What treatment options are available for a patient with gout, elevated uric acid level (hyperuricemia), and knee swelling, who has a known allergy to Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)?

Treatment for Acute Gout with NSAID Allergy

For a patient with acute gout (knee swelling) who is allergic to NSAIDs, corticosteroids are the first-line treatment of choice, with oral prednisone 30-35 mg daily for 5 days being the preferred regimen. 1, 2

Immediate Management of Acute Flare

First-Line: Oral Corticosteroids

• Start oral prednisone at 0.5 mg/kg per day (approximately 30-35 mg daily for most adults) 1, 2
• Give full dose for 5-10 days then stop abruptly, OR give for 2-5 days at full dose followed by a 7-10 day taper 2
• The American College of Rheumatology provides Level A evidence (highest quality) supporting corticosteroids as equally effective as NSAIDs with fewer adverse effects 1, 2
• Corticosteroids should be considered first-line therapy in patients without contraindications because they are generally safer and lower cost 1, 2

Alternative Routes if Oral Not Feasible

• Intramuscular triamcinolone acetonide 60 mg as a single injection for patients who cannot take oral medications 2
• Intra-articular corticosteroid injection directly into the knee joint provides targeted therapy with minimal systemic effects 2
• IV methylprednisolone 0.5-2.0 mg/kg (40-140 mg) for NPO patients or those unable to tolerate oral therapy 2

Second-Line: Low-Dose Colchicine

If corticosteroids are contraindicated, use low-dose colchicine: 1.2 mg initially, followed by 0.6 mg one hour later 1

• Continue with 0.6 mg once or twice daily until flare resolves 1
• Never use high-dose colchicine regimens - they cause severe GI toxicity without added benefit 1, 3
• Colchicine is contraindicated in patients with severe renal impairment (eGFR <30 mL/min) or hepatic impairment, especially if using cytochrome P450 3A4 inhibitors or P-glycoprotein inhibitors 1

Third-Line: IL-1 Inhibitors (For Refractory Cases)

For patients in whom both corticosteroids and colchicine are contraindicated or ineffective, canakinumab 150 mg subcutaneously is conditionally recommended 1, 4

• FDA-approved specifically for gout flares when NSAIDs and colchicine are contraindicated, not tolerated, or provide inadequate response, and repeated corticosteroid courses are inappropriate 4
• Requires at least 12-week interval before re-treatment 4
• Significantly more expensive than corticosteroids, making it appropriate only when other options have failed 1

Critical Contraindications to Assess

Corticosteroid Contraindications

• Active systemic fungal infections (absolute contraindication) 1, 2
• Uncontrolled diabetes (relative - requires close glucose monitoring) 2
• Active peptic ulcer disease (relative - consider PPI co-therapy) 2
• Current active infection 2

When Corticosteroids Are Actually PREFERRED

• Severe renal impairment (eGFR <30 mL/min) - no dose adjustment needed 2, 3
• Cardiovascular disease or heart failure 1, 2
• Cirrhosis or hepatic impairment 1
• History of peptic ulcer disease or GI bleeding 2
• Patients on anticoagulation 2

Management of Hyperuricemia (Uric Acid 9.7 mg/dL)

DO NOT Start or Stop Urate-Lowering Therapy During Acute Flare

• The American College of Rheumatology conditionally recommends continuing existing ULT during a flare, but NOT initiating new ULT until the acute attack resolves 1, 3
• Starting or stopping ULT during an acute flare can prolong or worsen the attack 3

After Acute Flare Resolves: Initiate Urate-Lowering Therapy

• Start allopurinol as first-line ULT at low dose (100 mg daily) and titrate upward every 2-4 weeks to achieve target serum urate <6 mg/dL 1
• Target <5 mg/dL for severe gout with tophi or frequent attacks 1
• Strongly recommend initiating prophylaxis with low-dose colchicine (0.6 mg once or twice daily) when starting ULT 1
• If colchicine contraindicated, use low-dose prednisone (<10 mg/day) for prophylaxis 1, 2
• Continue prophylaxis for 3-6 months minimum 1

Common Pitfalls to Avoid

• Never use high-dose colchicine (old regimens) - causes severe diarrhea without added benefit 1, 3
• Never start allopurinol during an acute flare - will worsen or prolong the attack 3
• Never use standard-dose colchicine in renal impairment without significant dose reduction - risk of fatal toxicity 2, 3
• Never assume corticosteroids are contraindicated in diabetes - short courses (5-10 days) are safe with glucose monitoring 2
• Never use NSAIDs as "rescue" in NSAID-allergic patients - the allergy history must be respected 1

Monitoring Response

• Define inadequate response as <20% improvement in pain within 24 hours OR <50% improvement at ≥24 hours 2
• If inadequate response occurs, consider alternative diagnosis or add a second agent (e.g., combine oral corticosteroids with intra-articular injection for severe attacks) 2
• Initiate pharmacologic treatment within 24 hours of symptom onset for optimal efficacy 3