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Gout Flare on Anticoagulant — SCE Rheumatology MCQ

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ModerateCrystal ArthropathyGout Flare on AnticoagulantSCE Rheumatology

A 60-year-old man with gout and atrial fibrillation on Warfarin develops an acute gout flare. Colchicine and NSAIDs are both relatively contraindicated due to drug interactions (Colchicine-Warfarin interaction and NSAID-anticoagulant GI bleeding risk). What is the safest acute treatment option?

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Correct answer: E — Short course of oral Prednisolone (20-30 mg daily for 5 days) or intra-articular corticosteroid injection which avoids significant interactions with Warfarin

In gout patients on anticoagulation NSAIDs carry significant GI bleeding risk and Colchicine interacts with many drugs (including Warfarin and Clarithromycin through CYP3A4 and P-glycoprotein pathways). Glucocorticoids (oral Prednisolone 20-30 mg daily for 5-7 days or IA injection) provide effective acute flare management without significant anticoagulant interaction. IA corticosteroid injection is particularly useful for monoarticular flares and avoids systemic effects. ACTH (Synacthen) is another option though less commonly used. BSR 2017 and NICE 2022 guidelines recommend tailoring acute gout treatment to comorbidities and comedications.

Reference: BSR 2017 gout; NICE NG219 (2022)