What is the recommended Non-Steroidal Anti-Inflammatory Drug (NSAID) regimen for managing a gout flare?

NSAID Regimen for Gout Flare

NSAIDs at full FDA-approved doses (such as naproxen 500 mg twice daily or indomethacin 50 mg three times daily) are recommended as first-line treatment for acute gout flares, with treatment continuing until complete resolution of symptoms, typically 3-5 days. 1

Specific NSAID Dosing Recommendations

• Naproxen 500 mg twice daily is the most commonly recommended NSAID regimen for acute gout flares 1
• Indomethacin 50 mg three times daily is an alternative NSAID option with equivalent efficacy 1
• Treatment should continue at full dose until the flare has completely resolved, typically requiring 3-5 days of therapy 1
• Early initiation is critical—NSAIDs are most effective when started within 12 hours of symptom onset 2

When NSAIDs Are the Preferred Choice

• NSAIDs are equally effective as colchicine and corticosteroids for treating acute gout flares 1
• They should be selected as first-line therapy in patients without cardiovascular disease, chronic kidney disease, gastrointestinal bleeding risk, or active peptic ulcer disease 1

Critical Contraindications and Safety Considerations

NSAIDs should be avoided entirely in the following situations:

• Chronic kidney disease with GFR <30 mL/min—NSAIDs can precipitate acute kidney injury and worsen renal function 1
• Cardiovascular disease or heart failure—NSAIDs increase the risk of myocardial infarction, stroke, and heart failure exacerbation 3
• Active peptic ulcer disease or history of gastrointestinal bleeding—NSAIDs significantly increase bleeding risk 1
• Concurrent anticoagulation therapy—the combination substantially increases bleeding risk 1

Alternative First-Line Options When NSAIDs Are Contraindicated

If NSAIDs cannot be used, the following alternatives are equally effective:

• Colchicine: 1.2 mg loading dose followed by 0.6 mg one hour later (total 1.8 mg on day 1), most effective when given within 12 hours of flare onset 2, 4
• Oral corticosteroids: Prednisone 30-35 mg daily for 5 days (no taper needed for short courses) 2
• Intra-articular corticosteroid injection: For monoarticular or oligoarticular gout involving 1-2 joints 2

Combination Therapy for Severe Flares

• For severe acute gout with multiple joint involvement, combination therapy with NSAIDs plus colchicine can be considered for enhanced efficacy 2
• Acceptable combinations include oral corticosteroids with colchicine, or intra-articular steroids with any other modality 2

Common Pitfalls to Avoid

• Do not use NSAIDs in patients with cardiovascular disease or heart failure—this significantly increases the risk of cardiovascular events and heart failure hospitalization 3
• Do not continue NSAIDs beyond flare resolution—prolonged use increases adverse event risk without additional benefit 1
• Do not use NSAIDs for flare prophylaxis during urate-lowering therapy initiation in patients with renal impairment—colchicine or low-dose corticosteroids are safer options 1
• Do not delay treatment—waiting beyond 12 hours of symptom onset significantly reduces NSAID efficacy 2

Monitoring During NSAID Therapy

• Monitor for gastrointestinal symptoms (dyspepsia, nausea, abdominal pain) which occur more frequently with NSAIDs compared to corticosteroids 5
• In patients with mild-moderate renal impairment (GFR 30-60 mL/min), NSAIDs can be used cautiously with close monitoring of renal function 1
• Assess for signs of fluid retention or blood pressure elevation, particularly in patients with borderline cardiovascular risk 3