Oral steroid instead of NSAIDs for ACUTE gout

Consider a corticosteroid instead of an NSAID for more patients especially those with kidney disease, cirrhosis, heart failure, etc....
Abdelwahab Ward, BS Pharm, PharmD

Overview

Corticosteroids will be used more often for acute gout flares. Oral corticosteroids work as well as NSAIDs for pain during a gout attack and are a safer choice for some patients. For further information, see our note on "Comparison of Gout Therapies".

Management of acute gout flares

Considerations for Corticosteroids vs. NSAIDs

Consider a corticosteroid instead of an NSAID for more patients, especially those with kidney disease, cirrhosis, heart failure, etc.

  • Be aware that a short-term corticosteroid is likely less risky than an NSAID in most patients at risk for GI bleeding.
  • If a steroid is used, administer prednisone 30 to 40 mg/day for 5 days in most cases. A taper usually isn't needed.

NSAID recommendations

However, it’s also acceptable to stick with an NSAID first for many patients. Feel comfortable using ibuprofen or naproxen. There’s no evidence that indomethacin is more effective and it is considered high-risk in the elderly due to its adverse effects compared to other NSAIDs. Use anti-inflammatory doses, such as naproxen 500 mg BID. Continue the NSAID for about two days after symptoms resolve.

Colchicine usage

Save colchicine as a last resort for acute gout due to side effects, interactions, and cost. If colchicine is used, administer 1.2 mg followed by 0.6 mg one hour later in most cases. There isn’t substantial evidence for continuing it longer. CONTINUE chronic gout medications (e.g., allopurinol) during a flare, but generally wait one to two weeks after resolution to start NEW treatment with chronic medications, as this may trigger a flare. For further information, see our note on "Recommending Allopurinol Instead of Febuxostat for Most Chronic Gout Patients".

NPS-adv

References

  1. Richette P, Doherty M, Pascual E, et al. 2016 updated EULAR evidence-based recommendations for the management of gout. Ann Rheum Dis. 2017;76(1):29-42.
  2. Qaseem A, Harris RP, Forciea MA, et al. Management of Acute and Recurrent Gout: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017;166(1):58-68.
  3. Rainer TH, Cheng CH, Janssens HJ, et al. Oral Prednisolone in the Treatment of Acute Gout: A Pragmatic, Multicenter, Double-Blind, Randomized Trial. Ann Intern Med. 2016;164(7):464-471.
  4. Khanna D, Khanna PP, Fitzgerald JD, et al. 2012 American College of Rheumatology guidelines for management of gout. Part 2: therapy and antiinflammatory prophylaxis of acute gouty arthritis. Arthritis Care Res (Hoboken). 2012;64(10):1447-1461.
Abdelwahab Ward, BS Pharm, PharmD