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Gout - Management
What dosing regimen of nonsteroidal anti-inflammatory drug should I use?
For the treatment of an acute attack of gout, CKS recommends prescribing diclofenac, indometacin, or naproxen.
- Doses recommended are:
- If effective, continue the NSAID until 48 hours after the attack has finished (up to 1–2 weeks). As the pain resolves, the dose of the NSAID should be rapidly reduced.
For the prevention of gout (while urate-lowering therapy is initiated), CKS recommends prescribing ibuprofen, diclofenac, or naproxen.
- These NSAIDs are preferred because of their more favourable adverse-effect profiles. Lower doses are widely co-prescribed by physicians when initiating allopurinol treatment, with the aim of preventing a flare of disease. Similar regimes should be considered if starting febuxostat urate-lowering therapy. CKS recommends:
- Ibuprofen 400 mg three times a day.
- Diclofenac 25–50 mg three times a day.
- Naproxen 250 mg three times a day.
- Prophylactic NSAIDs are usually given for up to 3 months when using allopurinol, but may be needed for up to 6 months when using febuxostat [ABPI Medicines Compendium, 2010].
Basis for recommendation
- Diclofenac, naproxen, and indometacin are recommended as preferred choices of nonsteroidal anti-inflammatory drug (NSAID). Diclofenac and naproxen are widely considered to have acceptable adverse-effect profiles [CSM, 2002]. Indometacin has been studied more in gout than any other NSAID, and similar to diclofenac and naproxen, its safety profile is classed as intermediate risk of causing serious gastrointestinal (GI) adverse effects, although it is associated with more GI adverse events than naproxen or diclofenac.
- For the treatment of an acute attack of gout, other NSAIDs may be used but are less preferred:
- Ketoprofen, piroxicam, and sulindac are other standard NSAIDs that are licensed for the treatment of gout, but they are less frequently used and their adverse-effect profiles are probably less favourable than diclofenac or naproxen. Although adverse effects are commonly reported with indometacin, it has been used more that other NSAIDs in trials investigating acute gout.
- Ibuprofen and other standard NSAIDs not listed here are not licensed for the treatment of acute gout.
- Of the cyclooxygenase-2 selective NSAIDs, only etoricoxib is licensed for the treatment of gout and there are trial data to support its effect [Schumacher et al, 2002; Rubin et al, 2004]. Etoricoxib may be associated with a slightly lower rate of gastrointestinal events compared with standard NSAIDs, but there may be a small increased risk of cardiovascular thrombotic events associated with its use [Aldington et al, 2005], and people with gout often have associated cardiovascular morbidity.
- Modified-release NSAIDs offer no benefit in terms of efficacy over standard preparations.
- The recommendation for needing gout flare prophylaxis for at least 6 months when using febuxostat is based on the Summary of Product Characteristics [ABPI Medicines Compendium, 2010].
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