What are alternative analgesics for gout in a patient with Non-Steroidal Anti-Inflammatory Drug (NSAID) intolerance?

From the Guidelines

For patients with gout who cannot tolerate NSAIDs, colchicine is the first-line alternative analgesic, typically prescribed at a low dose of 1.2 mg followed by 0.6 mg 1 hour later, due to its efficacy and lower risk of gastrointestinal adverse effects compared to higher doses 1. When considering alternative analgesics for gout in an NSAID-intolerant patient, it is essential to weigh the benefits and risks of each option.

• Colchicine is recommended as the first-line alternative due to its effectiveness in reducing pain and its favorable side effect profile when used at low doses 1.
• Corticosteroids, such as prednisolone, can be used for severe pain, but their use is associated with potential adverse effects like dysphoria, mood disorders, and immune suppression 1.
• The American College of Physicians recommends using low-dose colchicine for treating acute gout, with a strong recommendation based on moderate-quality evidence 1. Key considerations for managing gout in NSAID-intolerant patients include:
• Using the lowest effective dose of colchicine to minimize gastrointestinal adverse effects 1.
• Avoiding the use of corticosteroids in patients with contraindications, such as systemic fungal infections or known contraindications 1.
• Considering alternative therapies, such as acetaminophen or preventive therapy with allopurinol or febuxostat, for patients with recurrent flares or those who cannot tolerate colchicine or corticosteroids. The most recent and highest-quality study, published in 2017, provides the basis for these recommendations, emphasizing the importance of using low-dose colchicine as the first-line alternative analgesic for gout in NSAID-intolerant patients 1.

From the FDA Drug Label

ILARIS is indicated for the symptomatic treatment of adult patients with gout flares in whom non-steroidal anti-inflammatory drugs (NSAIDs) and colchicine are contraindicated, are not tolerated, or do not provide an adequate response, and in whom repeated courses of corticosteroids are not appropriate. The recommended dose of ILARIS for adult patients with a gout flare is 150 mg administered subcutaneously. For patients who require re-treatment, there should be an interval of at least 12 weeks before a new dose of ILARIS may be administered.

Alternative analgesic for gout in an NSAID intolerant patient:

• Canakinumab (ILARIS) is an alternative for the symptomatic treatment of adult patients with gout flares who are intolerant to NSAIDs.
• The dose is 150 mg subcutaneously.
• Re-treatment should not be done before an interval of at least 12 weeks 2

From the Research

Alternative Analgesics for Gout in an NSAID Intolerant Patient

Overview of Alternative Treatments

• Interleukin-1 inhibitors, such as canakinumab, have been shown to be effective in treating acute gout flares, with moderate-quality evidence indicating that canakinumab 150 mg is probably superior to triamcinolone acetonide 40 mg in terms of pain relief, resolution of joint swelling, and achieving a good treatment response at 72 hours following treatment 3.
• Glucocorticoids, such as systemic glucocorticoids, have been found to be as effective as NSAIDs but safer, with moderate-quality evidence supporting their use 4.
• Colchicine, particularly low-dose colchicine, has been shown to be effective and safer than high-dose colchicine, with low-quality evidence supporting its use 4, 5.
• Other alternatives, such as adrenocorticotropic hormone (ACTH) and herbal supplements, have also been suggested as potential treatments for acute gout, although the evidence is limited 5.

Comparison of Alternative Treatments

• A systematic review and meta-analysis found that etoricoxib, a selective cyclo-oxygenase-2 inhibitor, was comparable to indomethacin and diclofenac in terms of pain relief, but may confer a greater benefit in terms of investigator's global assessment of response and patient's global assessment of response 6.
• Another study found that canakinumab was more effective than rilonacept in treating acute gout flares, with moderate-quality evidence supporting its use 3.
• A comparison of systemic glucocorticoids and NSAIDs found that they were probably equally beneficial in terms of pain relief, improvement in function, and treatment success, although NSAIDs probably result in more total adverse events 7, 4.

Considerations for NSAID Intolerant Patients

• For patients who are intolerant to NSAIDs, alternative treatments such as interleukin-1 inhibitors, glucocorticoids, and colchicine may be considered, with the choice of treatment depending on the individual patient's needs and medical history 3, 4, 5.
• It is essential to weigh the benefits and harms of each treatment option and consider the patient's comorbidities and potential interactions with other medications 7, 4, 5.