifically FDA-approved for acute gout 1

Duration of Treatment

• Continue at full dose until the gouty attack has completely resolved, not just until symptoms improve 3
• Do not arbitrarily stop at a predetermined number of days—treat until complete resolution 3
• Typical duration is 5-10 days, but this varies based on clinical response 3

Critical Implementation Points

Timing Considerations

• Initiate treatment within 24 hours of acute gout attack onset for optimal outcomes 3
• Earlier treatment (within 12-24 hours) provides superior pain relief 4

Contraindications and Precautions for This Patient

• Screen for renal impairment: Naproxen is not recommended if creatinine clearance <30 mL/min 1
• Assess cardiovascular risk factors: NSAIDs carry cardiovascular risks, particularly relevant in women over 40 1
• Check for gastrointestinal risk: Consider adding a proton pump inhibitor if history of GI bleeding, ulcers, or concurrent corticosteroid use 3
• Avoid if history of NSAID-induced acute kidney injury 4

Alternative Approaches if NSAIDs Are Contraindicated

First-Line Alternatives

• Oral prednisone 30-35 mg daily for 3-5 days if NSAIDs are contraindicated 4
• Colchicine 1.2 mg immediately, followed by 0.6 mg one hour later (only if started within 36 hours of symptom onset) 3

Combination Therapy

• For severe polyarticular attacks, consider combining full-dose naproxen with colchicine or corticosteroids from the outset 3
• This approach is appropriate for severe pain involving multiple large joints 3

Concurrent Urate-Lowering Therapy Management

If Patient Is Already on Allopurinol or Febuxostat

• Do not interrupt ongoing urate-lowering therapy during the acute attack 3, 4
• Continue the current dose without modification 3

If Initiating Urate-Lowering Therapy

• You can start urate-lowering therapy during the acute flare rather than waiting for resolution 3
• Provide anti-inflammatory prophylaxis (naproxen 250 mg twice daily or colchicine 0.6 mg once or twice daily) for at least 6 months when initiating urate-lowering therapy 3
• Prophylaxis should continue for the greater of: 6 months OR 3 months after achieving target serum urate 3

Common Pitfalls to Avoid

• Do not use inadequate doses: The full FDA-approved dose is required for acute gout, not the lower doses used for chronic pain 1
• Do not stop treatment prematurely: Continue until complete resolution, not just symptom improvement 3
• Do not delay treatment: Efficacy decreases significantly if treatment is not started within 24 hours 3, 4
• Do not forget renal dose adjustments: Even mild-moderate renal impairment may require dose reduction or alternative therapy 1
• Do not combine with other NSAIDs or high-dose aspirin: This increases toxicity without improving efficacy 4

Monitoring During Treatment

• Assess pain reduction at 24 hours: Expect at least 20% improvement; if <50% improvement at 24 hours, consider adding or switching to alternative therapy 3
• Monitor for gastrointestinal symptoms: Nausea, dyspepsia, or abdominal pain warrant dose reduction or discontinuation 1
• Watch for fluid retention or blood pressure elevation: Particularly important in this age group 1