What is the recommended dose and treatment of naproxen (nonsteroidal anti-inflammatory drug, NSAID) for acute gouty arthritis in a 93-year-old patient with potential impaired renal function?

From the Guidelines

For a 93-year-old with gout, naproxen should be used cautiously at a reduced dose of 250 mg twice daily for a short duration of 3-5 days, but it is not the preferred first-line treatment due to potential adverse effects. According to the American College of Physicians guideline 1, corticosteroids, such as prednisolone, are generally safer and more effective for managing gout in elderly patients, with fewer adverse effects compared to NSAIDs like naproxen. The guideline recommends prednisolone at a dose of 35 mg for 5 days as a first-line therapy for acute gout.

Some key points to consider when treating gout in a 93-year-old patient include:

• The increased risk of gastrointestinal bleeding, kidney problems, and cardiovascular events associated with NSAIDs like naproxen 1
• The importance of monitoring for side effects, particularly gastrointestinal symptoms and changes in kidney function
• The need for dosage reduction and careful monitoring due to age-related physiological changes that affect medication metabolism and elimination
• The potential benefits of alternative treatments, such as colchicine at a lower dose (0.6 mg once or twice daily) or a short course of low-dose prednisone (10-15 mg daily for 5 days, then tapered)

It is essential to weigh the potential benefits and risks of each treatment option and to consider the individual patient's medical history, comorbidities, and current medications when making a treatment decision. Additionally, lifestyle modifications, such as rest, ice application to affected joints, and elevation of the affected limb, can help alleviate symptoms and improve quality of life.

From the FDA Drug Label

Although naproxen tablets, naproxen suspension, naproxen delayed-released tablets, and naproxen sodium tablets all circulate in the plasma as naproxen, they have pharmacokinetic differences that may affect onset of action A lower dose should be considered in patients with renal or hepatic impairment or in elderly patients Caution is advised when high doses are required and some adjustment of dosage may be required in elderly patients. The recommended starting dose is 750 mg of naproxen followed by 250 mg every 8 hours until the attack has subsided. For a 93-year-old patient with gout, a lower dose of naproxen should be considered due to the patient's elderly status. The recommended starting dose for acute gout is 750 mg, followed by 250 mg every 8 hours. However, caution is advised when using high doses in elderly patients, and some adjustment of dosage may be required. 2

From the Research

Treatment of Gout in the Elderly

• Gout in the elderly differs from classical gout in several respects, including a more equal gender distribution and frequent polyarticular presentation 3.
• Extreme caution is necessary when prescribing nonsteroidal anti-inflammatory drugs (NSAIDs) for the treatment of acute gouty arthritis in the elderly 3.

Naproxen Dose and Treatment for Gout

• There is no specific mention of naproxen dose and treatment for gout in the provided studies.
• However, NSAIDs, including naproxen, are commonly used to treat acute gout, but their use in the elderly should be done with caution due to potential side effects and interactions with other medications 4, 5.

Alternative Treatment Options

• Intra-articular corticosteroid injection remains the treatment of choice for accessible joints, and oral prednisolone is preferred over low-dose colchicine 6.
• Xanthine oxidase inhibitors (XOI) remain the first-line treatment for hyperuricemia in the elderly, and allopurinol is the urate-lowering drug of choice, but its use in the aged is associated with an increased incidence of both cutaneous and severe hypersensitivity reactions 3, 6.

Considerations for 93-Year-Old Patients

• Comorbidities and polypharmacy make the management of gout flares challenging in this population, and treatment should be individualized based on the patient's medical history and current medications 6.
• Diuretics and beta-blockers should be discontinued where feasible, whereas low-dose aspirin can be continued if otherwise indicated 6.