First line pharmacologic options
›NSAIDs
›Ibuprofen PO
›400 to 600 mg every 6 to 8 hours as needed
›Max 2400 mg per day
›Shortest effective duration
›Avoid in CKD stage 3 or higher
›AKI risk
›Hyperkalemia risk
›Avoid in active GI bleed or high risk
›PPI gastroprotection consideration
›Anticoagulation increases bleed risk
›Naproxen PO
›500 mg once then 250 mg every 8 hours
›Max 1000 mg per day
›Use with food
›Avoid in decompensated heart failure
›Fluid retention risk
›Blood pressure increase
›Indomethacin PO
›50 mg three times daily
›Max 200 mg per day
›Higher CNS adverse effects in older adults
›Geriatric avoidance preferred
›Delirium risk
›Falls risk
›Colchicine
›Low dose flare regimen
›1.2 mg PO once
›Followed by 0.6 mg PO one hour later
›Total 1.8 mg in 24 hours
›Then 0.6 mg PO once to twice daily
›Stop when flare resolves
›GI intolerance monitoring
›Renal adjustment
›eGFR under 30 mL per minute
›Avoid repeat loading within 14 days
›Use reduced maintenance dosing
›Dialysis
›Single 0.6 mg dose
›No repeat for at least 14 days
›Drug interaction risk
›Strong CYP3A4 inhibitors
›Avoid combination
›Toxicity risk myopathy cytopenias
›P glycoprotein inhibitors
›Avoid combination in renal or hepatic impairment
›Toxicity risk
›Glucocorticoids
›Intraarticular triamcinolone acetonide
›Large joint dose
›20 to 40 mg intraarticular once
›Aseptic technique
›Small joint dose
›5 to 20 mg intraarticular once
›Ultrasound guidance as needed
›Avoid if septic arthritis not excluded
›Culture pending with high suspicion
›Overlying cellulitis at injection site
›Prednisone PO
›20 to 40 mg daily
›Duration 3 to 5 days
›Taper 5 to 10 mg every 2 to 3 days if longer course
›Diabetes monitoring
›Capillary glucose checks
›Adjustment plan for insulin or oral agents
›Dexamethasone IM or IV
›8 to 10 mg once
›Bridge when PO not tolerated
›Follow with short oral course if needed
Refractory or specialist directed therapy
›IL 1 inhibition
›Anakinra SQ
›100 mg daily for 3 days
›Consider in refractory disease
›Consider when NSAIDs colchicine steroids contraindicated
›Infection exclusion required
›Avoid in active infection
›Neutropenia monitoring
›Rheumatology consultation
›Recurrent frequent flares
›Prophylaxis planning
›Evaluation for metabolic contributors
›Atypical presentation
›Polyarticular severe disease
›Poor response to standard therapy
Evidence and guideline notes
›General evidence statements
›Intraarticular glucocorticoid effective for monoarticular CPP crystal arthritis (Class I expert consensus)
›Preferred when systemic drug risk is high
›Requires infection exclusion
›Low dose colchicine preferred over high dose due to adverse effect profile (Class I expert consensus)
›GI toxicity increases with higher dosing
›Drug interaction toxicity risk
›NSAIDs effective for acute crystal arthritis flares but limited by renal GI CV risks (Class I expert consensus)
›Use shortest effective course
›Avoid high risk patients