Low-Dose Aspirin and Gout Flares
Yes, low-dose aspirin (baby aspirin) can increase gout flares, but you should NOT stop it if the patient is taking it for appropriate cardiovascular indications. 1
The Evidence on Aspirin and Gout Risk
Mechanism and Clinical Impact
Low-dose aspirin elevates serum uric acid levels by inhibiting renal uric acid excretion, which can precipitate gout flares in susceptible individuals. 2, 3
The risk of recurrent gout attacks increases by 81% (OR=1.81,95% CI 1.30-2.51) when patients use ≤325 mg/day of aspirin on two consecutive days, with even stronger associations at lower doses (OR=1.91 for ≤100 mg daily). 3
This increased flare risk persists across all patient subgroups, including variations in sex, age, body mass index, and renal function status. 3
The Critical Management Decision
Do NOT Stop Aspirin
The 2020 American College of Rheumatology conditionally recommends AGAINST stopping low-dose aspirin in patients with gout when it is being taken for appropriate cardiovascular indications, regardless of disease activity. 1
The rationale is straightforward: there are few practical alternatives to low-dose aspirin for cardiovascular prophylaxis, and the cardiovascular mortality risk from stopping aspirin far outweighs the morbidity from gout flares. 1
The potential benefits of stopping aspirin for serum urate reduction do not exceed the cardiovascular risks of medication cessation in patients with appropriate indications. 1
The Correct Management Strategy
Optimize Urate-Lowering Therapy Instead
Concomitant use of allopurinol nullifies the detrimental effect of aspirin on gout flare risk, making urate-lowering therapy the appropriate intervention rather than aspirin cessation. 3
Initiate or intensify urate-lowering therapy (allopurinol as first-line) with a treat-to-target approach aiming for serum urate <6 mg/dL (or <5 mg/dL if tophi present). 1
Provide prophylaxis against flares when initiating or adjusting urate-lowering therapy using colchicine (up to 1.2 mg daily), NSAIDs, or low-dose glucocorticoids for 3-6 months. 1
Monitor and Adjust
Regular serum urate monitoring is especially important in patients taking low-dose aspirin to ensure adequate urate-lowering therapy dosing and to help avoid aspirin-associated gout attacks. 3
Titrate urate-lowering therapy upward as needed to overcome the hyperuricemic effect of aspirin and achieve target serum urate levels. 1
Common Pitfalls to Avoid
Never discontinue aspirin solely to manage gout without consulting the prescribing physician about cardiovascular risk, as this prioritizes quality of life over mortality. 1
Do not assume that because aspirin causes hyperuricemia, stopping it will adequately control gout—proper urate-lowering therapy is required regardless. 3
Avoid using the aspirin-gout association as justification to withhold aspirin from patients who have clear cardiovascular indications for its use. 1