Written by Mary Marschner
Spoon Feed
When starting a patient with gout on urate-lowering therapy, preferentially choose colchicine over NSAIDs for gout flare prophylaxis, since NSAIDs are associated with increased cardiovascular risk.
Flout gout with colchicine, not NSAIDs
Gout is a common inflammatory arthritis often treated by internists. It is well known that when starting urate-lowering therapies, there can be a paradoxical gout flare, and current recommendation is to start colchicine vs. NSAIDs to mitigate this risk. We tend to forget the cardiovascular risks of NSAIDs in gout patients, and this study emphasizes that these risks are not insignificant.
This propensity-score-matched target trial emulation compared flare prophylaxis using NSAIDs versus colchicine (n = 18,120; mean age 60.9, 83.5% male) in patients with gout initiating allopurinol. Over follow-up, NSAID use was associated with significantly higher risk of major adverse cardiovascular events (MACE HR 1.56, 95%CI 1.11–2.17; +38.8/1,000 person-years) and cardiovascular death (HR 2.50, 95%CI 1.14–5.26). Both MACE (HR 1.50, 95%CI 1.17–1.91) and MI risk (HR 1.93, 95%CI 1.35–2.75) were elevated compared to no prophylaxis. Findings support colchicine’s cardiovascular safety advantage.
This is an excellent study. It pushed me to review the pathophysiology of why NSAIDs have cardiovascular risk factors, as well as the inflammatory pathways that I’ve gotten further away from. Additionally, it reminded me of the cardiovascular risk factors for my gout patients. The gold standard would still be an RCT, but this study has me convinced.
How does this change my practice?
When starting allopurinol for my gout patients, I will definitely be choosing colchicine over NSAIDs for paradoxical gout flare prophylaxis.
Source
Comparative Cardiovascular Safety of NSAID versus Colchicine Use When Initiating Urate-Lowering Therapy Among Patients with Gout: Target Trial Emulations. Arthritis Rheumatol. 2025 May 26. doi: 10.1002/art.43259. Epub ahead of print. PMID: 40415645
