What is the adjunct treatment of a gout attack along with colchicine (Nonsteroidal Anti-Inflammatory Drugs)?

Adjunct Treatment of Gout Attack with Colchicine

NSAIDs at full anti-inflammatory doses are the recommended adjunct treatment to colchicine for acute gout attacks, particularly when pain is severe (≥7/10) or multiple joints are involved. 1

Treatment Algorithm Based on Severity

Mild to Moderate Gout (Pain ≤6/10,1-3 Small Joints)

• Colchicine monotherapy is sufficient without requiring adjunct NSAIDs 2
• Dosing: 1.2 mg at onset, followed by 0.6 mg one hour later 1

Severe Gout (Pain ≥7/10 or Polyarticular Involvement)

• Combination therapy with colchicine plus NSAIDs is recommended 2, 3
• Alternative combinations include:
  • Oral corticosteroids plus colchicine 2, 3
  • Intra-articular steroids with colchicine (for 1-2 affected joints) 2, 3

NSAID Selection and Dosing

No single NSAID is superior to another - use any NSAID at full anti-inflammatory doses 1

FDA-Approved Options:

• Naproxen (Evidence A) 1
• Indomethacin (Evidence A) 1
• Sulindac (Evidence B) 1

Key Principle:

• Continue the NSAID at full dose until the acute attack completely resolves 1
• Do not taper prematurely unless comorbidities require dose adjustment 1

COX-2 Inhibitor Alternative

For patients with GI contraindications or NSAID intolerance:

• Celecoxib regimen: 800 mg once, then 400 mg on day 1, then 400 mg twice daily for one week 1
• This is Evidence C and should only be used in carefully selected patients 1

Critical Contraindications to NSAIDs

Avoid NSAIDs entirely in patients with: 1, 4

• Moderate to severe chronic kidney disease
• Congestive heart failure
• Peptic ulcer disease
• Patients on anticoagulation or antiplatelet therapy
• Hepatic disease

In these patients, use corticosteroids instead of NSAIDs as the adjunct to colchicine 2, 4

Non-Pharmacologic Adjunct

• Topical ice application is appropriate as an adjunctive measure to pharmacologic therapy 1

Timing Considerations

• Initiate treatment within 24 hours of symptom onset for optimal efficacy 2, 3
• Colchicine is most effective when started within 12-36 hours of symptom onset 1, 2
• Educate patients on "pill in the pocket" approach to self-initiate treatment at first warning symptoms 2, 3

Common Pitfalls to Avoid

• Do not use indomethacin preferentially - it has no efficacy advantage over other NSAIDs and potentially more adverse effects 2
• Do not use high-dose colchicine regimens - they increase toxicity without improving efficacy 2, 3
• Do not use intramuscular ketorolac or topical NSAIDs - there is no consensus supporting their use 1
• Avoid oral complementary agents (cherry juice, ginger, willow-bark extract, etc.) - these are inappropriate for acute gout treatment 1

Drug Interaction Warning

Major colchicine interactions requiring dose reduction or avoidance: 1

• Clarithromycin
• Erythromycin
• Cyclosporine
• Strong CYP3A4 and P-glycoprotein inhibitors

Adjust colchicine dose in moderate to severe CKD 1

Management of Inadequate Response

If <20% pain improvement within 24 hours or <50% improvement after 24 hours: 3

• Switch to another monotherapy agent
• Add a second recommended agent (e.g., add corticosteroids to colchicine)
• Consider IL-1 inhibitors for severe refractory cases (off-label) 3