• gout
• NSAIDs
• treatment

We read with great interest the article by Roddy et al 1, published in the Annals of Rheumatic Disease, an open-label study that examined 399 patients presented at primary care centres with exacerbation of gout. The patients were allocated to two treatment arms, one group received naproxen and the second group treated with colchicine, and the primary outcome measured changes in the pain level from baseline over the first 7 days after presentation. Diarrhoea and headaches were more commonly reported in the colchicine group and given there was no difference between the two groups in the primary outcome, the authors recommended naproxen as the first line of treatment in acute gout arthritis, if no contraindication exists.

Although the authors pointed out that naproxen might be associated with decreased risk of cardiovascular events compared with the other non-steroidal anti-inflammatory drugs (NSAIDs) commonly used in gout, a recent metanalysis conducted by Bally et al 2 demonstrated that all NSAIDs, including naproxen, have been linked to a higher risk of myocardial infarction. Therefore, given the evidence of serious adverse effects, we do not concur with the recommendation naproxen should be considered as the only first step treatment option. Furthermore, patients with a history of hypertension and/or diabetes mellitus were included in the study, and colchicine would be a reasonable first therapeutic option from a safety profile in this subgroup of patients.

Regarding the side effect profile, diarrhoea was evident in 45.9% of patients in the colchicine group versus 20% in the naproxen group, a significantly higher frequency compared with the 23% seen in the low-dose colchicine arm in the Acute Gout Flare Receiving Colchicine Evaluation (AGREE) trial.3 We wonder why the authors did not use a lower dose regimen from day 2 to 4, for example, the prophylactic dose regime of 0.5–1 mg/day, a widely use dose with an acceptable safety profile supported by the European League Against Rheumatism guidelines.4

Lastly, given the individual patient’s characteristics, comorbidities, preferences and shared decision making, we believe that NSAIDs and colchicine have an essential role in the management of gout flares, and both regimens can be used as first-line treatment.