Which medications in the drug class Nonsteroidal Anti-inflammatory Drugs (NSAIDs) are used in the treatment of Gout and Pseudogout?

Updated: Jan 26, 2021
  • Author: Bruce M Rothschild, MD; Chief Editor: Herbert S Diamond, MD  more...
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Answer

Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

As a class, NSAIDs are the drugs most widely used to treat the pain and inflammation of acute gout attacks in patients who can safely take these medications. Although NSAID effects on pain tend to be patient-specific, naproxen and indomethacin are common choices. Nevertheless, the choice of an NSAID is a matter more of habit than of science. Use of concomitant gastric protection with misoprostol or consideration of a cyclooxygenase-2 (COX-2)–specific NSAID might be considered if the patient has gastrointestinal (GI) risk or is older than 51 years.

To control the attack as quickly and safely as possible (recalling that it takes 5 half-lives to reach steady state), consider using an NSAID with a short half-life (eg, ketoprofen, ibuprofen, or diclofenac). Use the maximum dosage of NSAID, and taper over approximately 10-14 days, depending on patient response.

Naproxen (Aleve, Mediproxen, Naprelan, Naprosyn, EC-Naprosyn)

Naproxen is used for relief of mild to moderate pain. It inhibits inflammatory reactions and pain by decreasing activity of the enzyme cyclooxygenase, which in turn decreases prostaglandin synthesis.

Ketoprofen

Ketoprofen is used for the relief of mild-to-moderate pain and inflammation. Small doses are initially indicated in small and elderly patients and in those with renal or liver disease. Individual doses greater than 75 mg do not increase therapeutic effects. Administer high doses with caution, and closely observe the patient for response.

Diclofenac (Dyloject, Zorvolex, Zipsor, Cambria)

Diclofenac inhibits prostaglandin synthesis by decreasing activity of the enzyme cyclooxygenase, which in turn decreases formation of prostaglandin precursors.

Indomethacin (Indocin, Tivorbex)

Indomethacin has been the NSAID traditionally used to treat acute inflammation in gout, though other NSAIDs are effective in this setting as well. Like all NSAIDs, indomethacin blocks cyclooxygenase and thereby reduces the generation of prostaglandins.

Celecoxib (Celebrex)

Unlike most NSAIDs, which inhibit both COX-1 and COX-2, the selective COX-2 inhibitor celecoxib offers the possibility of relieving inflammation and pain, but with a lower risk of GI side effects. It has been suggested that COX-2 expression in monocytes is induced in response to urate crystals.

Several studies have found that selective COX-2 inhibitors are comparable to other NSAIDs for treating acute gouty arthritis. However, celecoxib requires particularly high doses to provide pain relief comparable to that provided by indomethacin in acute gout. [108]

Selective COX-2 inhibitors may increase the risk of cardiac disease; 1 drug in this class, rofecoxib, was removed from the market for this reason. Celecoxib has been under investigation for associated risk of accelerated cardiac disease. Curiously, the risk appears to be associated with ingestion of 200 mg twice daily, but not with ingestion of 400 mg once daily.


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