Gout, once considered the “Rich Man’s Disease” or the “Disease of Kings,” is increasingly finding a home for itself amongst the general American population. According to one recent study, almost 4% of the US population is affected by gout.
What is a Gout Flare?
Patients with gout could have sudden onset of joint pain leading to significant joint swelling. This is referred to as a gout flare. Such flare needs special treatment beyond your regular gout care. Gout flares lead to increased ER visits and hospitalization. There has been a significant increase in the rate of hospitalization due to gout flares. With this growth in patient numbers, there is a need to review the way the condition is being treated.
Treatment
Treatments for acute gout flares can be both non-pharmacological, such as icing and elevation of the joint, as well as use of medications. The treatment of acute gout flares depends on the severity of the joint pain and the number of joints involved.
Non-steroidal anti-inflammatory drugs (NSAIDs) taken at higher doses are considered the first line treatment for gout flares. There are different options of NSAIDs including Ibuprofen, diclofenac, indomethacin, naproxen etc. An important caution regarding these medications is that if you have kidney disease, you should avoid these, as they increase the risk of worsening your kidney function. If you have a history of gastric ulcers, they could also increase your risk of bleeding.
Colchicine is another medication that is very effective in controlling the gout flares. Some of you may not be able to tolerate it due to diarrhea. If you are not able to tolerate either NSAIDs or the colchicine, then corticosteroids (steroids) are the next best option. If you have severe joint pain with multiple joints involved, you might need a combination treatment. Even with such effective treatments, there is still overuse of opioids medications. A 2015 study of ED visits due to acute gout revealed that opioids were being prescribed to a significant number of patients (54%). While opioids are not a recommended form of treatment, there is still a significant overuse of this form of treatment in the management of gout.
Reconsidering Opioids As A Form of Treatment for Acute Gout
Opioids are considered one of the most effective medications for acute pain management in cases of moderate to severe pain. This fact, coupled with the reassurance by pharmaceutical companies in the 1990s of the non-addictive nature of the drug, led to the over-prescribing of opioids by healthcare providers. This has resulted in the current opioid epidemic, with 10.1 million Americans misusing the medications.
To combat the crisis, a change of focus has been evident with the prescription of opioids by emergency department providers. According to a recent National Center for Health Statistics (NCHS) report, the percentage of ED visits that resulted in prescriptions of an opioid upon discharge declined from 21.5% in 2011 to 14.6% by 2017. This correlates with an overall 37.1% decrease in the general prescribing of opioids between 2014 and 2019, according to the American Medical Association (AMA). In the case of gout flares, the use of opioids needs to be minimized in favor of other more effective therapies.
Conclusion
NSAIDs, colchicine and corticosteroids should be considered and recommended before using opioids in acute gout flares. Other methods, such as icing and elevating the affected joints could decrease your gout flare symptoms. Dietary modifications and use of uric acid lowering medications could help reduce your risk of future gout flares.
Written by Chaim Ford
References
- Opioids and the Treatment of Chronic Pain: Controversies, Current Status, and Future Directions
- What is the U.S. Opioid Epidemic?
- Trends in Opioids Prescribed at Discharge From Emergency Departments Among Adults: United States, 2006–2017
- Physicians’ progress toward ending the nation’s drug overdose and death epidemic