What are the recommended nonsteroidal anti‑inflammatory drug (NSAID) regimens for treating an acute gout flare in adults and their contraindications?

NSAIDs for Acute Gout: Recommended Regimens and Contraindications

Direct Answer

Use any FDA-approved NSAID (naproxen, indomethacin, or sulindac) at full anti-inflammatory dose within 24 hours of symptom onset and continue at full dose until complete resolution—no single NSAID is superior to another for gout treatment. 1

---

FDA-Approved NSAID Options

The following NSAIDs have specific FDA approval for acute gout and should be prescribed at maximum anti-inflammatory doses: 1

• Naproxen 1
• Indomethacin 1
• Sulindac 1

No evidence demonstrates that one NSAID provides better pain relief or anti-inflammatory efficacy than another for gout. 1, 2 Selection should be based on availability, cost, and patient-specific contraindications rather than perceived superiority of any particular agent. 2

---

Dosing Strategy

• Initiate treatment within 24 hours of symptom onset for optimal efficacy 1, 2
• Use full FDA-approved anti-inflammatory doses 1
• Continue at full dose throughout the entire attack until complete resolution—do not reduce dose early 1
• Consider NSAIDs with rapid absorption and short half-life to minimize accumulation in patients with subclinical renal impairment 2, 3

---

Absolute Contraindications to NSAIDs

NSAIDs must be avoided entirely in the following conditions:

• Severe renal impairment (eGFR <30 mL/min)—NSAIDs can precipitate or worsen acute kidney injury 1, 4, 2
• Active or recent gastrointestinal bleeding 1
• Cirrhosis or hepatic impairment 1, 2
• Heart failure—NSAIDs increase cardiovascular risk and fluid retention 1, 2

---

Relative Contraindications Requiring Extreme Caution

Use NSAIDs only with extreme caution and close monitoring in:

• Any degree of renal disease (even mild-to-moderate impairment) 1, 2
• Cardiovascular disease 2
• History of peptic ulcer disease—add proton pump inhibitor co-therapy 1, 2
• Patients on anticoagulation therapy—increased bleeding risk 1, 3
• Elderly patients—higher risk of adverse effects 1

---

Preferred Alternative: Corticosteroids

Corticosteroids are recommended as first-line therapy over NSAIDs due to superior safety profile, equal efficacy, and lower cost. 2, 5

• Prednisone 30–35 mg daily for 5 days provides pain relief equivalent to NSAIDs but with significantly fewer adverse events (27% vs 63% with indomethacin) 4, 5
• Corticosteroids are explicitly preferred in patients with renal impairment, cardiovascular disease, heart failure, cirrhosis, or GI risk factors 4, 2

---

Combination Therapy for Severe Attacks

For severe gout involving multiple large joints or polyarticular arthritis, initial combination therapy is appropriate: 1

• Colchicine + NSAID (if no contraindications) 1
• Avoid combining NSAIDs with systemic corticosteroids—synergistic gastrointestinal toxicity 1

---

Critical Pitfalls to Avoid

• Do not use NSAIDs in severe renal impairment (eGFR <30 mL/min)—this can cause acute kidney injury 1, 4, 2
• Do not reduce NSAID dose early—maintain full anti-inflammatory dose until complete attack resolution 1
• Do not delay treatment beyond 24 hours—efficacy drops significantly 1, 2
• Do not combine NSAIDs with systemic corticosteroids—increased GI toxicity 1
• Do not interrupt ongoing urate-lowering therapy during an acute flare 1

---

Gastrointestinal Protection

When NSAIDs must be used in patients with GI risk factors:

• Add proton pump inhibitor co-therapy 1, 2
• Consider COX-2 selective agents as an alternative 6

---

Prophylaxis During Urate-Lowering Therapy Initiation

When starting or adjusting urate-lowering therapy, provide prophylaxis to prevent flares: 1

• Low-dose NSAID with proton pump inhibitor (where indicated) for at least 6 months 1, 7
• Example: Naproxen 250 mg twice daily 7
• Continue prophylaxis for at least 6 months, or 3 months after achieving target serum urate if no tophi present 1