What medication can be used to treat an acute gout flare in a patient who is allergic to nonsteroidal anti‑inflammatory drugs (NSAIDs)?

Treatment of Acute Gout in NSAID-Allergic Patients

For a patient with acute gout who is allergic to NSAIDs, oral corticosteroids are the first-line treatment: prescribe prednisone 30–35 mg once daily for 5 days, or alternatively 0.5 mg/kg/day for 5–10 days at full dose then stop abruptly. 1, 2

First-Line Option: Oral Corticosteroids

Oral corticosteroids are equally effective as NSAIDs for acute gout and are often safer in patients with comorbidities. 1, 2 The American College of Rheumatology provides Level A evidence (highest quality) supporting this recommendation. 1

Dosing Regimens

You have two evidence-based options:

• Fixed-dose regimen: Prednisone 30–35 mg once daily for 5 days without taper—this is the simplest and most practical approach for most patients. 1, 2

• Weight-based regimen with optional taper: Prednisone 0.5 mg/kg/day (approximately 30–35 mg for average adults) for 5–10 days at full dose then stop, OR give for 2–5 days at full dose followed by a 7–10 day taper. 1, 2 The tapered approach is preferred for more severe attacks, polyarticular involvement, or patients at higher risk for rebound flares. 1

When Corticosteroids Are Particularly Preferred

Corticosteroids are explicitly the safest first-line option in patients with: 1

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

Second-Line Option: Colchicine

Colchicine is safe and effective in NSAID-allergic patients because it works through a completely different mechanism (inhibiting microtubule polymerization) with no cross-reactivity to NSAIDs. 3 The American College of Rheumatology strongly recommends colchicine as appropriate first-line therapy for gout flares. 3

Dosing Protocol

• Loading dose: 1.2 mg (or 1 mg) at the first sign of flare, followed by 0.6 mg (or 0.5 mg) one hour later (total 1.8 mg over one hour). 3, 4

• Maintenance: After 12 hours, resume 0.6 mg once or twice daily until the attack resolves. 3

• Critical timing: Colchicine should only be started within 36 hours of symptom onset; effectiveness drops significantly beyond this window. 3 Maximum benefit occurs when treatment begins within 12–24 hours. 3

Important Contraindications for Colchicine

Absolute contraindications: 3

• Severe renal impairment (eGFR <30 mL/min) 3
• Concurrent use of strong CYP3A4 or P-glycoprotein inhibitors (clarithromycin, erythromycin, cyclosporine, ketoconazole, ritonavir)—this combination can cause fatal toxicity 3
• Combined renal or hepatic impairment AND potent CYP3A4/P-gp inhibitor use 3

Alternative Routes: Parenteral Corticosteroids

When oral medications cannot be taken (NPO status, vomiting, surgical conditions): 1

• Intramuscular: Triamcinolone acetonide 60 mg IM as a single injection 1
• Intravenous: Methylprednisolone 0.5–2.0 mg/kg (approximately 40–140 mg for most adults), repeat as clinically indicated 1
• Intra-articular: For monoarticular or oligoarticular gout involving 1–2 large, accessible joints—dose varies by joint size (e.g., 40 mg for knee, 20–30 mg for ankle) 1, 2

Combination Therapy for Severe Attacks

For severe acute gout with polyarticular involvement (≥4 joints) or multiple large joints, initial combination therapy is more effective than monotherapy. 3, 2 Acceptable combinations include: 3, 2

• Oral corticosteroids + colchicine
• Intra-articular steroids + any other oral anti-inflammatory agent
• Colchicine + oral corticosteroids

Avoid combining NSAIDs with systemic corticosteroids due to synergistic gastrointestinal toxicity. 3

Critical Timing Principle

Initiate treatment within 24 hours of symptom onset for optimal efficacy—delays beyond this window markedly reduce effectiveness of any treatment. 3, 2

Important Safety Considerations for Corticosteroids

Absolute contraindication: Systemic fungal infections 1, 2

Monitor closely for: 1, 2

• Elevated blood glucose (especially in diabetic patients—adjust medications proactively)
• Fluid retention
• Dysphoria and mood disorders
• Short-term use (5–10 days) poses minimal bone density risk

Common Pitfalls to Avoid

• Do not interrupt ongoing urate-lowering therapy (allopurinol, febuxostat) during an acute gout attack if the patient is already taking it—continuation does not worsen the flare. 1, 3

• Do not delay treatment beyond 24 hours—this is the single most important determinant of therapeutic success, not which agent is chosen. 3, 2

• Do not use high-dose prednisone (>10 mg/day) for prophylaxis when initiating urate-lowering therapy—use ≤10 mg/day as a second-line prophylaxis option if colchicine is contraindicated. 1, 2