NSAID Treatment for Acute Gout
NSAIDs are a first-line treatment option for acute gout and should be initiated at full FDA-approved anti-inflammatory doses within 24 hours of symptom onset for optimal effectiveness. 1, 2
FDA-Approved NSAIDs and Dosing
The following NSAIDs are specifically FDA-approved for acute gout treatment 2:
- Naproxen: 500 mg twice daily 3
- Indomethacin: 50 mg three times daily for 2-3 days, then 25 mg three times daily for an additional 3-5 days until symptoms resolve 2
- Sulindac: Full anti-inflammatory doses 2
Despite indomethacin's traditional reputation as the "go-to" NSAID for gout, there is no evidence that it is more effective than other NSAIDs like naproxen or ibuprofen. 1 All NSAIDs should be used at maximum FDA-approved anti-inflammatory/analgesic doses and continued until the attack has completely resolved 2, 3.
Timing Is Critical
Treatment must be initiated within 24 hours of symptom onset to achieve optimal pain relief and anti-inflammatory effects 1, 2, 3. Delaying treatment beyond this window significantly reduces effectiveness 2.
Comparative Effectiveness
NSAIDs vs. Placebo
Low-quality evidence from one trial demonstrated that NSAIDs resulted in significantly more participants achieving 50% pain reduction at 24 hours (73% vs. 27%) compared to placebo 4, 5.
NSAIDs vs. COX-2 Inhibitors
Moderate-quality evidence shows that non-selective NSAIDs and selective COX-2 inhibitors (COXIBs) are equally effective for pain relief, inflammation reduction, and treatment success 1, 4, 5. However, COX-2 inhibitors cause significantly fewer gastrointestinal adverse events (38% vs. 60% total adverse events; fewer withdrawals due to adverse events: 3% vs. 8%) 4, 5.
NSAIDs vs. Corticosteroids
Moderate-quality evidence indicates that NSAIDs and systemic corticosteroids provide equivalent pain relief and functional improvement 1, 4, 5. The American College of Physicians recommends corticosteroids as first-line therapy in patients without contraindications due to their superior safety profile and lower cost. 1
Contraindications and Safety
NSAIDs are contraindicated in patients with 1, 2, 3:
- Severe renal impairment or chronic kidney disease
- History of gastrointestinal bleeding or peptic ulcer disease
- Heart failure
- Cirrhosis
Common adverse effects include 1:
- Dyspepsia
- Gastrointestinal perforations, ulcers, and bleeding
- Renal dysfunction
- Cardiovascular events
Critical Pitfalls to Avoid
Never discontinue ongoing urate-lowering therapy during an acute attack - this should be continued without interruption 1, 2, 3, 6
Do not delay treatment - waiting beyond 24 hours significantly reduces efficacy 2, 3
Do not underdose - use full FDA-approved anti-inflammatory doses, not analgesic doses 2, 3
Do not stop treatment prematurely - continue at full dose until the attack has completely resolved 3
When NSAIDs Are Not Appropriate
For patients with NSAID contraindications, use 1, 2, 3:
- Corticosteroids (oral prednisolone 35 mg daily for 5 days, or intra-articular injection, or intramuscular administration) 1
- Low-dose colchicine (1.2 mg at first sign, followed by 0.6 mg one hour later) if started within 36 hours of symptom onset 1, 3
Combination Therapy for Severe Attacks
For polyarticular or severe attacks with inadequate response to monotherapy, consider adding a second agent such as combining NSAIDs with corticosteroids or colchicine 1, 2.
Prophylaxis Considerations
When initiating urate-lowering therapy after the acute attack resolves, prophylactic therapy with low-dose colchicine (0.6 mg once or twice daily) or low-dose NSAIDs should be started and continued for at least 6 months 1, 3, 6.