From the Guidelines
For gout treatment without NSAIDs, corticosteroids should be considered as first-line therapy in patients without contraindications because they are generally safer and a low-cost treatment option, as supported by high-quality evidence from the American College of Physicians 1.
Key Considerations
- Corticosteroids, such as oral prednisone (30-40 mg daily for 3-5 days, then tapered over 10-14 days), intra-articular injections, or intramuscular injections, are effective for acute gout management.
- Colchicine is another alternative, typically prescribed as 0.6 mg taken twice daily until symptoms resolve, with a loading dose of 1.2 mg followed by 0.6 mg one hour later during acute attacks.
- For long-term management, allopurinol (starting at 100 mg daily and gradually increasing to 300-600 mg daily) or febuxostat (40-80 mg daily) can prevent future attacks by lowering uric acid levels, and should be started after the acute attack resolves, with colchicine used as prophylaxis during initiation.
Lifestyle Modifications
- Limiting alcohol (especially beer) intake
- Reducing intake of purine-rich foods like red meat and seafood
- Maintaining adequate hydration
- Weight management if overweight These approaches work by either reducing inflammation during acute attacks or lowering uric acid levels to prevent crystal formation in joints, addressing the underlying cause of gout without relying on NSAIDs, as recommended by the American College of Physicians 1 and the European League Against Rheumatism (EULAR) 1.
From the FDA Drug Label
The recommended dosage of Colchicine Tablets, USP for prophylaxis of gout flares for adults and adolescents older than 16 years of age is 0.6 mg once or twice daily. The maximum recommended dose for prophylaxis of gout flares is 1.2 mg/day. The recommended dose of Colchicine Tablets, USP for treatment of a gout flare is 1.2 mg (two tablets) at the first sign of the flare followed by 0.6 mg (one tablet) one hour later.
Gout treatment without NSAIDs can be achieved with colchicine. The dosage for prophylaxis of gout flares is 0.6 mg once or twice daily, with a maximum recommended dose of 1.2 mg/day. For treatment of a gout flare, the recommended dose is 1.2 mg at the first sign of the flare, followed by 0.6 mg one hour later 2. Allopurinol can also be used for gout treatment, it is recommended to start with a low dose of 100 mg daily and increase at weekly intervals by 100 mg until a serum uric acid level of 6 mg/dL or less is attained, but without exceeding the maximum recommended dose (800 mg per day) 3.
From the Research
Gout Treatment Without NSAIDs
- Gout is a common inflammatory arthritis that can be managed with various treatments, including non-steroidal anti-inflammatory drugs (NSAIDs), colchicine, and corticosteroids 4.
- For patients who cannot take NSAIDs, alternative treatments such as colchicine, corticosteroids, and urate-lowering therapies like allopurinol and febuxostat can be considered 4, 5.
- Colchicine is an effective treatment for acute gout, with low-dose colchicine being a viable option for patients who cannot tolerate NSAIDs 6.
- Urate-lowering therapies like allopurinol and febuxostat can help reduce serum uric acid levels and prevent gout flares, and can be used in combination with colchicine or corticosteroids for optimal management 4, 7, 5.
- Novel therapies like pegloticase and uricosurics like verinurad and arhalofenate are also being developed for the treatment of gout, and may provide alternative options for patients who cannot take NSAIDs 5, 8.
Treatment Options
- Colchicine: effective for acute gout, with low-dose colchicine being a viable option for patients who cannot tolerate NSAIDs 6.
- Corticosteroids: can be used to manage acute gout flares, especially in patients who cannot take NSAIDs 4.
- Allopurinol: a urate-lowering therapy that can help reduce serum uric acid levels and prevent gout flares 4, 7, 5.
- Febuxostat: another urate-lowering therapy that can be used in combination with colchicine or corticosteroids for optimal management 4, 7, 5.
- Pegloticase: a novel therapy that can be effective for patients with recalcitrant gout, but requires careful consideration of pharmacokinetics and pharmacodynamics 8.