Drugs & Therapy Perspectives

, Volume 34, Issue 8, pp 377–385 | Cite as

Reducing clinical risks associated with the pharmacological treatment of acute gout attacks

  • Sanja Mirkov
Therapy in Practice


Pharmacological treatment of acute gout attacks includes colchicine, nonsteroidal anti-inflammatory drugs (NSAIDs) and glucocorticoids. The choice of treatment depends on comorbidities and drug–drug interactions, requiring careful patient screening. As the use of these medications is associated with increased clinical risks, they should be used at the lowest effective dose for the shortest period of time alongside ongoing urate-lowering therapy to prevent gout attacks and to minimise their use. This article discusses the major clinical risks associated with colchicine, NSAIDs and glucocorticoids and risk minimisation strategies for their safe and effective use in this patient population.


  1. 1.
    Robinson PC, Stamp LK. The management of gout: much has changed. Aust Fam Physician. 2016;45(5):299–302.PubMedGoogle Scholar
  2. 2.
    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.CrossRefGoogle Scholar
  3. 3.
    Krishnan E. Chronic kidney disease and the risk of incident gout among middle-aged men: a seven-year prospective observational study. Arthritis Rheum. 2013;65(12):3271–8.CrossRefGoogle Scholar
  4. 4.
    Wang W, Bhole VM, Krishnan E. Chronic kidney disease as a risk factor for incident gout among men and women: retrospective cohort study using data from the Framingham Heart Study. BMJ Open. 2015;5(4):e006843.CrossRefGoogle Scholar
  5. 5.
    Graf SW, Whittle SL, Wechalekar MD, et al. Australian and New Zealand recommendations for the diagnosis and management of gout: integrating systematic literature review and expert opinion in the 3e initiative. Int J Rheum Dis. 2015;18(3):341–51.CrossRefGoogle Scholar
  6. 6.
    Doghramji PP, Fermer S, Wood R, et al. Management of gout in the real world: current practice versus guideline recommendations. Postgrad Med. 2016;128(1):106–14.CrossRefGoogle Scholar
  7. 7.
    Dalbeth N, Petrie KJ. It’s time to change the name of gout. BMJ Opin. 2018.
  8. 8.
    Shekelle PG, Newberry SJ, FitzGerald JD, et al. Management of gout: a systematic review in support of an American College of Physicians clinical practice guideline. Ann Intern Med. 2017;166(1):37–51.CrossRefGoogle Scholar
  9. 9.
    Khanna D, Fitzgerald JD, Khanna PP, et al. 2012 American College of Rheumatology guidelines for management of gout. Part 1: systematic nonpharmacologic and pharmacologic therapeutic approaches to hyperuricemia. Arthritis Care Res (Hoboken). 2012;64(10):1431–46.CrossRefGoogle Scholar
  10. 10.
    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):1447–61.CrossRefGoogle Scholar
  11. 11.
    Cassagnol M, Saad M. Pharmacologic management of gout. US Pharm. 2013;38(3):22–6.Google Scholar
  12. 12.
    Rees F, Hui M, Doherty M. Optimizing current treatment of gout. Nat Rev Rheumatol. 2014;10(5):271–83.CrossRefGoogle Scholar
  13. 13.
    New Zealand formulary (NZF). NZF version 71. 2018. Available from:
  14. 14.
    Best Practice Advocacy Centre New Zealand (BPAC). Safer prescribing of high-risk medications: colchicine - extremely toxic in overdose. BPJ. 2014;63:58–60.Google Scholar
  15. 15.
    Terkeltaub RA, Furst DE, Bennett K, et al. High versus low dosing of oral colchicine for early acute gout flare: twenty-four-hour outcome of the first multicenter, randomized, double-blind, placebo-controlled, parallel-group, dose-comparison colchicine study. Arthritis Rheum. 2010;62(4):1060–8.CrossRefGoogle Scholar
  16. 16.
    Medsafe. Spotlight on colchicine. Prescriber update 2018;39(1):8–9.Google Scholar
  17. 17.
    Finkelstein Y, Aks SE, Hutson JR, et al. Colchicine poisoning: the dark side of an ancient drug. Clin Toxicol. 2010;48(5):407–14.CrossRefGoogle Scholar
  18. 18.
    Schwarz K. Diagnosis and treatment of colchicine poisoning. California Poison Control System; 2006.
  19. 19.
    Dalbeth N, Gow P. Prevention of colchicine toxicity in patients with gout. N Z Med J. 2007;120(1252):U2503.PubMedGoogle Scholar
  20. 20.
    Medsafe. Colchicine lower doses for greater safety. Prescr Update. 2005;26:26–7.Google Scholar
  21. 21.
    Gresham C, Utting K, Williams C, et al. Colchicine poisoning: defusing the ticking time bomb. N Z Med J. 2013;126(1370):115–6.PubMedGoogle Scholar
  22. 22.
    Boucher A, Dhanjal S, Kong J, et al. Medication incidents associated with patient harm in community pharmacy: a multi-incident analysis. Pharm Connect. Toronto: Ontario College of Pharmacists; 2018.Google Scholar
  23. 23.
    La Caze A. Safer dispensing labels for prescription medicines. Aust Prescr. 2018;41(2):46–9.CrossRefGoogle Scholar
  24. 24.
    Institute for Safe Medications Practices (ISMP). 2018–2019 targeted medication safety best practices for hospitals. Horsham: ISMP; 2018.Google Scholar
  25. 25.
    Day RO, Graham GG. Non-steroidal anti-inflammatory drugs (NSAIDs). BMJ. 2013;346:f3195.PubMedGoogle Scholar
  26. 26.
    Howard RL, Avery AJ, Slavenburg S, et al. Which drugs cause preventable admissions to hospital? A systematic review. Br J Clin Pharmacol. 2007;63(2):136–47.CrossRefGoogle Scholar
  27. 27.
    Pirmohamed M, James S, Meakin S, et al. Adverse drug reactions as cause of admission to hospital: prospective analysis of 18820 patients. BMJ. 2004;329(7456):15–9.CrossRefGoogle Scholar
  28. 28.
    Best Practice Advocacy Centre New Zealand (BPAC). Non-steroidal anti-inflammatory drugs (NSAIDs): making safer treatment choices. Best Pract J. 2013;55:8–18.Google Scholar
  29. 29.
    Perry L, Mosler C, Atkins A, et al. Cardiovascular risk associated with NSAIDs and COX-2 inhibitors. US Pharm. 2014;39(3):35–8.Google Scholar
  30. 30.
    McGettigan P, Henry D. Use of non-steroidal anti-inflammatory drugs that elevate cardiovascular risk: an examination of sales and essential medicines lists in low-, middle-, and high-income countries. PLoS Med. 2013;10(2):e1001388.CrossRefGoogle Scholar
  31. 31.
    Bally M, Dendukuri N, Rich B, et al. Risk of acute myocardial infarction with NSAIDs in real world use: bayesian meta-analysis of individual patient data. BMJ. 2017;357:j1909.CrossRefGoogle Scholar
  32. 32.
    Delmas P. Non-steroidal anti-inflammatory drugs and renal function. Br J Rheumatol. 1995;34(S1):25–8.CrossRefGoogle Scholar
  33. 33.
    De Broe ME. Renal injury due to environmental toxins, drugs, and contrast agents. In: Schrier R, editor. The Schrier atlas of diseases of the kidney, vol. 1. Philadephia: Current Medicine, Inc.; 1999.Google Scholar
  34. 34.
    Hörl W. Nonsteroidal anti-inflammatory drugs and the kidney. Pharmaceuticals. 2010;3(7):2291–321.CrossRefGoogle Scholar
  35. 35.
    Jefferson JA, Thurman JM, Schrier RW. Pathophysiology and etiology of acute kidney injury. In: Floege J, Johnson R, Feehally J, editors. Comprehensive clinical nephrology. 4th ed. Maryland Heights: Mosby; 2010.Google Scholar
  36. 36.
    Best Practice Advocacy Centre New Zealand (BPAC). Acute-on-chronic kidney disease: prevention, diagnosis, management and referral in primary care. Best Prac J. 2012;46:10–5.Google Scholar
  37. 37.
    Lapi F, Azoulay L, Yin H, et al. Concurrent use of diuretics, angiotensin converting enzyme inhibitors, and angiotensin receptor blockers with non-steroidal anti-inflammatory drugs and risk of acute kidney injury: nested case-control study. BMJ. 2013;346:e8525.CrossRefGoogle Scholar
  38. 38.
    Medsafe. Reducing the risk of GI reactions with NSAIDs and/or COX-2 inhibitors. Prescrib Update. 2010;31(4):32.Google Scholar
  39. 39.
    Drini M. Peptic ulcer disease and non-steroidal anti-inflammatory drugs. Aust Prescr. 2017;40(3):91–3.CrossRefGoogle Scholar
  40. 40.
    Stosic R, Dunagan F, Palmer H, et al. Responsible self-medication: perceived risks and benefits of over-the-counter analgesic use. Int J Pharm Pract. 2011;19(4):236–45.CrossRefGoogle Scholar
  41. 41.
    Lepist EI, Ray AS. Renal drug–drug interactions: what we have learned and where we are going. Expert Opin Drug Metab Toxicol. 2012;8(4):433–48.CrossRefGoogle Scholar
  42. 42.
    Buttgereit F, da Silva JA, Boers M, et al. Standardised nomenclature for glucocorticoid dosages and glucocorticoid treatment regimens: current questions and tentative answers in rheumatology. Ann Rheum Dis. 2002;61(8):718–22.CrossRefGoogle Scholar
  43. 43.
    Janssens HJ, Janssen M, van de Lisdonk EH, et al. Use of oral prednisolone or naproxen for the treatment of gout arthritis: a double-blind, randomised equivalence trial. Lancet. 2008;371(9627):1854–60.CrossRefGoogle Scholar
  44. 44.
    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):464–71.CrossRefGoogle Scholar
  45. 45.
    Wechalekar MD, Vinik O, Moi JH, et al. The efficacy and safety of treatments for acute gout: results from a series of systematic literature reviews including Cochrane reviews on intraarticular glucocorticoids, colchicine, nonsteroidal antiinflammatory drugs, and interleukin-1 inhibitors. J Rheumatol Suppl. 2014;92:15–25.CrossRefGoogle Scholar
  46. 46.
    Da Silva JA, Jacobs JW, Kirwan JR, et al. Safety of low dose glucocorticoid treatment in rheumatoid arthritis: published evidence and prospective trial data. Ann Rheum Dis. 2006;65(3):285–93.CrossRefGoogle Scholar
  47. 47.
    Avina-Zubieta JA, Abrahamowicz M, De Vera MA, et al. Immediate and past cumulative effects of oral glucocorticoids on the risk of acute myocardial infarction in rheumatoid arthritis: a population-based study. Rheumatology. 2013;52(1):68–75.CrossRefGoogle Scholar
  48. 48.
    Gurwitz JH, Bohn RL, Glynn RJ, et al. Glucocorticoids and the risk for initiation of hypoglycemic therapy. Arch Intern Med. 1994;154(1):97–101.CrossRefGoogle Scholar
  49. 49.
    Black DM, Filak AT. Hyperglycemia with non-insulin-dependent diabetes following intraarticular steroid injection. J Fam Pract. 1989;28(4):462–3.PubMedGoogle Scholar
  50. 50.
    Garcia Rodriguez LA, Hernandez-Diaz S. The risk of upper gastrointestinal complications associated with nonsteroidal anti-inflammatory drugs, glucocorticoids, acetaminophen, and combinations of these agents. Arthritis Res. 2001;3(2):98–101.CrossRefGoogle Scholar
  51. 51.
    Best Practice Advocacy Centre New Zealand (BPAC). Long-term use of corticosteroids: think about bone health. BPAC Report 2013.
  52. 52.
    Sheu A, Diamond T. Secondary osteoporosis. Aust Prescr. 2016;39(3):85–7.PubMedPubMedCentralGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.School of PharmacyUniversity of OtagoDunedinNew Zealand

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