Pharmacological Options for Acute Flares

Drug Doses Duration of Treatment Benefits Limitations Cautions Comments

NSAID's Indomethacin

Acute Attack:
75 mg STAT,then 50mg Q6Hx2 days then 50 mg Q8Hx1 day then 25 mg Q8Hx1 day Prophylaxis: 25mg BID

ACute attack:
7-14 days

Prophylaxis: up to 6 months

For all (NSAIDs)

Gl disturbances; other adverse effects uncommon with short-term therapy but include fluid retention, hypertension, renal impairment, hypersensitivity.

Warfarin: Up anticoagulant effect.

Antihypertensives: Possibe lower in antihypertensive efefct; may require additional antihypertensive therapy.

Lithium: May interfere with sodium/water balance. Monitor lithium levels when NSAID added.

SSRIs may up risk of GI bleeding when used with NSAIDs.

Indomethacin and naproxen are listed as examples. There is no good evidence to suggest one NSAID is more efficacious than another.

Suppositories may be used if oral route inadvisable.

NSAIDS Naproxen

Acute attack:
750 mg STAT, then 500mg BID x4-5 days
Prophylaxis: 250 mg BID

ACute attack:
7-14 days

Prophylaxis: up to 6 months

For all (NSAIDs)

Gl disturbances; other adverse effects uncommon with short-term therapy but include fluid retention, hypertension, renal impairment, hypersensitivity.

Warfarin: Up anticoagulant effect.

Antihypertensives: Possibe lower in antihypertensive efefct; may require additional antihypertensive therapy.

Lithium: May interfere with sodium/water balance. Monitor lithium levels when NSAID added.

SSRIs may up risk of GI bleeding when used with NSAIDs.

Indomethacin and naproxen are listed as examples. There is no good evidence to suggest one NSAID is more efficacious than another.

Suppositories may be used if oral route inadvisable.

NSAIDS Naproxen

100 mg BID or 200 mg once daily

Serious skin reactions have been reported. Patients with history of heart attack or stroke, seriouos heart disease-related chest pain or serious heart disease such as HF should not use COX-2 inhibitors. Assess risk in patients with risk factors for heart attack and stroke. Cardiovascular hypertension, congestive heart failure, MI,CVA.

Warfarin: up anticoagulant effect.

Antihypertensives (diuretics, betablockers, ACE inhibitors, alpha-blockers): possible reduction in hypotensive effect; may require additional antihypertensive therapy. Lithium may interfere with sodium/water balance. Monitor lithium levels when NSAID added.

SSRIs may up risk of GI bleeding when used with NSAIDs.

All NSAIDs have equivalent efficacy. When possible, avoid NSAIDs, including COX-2 inhibitors, in patients with a history of peptic ulcer disease, risk factors for heart attack or stroke, renal failure, heart failure or asthma.

Colchicine

Acute attack: 0.6 mg TID-QID until relief or side effects occur; Usual max 6 doses
Prophylaxis: 0.6-1.8mg/day; usual: 1mg/day

Very common: abdominal pain and cramps, diarrhea, nausea and vomiting.

Rare: Neurophathy, myopathy, bone marrow suppression.

Low benefit/toxicity ration in acute gout.

May be given iv: consult specialized references. Dosage should be down in elderly and in renal impairment.

Corticosteroids Prednisone

Acute attack: 30 mg daily x 5 days

Effective dose range: 20-50 mg/day

Except for GI disturbances and glucose intolerance, not usually significant in short term use.

Long term effects are numerous.

Doses <20 mg/day tend to be ineffective. Simultaneous low-dose colchicine or NSAID helps prevent rebound when steroid stopped.

Centrally acting analgesic tramadol HCI-acetaminophen

37.5 mg tramadol HCI/325mg acetaminophen tablets

1 or 2 tablets every 4 to 6 hours as needed for pain relief up to a maximum of 8 tablets per day.

Seizures, seizure risk, nausea, dizziness, somnolence, constipation, vomiting, and headache.

Significant drug interactions.

If CrCL <30 mL/min, dosing adjustment needed, should not exceed 2 tablets every 12 hours.

Opioids Morphine

Titrate to effect.

Immediate-release oral:

Adults: 10-30mg po Q4-6H

All Opioids: sedation, constipation

All opioids: additive sedation with other CNS depressants, e.g., alcohol; potential enhancement of opioid effects with lidocaine.

Opioids Codeine

Adults: 15-60 mg po Q4-6H
Max: 60mg/dose

All opioids: sedation, constipation.

All opioids: additive sedation with other CNS depressants, e.g., alcohol; potential enhancement of opioid effects with lidocaine.

Codeine: down analgesic effect with somatostatin, rifampin.

Inhibitors of CYP2D6 (e.g., celecoxib, cimetidine, desipramine, fluoxetine, imatinib, paroxetine, quinidine) may antagonize codeine's analgesic effect.

Opioid Analgesic Oxycodonea-
cetominophen

Titrate to effect oxycodone Dose: oxycodone HCI 5 mg and acetaminophen 325 mg. 1 tablet every 6 hours as needed for pain.

Light-headedness, dizziness, sedation nausea, and vomiting.

Status asthmaticus, preexisting respiratory depression or convulsive state

Source: e-Therapeutics. Accessed July 16, 2010

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