From the Guidelines
For patients with gout who have NSAID allergies, colchicine is the first-line alternative treatment option, as recommended by the American College of Physicians in their 2017 guideline 1. The management of gout in patients with NSAID allergies requires careful consideration of alternative treatment options.
- Colchicine is a strong recommendation for the treatment of acute gout, with a low-dose regimen (1.2 mg initially, followed by 0.6 mg one hour later) being preferred to minimize gastrointestinal side effects, as suggested by the guideline 1.
- Corticosteroids, either oral or intra-articular, are another effective option for treating acute gout in patients with NSAID allergies, with the guideline recommending their use as an alternative to NSAIDs 1.
- The guideline also emphasizes the importance of discussing benefits, harms, costs, and individual preferences with patients before initiating urate-lowering therapy, including concomitant prophylaxis, in patients with recurrent gout attacks 1. Key considerations in the management of gout in patients with NSAID allergies include:
- The use of low-dose colchicine to minimize side effects
- The consideration of corticosteroids as an alternative treatment option
- The importance of discussing treatment options and preferences with patients
- The need to continue any urate-lowering therapy during acute attacks and to consider initiating long-term urate-lowering therapy after the acute attack resolves, as recommended by the guideline 1.
From the FDA Drug Label
For treatment of gout flares in patients with mild (Cl cr 50 to 80 mL/min) to moderate (Cl cr 30 to 50 mL/min) renal function impairment, adjustment of the recommended dose is not required, but patients should be monitored closely for adverse effects of colchicine Data upon which the following estimates of incidence of adverse reactions are made are derived from experiences reported in the literature, unpublished clinical trials and voluntary reports since marketing of allopurinol tablets began
In the case of NSAIDs allergy, the treatment of gout can be managed with:
- Colchicine: can be used for the treatment of gout flares, with close monitoring for adverse effects, especially in patients with renal impairment.
- Allopurinol: can be used for the prophylaxis of gout flares, but it is not recommended to initiate therapy during an acute attack. Key considerations:
- Close monitoring for adverse effects is necessary when using colchicine, especially in patients with renal impairment.
- Allopurinol can cause severe skin reactions, and treatment should be discontinued immediately if a rash develops 2 3.
From the Research
Treatment Options for Gout in Case of NSAIDs Allergy
In patients with gout who are allergic to NSAIDs, several alternative treatment options are available:
- Colchicine: This is a commonly used medication for the treatment of acute gout flares, especially in patients who cannot tolerate NSAIDs 4, 5, 6.
- Corticosteroids: Systemic corticosteroids have been shown to be effective in treating acute gout flares, with efficacy similar to that of NSAIDs 6, 7.
- IL-1 inhibitors: These medications, such as canakinumab, have been shown to be effective in treating acute gout flares in patients who are refractory to or have contraindications to NSAIDs and/or colchicine 5, 6.
- Urate-lowering therapies: While not directly treating the acute flare, urate-lowering therapies such as allopurinol and febuxostat can help prevent future gout flares by reducing serum uric acid levels 4, 5, 7.
Considerations for Treatment
When treating gout in patients with NSAIDs allergy, it is essential to consider the patient's comorbidities and medical history to guide the choice of therapy:
- Renal function: This is crucial in determining the starting dose of allopurinol and the maintenance dose 7.
- Cardiovascular risk: Febuxostat has received a U.S. FDA black box warning for cardiovascular safety, and its use should be carefully considered in patients with cardiovascular risk factors 5.
- Patient preference: Treatment should be personalized to the individual patient, taking into account their preferences and values 4.