In an adult with an acute gout flare, are muscle‑relaxant agents such as methocarbamol (Robaxin) or baclofen appropriate for treating pain and stiffness?

Muscle Relaxants Are Not Appropriate for Gout Pain and Stiffness

Neither methocarbamol (Robaxin) nor baclofen should be used to treat pain and stiffness from an acute gout flare, as gout is an inflammatory arthritis requiring anti-inflammatory therapy—not muscle relaxation. The pain and stiffness in gout result from monosodium urate crystal deposition triggering intense synovial inflammation, not from muscle spasm. 1

Why Muscle Relaxants Don't Work for Gout

• Gout flares are caused by inflammatory reactions to urate crystal deposition in joints, producing severe pain through inflammatory mediators—not through muscle contraction or spasm. 1
• Muscle relaxants like methocarbamol and baclofen have no anti-inflammatory properties and do not address the underlying pathophysiology of acute gouty arthritis. 1
• No major gout guideline (ACR, ACP, or EULAR) mentions muscle relaxants as a treatment option for acute gout, reflecting the complete absence of evidence supporting their use. 1

What You Should Use Instead: Evidence-Based First-Line Options

The American College of Rheumatology and American College of Physicians both provide strong recommendations (Grade A evidence) that acute gout should be treated with one of three anti-inflammatory agents: NSAIDs, corticosteroids, or colchicine. 1

Corticosteroids (Often the Best Choice)

• Oral prednisone 30–35 mg daily for 5 days is as effective as NSAIDs but causes significantly fewer adverse events (27% vs 63% with indomethacin). 1, 2
• Corticosteroids should be considered first-line therapy in patients without contraindications because they are generally safer and lower cost than alternatives. 1, 2
• Start prednisone at 0.5 mg/kg/day (approximately 30–35 mg for most adults) for 5–10 days at full dose, then stop—or give 2–5 days at full dose followed by a 7–10 day taper. 1, 2
• Corticosteroids are particularly preferred over NSAIDs in patients with renal disease, heart failure, cirrhosis, peptic ulcer disease, or those on anticoagulation. 2

NSAIDs (If No Contraindications)

• Any NSAID at full anti-inflammatory doses is appropriate—there is no evidence that indomethacin is superior to naproxen, ibuprofen, or other NSAIDs. 1
• Naproxen 500 mg twice daily or indomethacin 50 mg three times daily are FDA-approved regimens with Level A evidence. 1
• NSAIDs are contraindicated in patients with severe renal impairment (eGFR <30 mL/min), active peptic ulcer disease, heart failure, or cirrhosis. 1, 2

Colchicine (Low-Dose Only)

• Low-dose colchicine (1.2 mg initially, then 0.6 mg one hour later) is as effective as high-dose regimens but causes significantly fewer gastrointestinal side effects (23% vs 77%). 1
• Colchicine is more expensive than corticosteroids or NSAIDs and requires dose adjustment in renal impairment. 1, 2

Critical Treatment Principles

• Initiate anti-inflammatory therapy within 24 hours of symptom onset for optimal outcomes. 1, 3
• Never stop established urate-lowering therapy (allopurinol, febuxostat) during an acute flare—continue it without interruption. 1, 3
• For severe polyarticular attacks (pain >6/10, multiple joints), consider combination therapy such as oral corticosteroids plus colchicine or intra-articular steroids with oral agents. 1, 2

Common Pitfall to Avoid

The most common error is treating gout pain as if it were musculoskeletal strain or muscle spasm. Gout requires anti-inflammatory suppression of the crystal-induced inflammatory cascade, not muscle relaxation. Using methocarbamol or baclofen will leave the patient in severe pain while the inflammatory process continues unchecked. 1, 3