- Nighttime Prednisone Could Address Morning Stiffness in RA
Prednisone (Sterapred®, Prednisone Intensol)
- How to Take Prednisone
- Storage and Handling
- Where do I get this medication?
- Insurance Information
- Possible Side Effects of Prednisone
- Gout: Management and Treatment
- What are the symptoms of gout?
- Causes of gout
- Gout attack
- How long does an attack of gout last?
- Who gets gout?
- Risk factors for developing gout
- Tests for gout
- Complications of gout
- How is gout treated?
- Treatment of a gout attack
- Treatment to prevent further attacks
- Lifestyle changes to prevent gout attacks
- Gout diet
Nighttime Prednisone Could Address Morning Stiffness in RA
In healthy patients, nighttime inflammation makes sense. The inflammatory system takes advantage of calories unavailable when muscles are in motion and digestion is active to attack pathogens or heal injuries.
The system follows a clock set by the suprachiasmatic nucleus, which responds to light and dark and sets the pace for such functions as sleep, heart rate, blood pressure and body temperature.
Acting on the endocrine system, it increases the production of melatonin and prolactin around 9 p.m, and these in turn activate cytokines, such as tumor necrosis factor (TNF) α and interleukin (L) 6, Dr. Cutolo says. Then around 3 a.m., it begins producing cortisol which will suppress these same cytokines over the next few hours.
In people with rheumatoid arthritis, this system is dysregulated, he explains. In particular, cortisol becomes less available in the wee hours of the morning. As a result, inflammation lingers as patients rise.
Exogenous glucocorticoids such as prednisone can take the place of the missing cortisol. Although prednisone plays a smaller role in the treatment of rheumatoid arthritis since the advent of drugs with fewer side effects, it can still be useful in low doses, Dr. Cutolo says.
He points out that the 2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis endorsed the use of 5 low-dose glucocorticoids (less than 10 mg/day of prednisone or equivalent) in patients with moderate or high rheumatoid arthritis activity when starting traditional disease-modifying anti-rheumatic drugs (DMARDS) and biologics and in patients with DMARD failure or biologic failure.
But too often patients take prednisone between 6 a.m. and 8 a.m., says Dr. Cutolo, when it may come too late to curb the inflammation. “The best time, the optimal time, in chronic long-term treatment with low-dose glucocorticoids is availability at the time of maximum need, which is the middle of the night.”
In one study, administering 5 mg or 7.5 mg of prednisolone at 2:00 a.m. daily showed significant improvements in morning stiffness, joint pain, the Lansbury index, the Richie index, and morning serum concentrations of IL-6. Patients who took the same dose at 7:30 a.m. experienced an improvement in morning stiffness and IL-6 levels, but not in joint pain or either index.
The new delayed-release formulation of prednisone offers the advantage that patients don’t need to get up in the middle of the night to take it. And large-scale trials have shown that it has greater efﬁcacy for long-term low-dose glucocorticoid treatment in patients with RA than the standard formula, with a similar safety proﬁle, Dr. Cutolo reports.
The delayed release formula costs more, he acknowledged. In a British study, the cost was £649.70 ($918.06) per year versus £46.54 ($65.76) for the standard formula. But the delayed release formula was so much more effective in improving patients’ quality of life, that the authors judged it to be cost effective. If factors such as the patient’s productivity were taken into consideration, it might be even more cost effective, they wrote.
If low-dose glucocorticoids work better late at night, what about anti-proliferative drugs, such as methotrexate, leflunomide and cyclophosphamide? Studies so far suggest that methotrexate, too, is more effective when taken at bedtime than according to standard dosing protocols, Dr. Cutolo reports.
Likewise, research suggests that non-steroidal anti-inflammatory drugs (NSAIDs) are more effective when the regimen includes an evening dose than when it doesn’t, he says. And delayed-release forms of these drugs have recently been developed.
Not only does the circadian principle apply to other drugs, it may apply to other diseases by rheumatoid arthritis, including polymyalgia rheumatic (PMR) and ankylosing spondylitis, says Dr. Cutolo.
“Think about gout,” he says. “You never get gout attacks during the day, but only during the night.”
Prednisone (Sterapred®, Prednisone Intensol)
How to Take Prednisone
Prednisone comes as a tablet to take by mouth. The tablet should be swallowed whole. You should not break or chew the tablet. Prednisone is best taken with food, as it can irritate your stomach. Your doctor will probably tell you to take your dose(s) of prednisone at certain time(s) of day every day. Your personal dosing schedule will depend on what the medication is being used for. If you miss a dose, take it as soon as possible. If it is too close to your next dose, skip the missed dose and resume your schedule.
Do not stop taking this medication without first speaking to your care provider as this could cause side effects such as weakness, fatigue, decreased appetite, weight loss, nausea, vomiting, diarrhea, and abdominal pain.
This medication can effect the levels of many other medications including warfarin, cyclosporine, oral birth control pills, phenytoin, bupropion, thalidomide, erythromycin, ketoconazole and ritonavir, among others. Be sure to tell your healthcare provider about all medications and supplements you take.
You, or anyone you live with, should avoid having live or live-attenuated vaccines while receiving this medication. These include herpes zoster (Zostavax) for shingles prevention, oral polio, measles, nasal flu vaccine (FluMist®), rotovirus and yellow fever vaccines.
Storage and Handling
Store your medication in the original, labeled container at room temperature and in a dry location (unless otherwise directed by your healthcare provider or pharmacist). Keep containers out of reach of children and pets.
Where do I get this medication?
Prednisone is available through most pharmacies. Your oncology team will work with your prescription drug plan to identify an in-network pharmacy for distribution of this medication.
This medication may be covered under your prescription drug plan. Patient assistance may be available to qualifying individuals without prescription drug coverage. Your care team can help you find these resources, if they are available.
Possible Side Effects of Prednisone
There are a number of things you can do to manage the side effects of prednisone. Talk to your care team about these recommendations. They can help you decide what will work best for you. These are some of the most common or important side effects:
Patients may notice swelling in their hands and/or feet. Elevating the feet may help to lessen swelling in the feet and ankles. Avoid restrictive or tight clothing that may make it harder for the fluid to drain from the hands, feet, and ankles.
Increased Risk of Infection
This medication can lower your ability to fight new and current infections. Contact your provider if you are experiencing any signs of infections including fever, chills, sore throat or cold, cough or burning with urination.
Tips to preventing infection:
- Washing hands, both yours and your visitors, is the best way to prevent the spread of infection.
- Avoid large crowds and people who are sick (i.e.: those who have a cold, fever or cough or live with someone with these symptoms).
- When working in your yard, wear protective clothing including long pants and gloves.
- Do not handle pet waste.
- Keep all cuts or scratches clean.
- Shower or bath daily and perform frequent mouth care.
- Do not cut cuticles or ingrown nails. You may wear nail polish, but not fake nails.
- Ask your doctor or nurse before scheduling dental appointments or procedures.
- Ask your doctor or nurse before you, or someone you live with, has any vaccinations.
Weakening of the Bones (Osteoporosis)
Long-term use can lead to early osteoporosis. Your doctor may have you get a bone density scan (dexa scan) to assess your bone health if you are on long- term therapy.
Long-term use of this medication can increase the pressure in your eyes. Report any changes in vision, blurry or double vision, and eye pain or redness.
Increase in Appetite
Prednisone can cause you to be hungrier or thirstier than usual. Drink plenty of fluids and try to make your snacks healthy ones.
Increase in Energy
Prednisone can cause an increase in energy. You may also develop insomnia, or difficulty sleeping. Taking the medication in the morning may help to prevent this.
Irritability or Change in Mood
Some patients report feeling irritable or notice a change in their mood while taking prednisone. If this becomes difficult to handle or if you feel like you may harm yourself or others, contact your healthcare provider immediately.
Nausea and Heartburn
Taking prednisone with food or milk is generally enough to prevent nausea and heartburn. If possible, take the medication when you can be upright (not lying down) for a few hours after the dose. Avoid things that worsen the symptoms, and try antacids (milk of magnesia and calcium tablets, like Tums), saltines, or ginger ale to lessen symptoms.
Increased Blood Sugar
Prednisone can increase your blood sugar. Diabetics should monitor their blood sugar closely and may require higher doses of insulin while taking prednisone. Patients who are not diabetics but are having increased blood sugar levels may be instructed to check their blood sugar and administer insulin while taking prednisone. Your provider will determine if this is necessary.
GI Bleed & Tear
This medication can cause bleeding or a tear in the intestinal wall. Signs of these problems include: unexpected bleeding, blood in the stool or black stools, coughing up blood, vomiting blood, vomit that looks like coffee grounds, fever, severe pain in the abdomen or new abdominal swelling. If you experience any of these, contact your oncology care team immediately or go to the emergency room.
Other Side Effects
Prednisone can cause delayed wound healing, headaches, muscle weakness, and cataracts (after long-term use).
Exposure of an unborn child to this medication could cause birth defects in rare cases, so you should not become pregnant or father a child while on this medication. Even if your menstrual cycle stops or you believe you are not producing sperm, you could still be fertile and conceive. You should consult with your healthcare team before breastfeeding while receiving this medication.
Gout: Management and Treatment
Gout can be treated and controlled. Symptoms are often dramatically improved within 24 hours after treatment has begun. Attacks can be prevented with appropriate therapy to lower the blood uric acid levels and change in lifestyle by addressing the modifiable risk factors.
The goals of treatment are to:
- Relieve pain and inflammation
- Prevent future gout attacks that could lead to permanent joint damage and tophi
- Prevent the development of tophi
- Prevent kidney damage from chronically elevated urate levels
The type of treatment prescribed will depend on several factors, including the person’s age, type of medicines he or she is taking, kidney function, overall health, other comorbidities (other medical problems), and other medications they are taking.
Medication used for the treatment of gout include those that treat the gout attack and those that prevent future gout attacks by lowering the uric acid.
Medications that treat gout attacks
Anti-inflammatory drugs will reduce the pain and swelling of attacks. They are usually continued until the gout attack completely resolves. If side effects from the therapy occur, treatment may be changed to a different medication. Your healthcare provider will discuss the potential side effects with you. If you have kidney disease, heart failure, diabetes, ulcer disease, stomach or intestinal bleeding history, or other chronic conditions, the choice of therapy to treat the gout is affected.
Colchicine is usually the medication of choice for gout attacks, if patient does not have renal failure. Colchicine is sometimes used in low doses for a long period of time to reduce the risk of recurrent attacks of gout.
Nonsteroidal anti-inflammatory drugs (NSAIDs) are prescribed to treat sudden gout attacks, if colchicine is not possible. NSAIDs usually reduce inflammation and pain within hours. However, these are contraindicated in certain patients who have impaired kidney function and the above mentioned health conditions.
Corticosteroids (also called steroids) may be prescribed for people who cannot take NSAIDs. Steroids also work by decreasing inflammation. Steroids can be injected into the affected joint or given as pills. Steroids have been used in certain severe gout attacks. These may also be contraindicated in certain cases.
Drugs that lower the uric acid levels
Some patients may need to take medicines that lower the level of uric acid in the blood. (Examples are allopurinol; febuxostat; rarely, probenecid; and, in severe cases, pegloticase). The most commonly used are allopurinol or febuxostat. These drugs are recommended for patients who have elevated uric acid and multiple attacks of gout or kidney stones due to uric acid. The goal of treatment is to reduce the uric acid level to less than 6 mg/dL.
The goal of lowering the blood uric acid is to slowly dissolve joint deposits of monosodium urate. Lowering the uric acid will not treat an acute attack but will, over time, prevent additional attacks from occurring. Sudden lowering of the uric acid level may cause an acute attack of gout. To prevent acute attacks in people who are taking uric acid-lowering drugs, colchicine, or an NSAID is temporarily prescribed. If an attack occurs while taking a medication to lower the uric acid, this medicine should NOT be stopped; stopping and starting the uric acid lowering medication may cause additional attacks.
Side effects of medicine
Not all patients will develop side effects from gout medications. How often any side effect occurs varies from patient to patient. The occurrence of side effects depends on the dose, type of medication, concurrent illnesses, or other medicines the patient may be taking. Before starting these medications, discuss with your doctor side effects and risks of these medications.
Some side effects are more serious than others. If any rash or itching develops while taking allopurinol, the medicine should be stopped immediately and your physician notified.
Can gout be treated through diet?
Dietary changes may play a significant role in controlling the uric acid levels. Limiting certain foods, such as fructose containing corn syrup, that cause an increased production of uric acid and reducing alcohol intake and decreasing the amount of meats/shellfish consumed and insuring adequate hydration have been shown to be helpful.
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Gout (sometimes called gouty arthritis) is a common type of arthritis caused by too much uric acid in the bloodstream. The uric acid forms clumps of small, sharp crystals inside and around the joints, leading to sudden attacks of severe pain, swelling and redness.
Gout can be very painful but there are ways to treat the symptoms, get relief from gout, and reduce the risk that it will return.
What are the symptoms of gout?
An attack of gout can begin anytime, but it often starts at night. Any joint can be affected – the most common joints are the big toes, middle foot joints, ankles, knees, fingers and elbows. Sometimes it affects more than one joint at a time.
The affected joints can also be extremely tender to touch. Gout can affect any joints, but is most commonly seen at the base of the big toe. It can happen quickly – often people wake up in the middle of the night with severe pain and a feeling like the joint is on fire.
The symptoms of a gout attack include:
- Sudden, intense pain in one or more joints.
- Swelling and inflammation in and around the joint.
- A feeling that the joint is very hot.
- Red, shiny skin around the joint.
- Extreme tenderness (for example, even a sheet over the skin can be unbearable).
- Reduced movement.
- Itchy, flaky skin as the swelling goes down.
Causes of gout
Gout occurs when there are abnormally high levels of uric acid in the blood (called hyperuricaemia) and tissues. Uric acid is a waste product that forms when the body breaks down chemicals called purines. Purines are found in many foods and also occur naturally in the body. Normally, the body’s kidneys filter out excess uric acid and it’s excreted via the urine. But in people with gout, the uric acid accumulates in the body.
This can happen when the kidneys don’t get rid of enough uric acid or when there is an overproduction of uric acid by the body. This build up of uric acid may also cause kidney stones. While high uric acid levels in the blood lead to gout, it’s not clear why some people with high levels of uric acid develop gout but others with the same high levels don’t.
When uric acid builds up it can form small, jagged, needle-shaped crystals. It can take months or even years for the crystals to develop. They usually form in and around joints, and if they get into the small spaces between the joint they can cause severe pain, swelling and redness. This is known as a gout attack.
How long does an attack of gout last?
An attack of gout usually strikes unexpectedly, and gout symptoms often last between 3 and 10 days. Some people might have some ongoing pain or discomfort for several weeks.
Gout attacks often recur and without proper treatment, the attacks may become more frequent. If it’s not treated, gout tends to affect more joints over time.
A person should contact their doctor if they have symptoms of gout so that they can get it treated as soon as possible.
Someone who develops a fever plus severe, worsening joint pain should seek immediate medical attention. It could signal a serious infection inside the joint called septic arthritis.
Who gets gout?
In Australia, gout affects around 70,000 people each year. Gout can affect anyone, but it is much more common in men than women, in particular, middle-aged and older men. In women, gout usually occurs after menopause. Experts have found that the prevalence of gout in elderly male Australians is one of the highest in the world, second only to New Zealand.
Risk factors for developing gout
A person is more likely to develop gout if they have high levels of uric acid in their body, a condition known as hyperuricaemia.
Things that can increase levels of uric acid include:
- Diet: Consuming large amounts of red meat and oily seafood and drinking large amounts of sweetened drinks.
- Alcohol: Drinking excessive amounts of alcohol, especially beer, fortified wine (e.g. port) and spirits.
- Overweight and obesity: Being overweight or obese makes it harder for the kidneys to get rid of uric acid.
- Certain medicines: The use of some blood pressure medications including diuretics, ACE inhibitors and beta blockers, as well as low-dose aspirin, cyclosporin (used to treat conditions such as psoriasis) and some medications used by people who have had an organ transplant.
- Medical conditions: Some diseases that increase uric acid levels include untreated high blood pressure, diabetes, heart disease, kidney disease and the metabolic syndrome.
- Age and sex: Men often have higher uric acid levels; after menopause, women’s uric acid levels may also rise.
- Family history of gout: people are more likely to develop gout if a family member has it.
- Recent surgery or trauma: People who have had a recent operation or experienced recent trauma often have high levels of uric acid in their blood.
Tests for gout
A doctor can often diagnose gout based on the symptoms and a person’s medical history. They will also ask the person about their diet and alcohol intake.
Sometimes the doctor will do blood tests to measure the amount of uric acid in the blood, although this may not be conclusive of gout.
The doctor may want to take a sample of fluid from the joint to check for the presence of uric acid crystals or to check for signs of infection.
X-rays are not usually done but sometimes an ultrasound is done to see if there are crystals in the joints.
Complications of gout
Gout can result in some complications, especially if left untreated.
- Tophi: Sometimes small lumps form under the skin (known as tophi). These look like white or yellowish raised spots and are usually painless. However, because they often form at the tips of the fingers or around the toes, they can make daily activities difficult. Tophi usually take several years to develop, and successful treatment can shrink them or stop them getting bigger.
- Joint damage: If gout isn’t treated it can start to damage the joints. In very serious cases it can cause extensive damage, and surgery may be needed to repair or replace a joint.
- Kidney stones: Some people with high levels of uric acid develop kidney stones. These can make it hard for urine to flow properly and may cause pain when trying to pass urine, or make the person feel as though they need to pee more often.
How is gout treated?
The treatment of gout involves several stages.
- Pain relief for a gout attack.
- Treatment to prevent further attacks.
- Strategies to prevent the complications of gout.
- Management of other medical conditions that can increase the chances of developing gout, such as excessive alcohol intake, high cholesterol, high blood pressure, diabetes and obesity.
Treatment of a gout attack
Australian guidelines recommend treatment with non-steroidal anti-inflammatory drugs (NSAIDs) for an attack of gout. These work to reduce inflammation and pain. Examples include indomethacin (e.g. Arthrexin), naproxen sodium (e.g. Crysanal) and etoricoxib (Arcoxia).
If NSAIDs can’t be tolerated or the person has a history of ulcers then they may try:
- Colchicine (brand names Colgout, Lengout).
- Corticosteroids given by mouth or injected into the joint.
Resting the joint and applying ice packs may also help with pain and inflammation. When the affected joint is a big toe, a box or cage to keep the bedclothes off the toe may be helpful.
Treatment to prevent further attacks
People can reduce their chances of having another attack of gout by taking certain medication and making lifestyle changes to reduce the level of uric acid in the body.
- Urate-lowering therapy (ULT): these medications can decrease the body’s production of uric acid. Examples include allopurinol (e.g. Allosig) and febuxostat (Adenuric).
- Colchicine (Colgout, Lengout) or NSAIDS given for several months can also be used to prevent attacks of gout.
- Uricosuric drugs: These medicines increase uric acid passed in the urine. Examples include probenecid (Pro-Cid).
People experiencing gout attacks should avoid medicines containing aspirin as these can make gout worse.
Lifestyle changes to prevent gout attacks
Preventing acute gout attacks is just as important as gout relief. Prevention of gout generally involves:
- Fluid: Maintaining an adequate fluid intake to promote the excretion of uric acid.
- Losing weight if overweight or obese.
- Exercise: Doing regular exercise.
- Limit alcohol: Reducing alcohol intake and avoiding binge drinking.
A simple change to the types of foods that you eat can help reduce the frequency and severity of gout attacks. Find out which foods are best avoided or eaten in moderation, and other dietary changes that can help prevent gout.
Gout is caused by raised levels of uric acid in the bloodstream. Uric acid is formed when compounds called purines are broken down in our bodies. Purines are found naturally in the body and also in certain foods. Some foods contain high levels of purines.
The dietary approach to reducing the frequency and severity of gout attacks is two-pronged:
- limit the body’s production of uric acid; and
- increase the elimination of uric acid.
Reduce purine-rich foods
To reduce the amount of uric acid produced by the body, reduce your intake of purine-rich foods. This table shows foods rich in purines which you can avoid or cut down on.
|Foods containing yeast||
|*According to Arthritis Australia, purine-rich vegetables appear less likely to cause gout than shellfish and meat.|
It’s also a good idea to avoid fructose — a type of sugar — as it can raise uric acid levels. Fructose can be found in fruit juices; it’s also 50 per cent of table sugar, and in some countries – especially the USA – soft drinks and other foods are sweetened with corn syrup, which is high in fructose.
Drink lots of water
Some substances can affect the level of uric acid in your blood by speeding up or slowing down its elimination from the body.
Drinking plenty of water helps your body flush out uric acid, so if you have gout, aim to drink at least eight glasses of water per day.
Alcohol can interfere with uric acid elimination. When you’re having an attack, it’s best to avoid alcohol altogether, especially beer. In between attacks, up to two standard drinks of wine per day should not greatly increase the risk of gout.
Other dietary considerations for gout
Choose low-fat or fat-free dairy products, as they have been shown to reduce the risk of gout. Vitamin C has also been shown to reduce the risk of gout.
A practical approach
Completely avoiding all purine-rich foods is not necessary and could result in you missing out on important nutrients. Fortunately, newer gout medicines have reduced the need for a strict gout diet, however, cutting down on the amount of purine-rich foods can still help to reduce the number of gout attacks and their severity.
Reduce the amount of meat, poultry and seafood in your diet, as animal proteins are high in purines. Try to avoid organ meats, anchovies, herring and mackerel altogether.
Remember, before starting a special gout diet it’s a good idea to get advice from your doctor or a dietitian.
Gout diets and weight loss
Low-purine diets are often low in calories so can also help keep your weight down, further reducing your risk of gout attacks. Gradual weight loss with healthy eating and regular physical activity is the way to go, as crash dieting and rapid weight loss can actually increase uric acid levels and may trigger a gout attack.
Keep taking your gout medicine
While following a gout diet can help limit the severity and number of attacks, it’s unlikely that it will decrease uric acid levels enough to allow people taking gout medicines to stop their treatment.
Last Reviewed: 11/05/2016
Global gout treatment guidelines tend to differ on which drug should be used as first-line therapy for gout flares.
According to the European League Against Rheumatism guidelines, colchicine and nonsteroidal anti-inflammatory drugs (NSAIDs), such as indomethacin, are the most effective first-line therapies for acute gout flares. Meanwhile, the American College of Rheumatology prefers allopurinol, though many patients of Asian descent who take it are at high risk for severe hypersensitivity reactions.
The Annals of Internal Medicine recently published a large, randomized, controlled trial that shows oral prednisolone is just as effective as indomethacin for analgesia in acute gout patients.
The researchers enrolled patients aged 18 years and older who presented to 4 emergency departments with arthritis symptoms consistent with gout.
The participants were randomized into either of the following groups:
· The indomethacin group received 50 mg of oral indomethacin 3 times a day and 6 tablets of oral placebo prednisolone once a day for 2 days, followed by halved doses for 3 days.
· The prednisolone group received 30 mg of oral prednisolone once a day and 2 tablets of placebo indomethacin 3 times a day for 2 days, followed by the same prednisolone dose and a halved placebo indomethacin dose for 2 days.
Both groups received 1 g of oral acetaminophen every 6 hours as needed.
Oral prednisolone and oral indomethacin were equally effective to treat pain at rest and with activity without serious adverse effects. These findings validate previous randomized, controlled trials, but they show lower rates of adverse effects associated with indomethacin.
Overall, the study results suggest that oral corticosteroids are an appropriate option alongside NSAIDs (eg, indomethacin) or colchicine. Notably, this research was statistically and methodologically more reliable than past studies, according to the researchers.
Steroids are a particularly well-suited alternative for patients who find NSAIDs and colchicine intolerable.
Although this study didn’t find any serious adverse events related to indomethacin, the researchers excluded high-risk patients with gastrointestinal bleed history, renal insufficiency, or unstable cardiovascular disease. Of note, patients with gout tend to be older patients at risk for serious gastrointestinal, renal, and cardiovascular complications.
I was placed on Coumadin 3 months ago and was simultaneously taken off of anti-inflammatory drugs that I was on for years for bilateral knee osteoarthritis and PRN anti-inflammatories for gouty arthritis flares. To date, none of my caregivers will support any on board meds other than tylenol and narcotics. I can’t imagine millions of individuals on coumadin w/OA not having some other options! Please help.
There are several important considerations for the management of arthritis pain in patients who take coumadin (also called warfarin), which is a blood thinner. Coumadin increases the propensity to bleed if there is a cut or other injury. NSAIDS which are commonly used to treat arthritis pain (medications such as ibuprofen, naproxen, etc) may cause injury and ulceration of the stomach lining and GI tract such that their combination with coumadin introduces a high risk of severe (and sometimes fatal) bleeding, and they are avoided. Medications such as acetaminophen (Tylenol) do not have this risk of stomach lining irritation and are first line pain medications in patients on Coumadin. There is another medication called Tramadol that can also be used safely in patients on coumadin and may provide some additional pain control. Beyond this narcotic agents may be needed (such as codeine, hydrocodone, etc). In your case with gout, the NSAIDS were not only pain relieving but also anti-inflammatory in preventing some of the specific gout symptoms. When someone like you presents (and this is not uncommon), we often will use either colchicine or steroid medications (such as prednisone) to manage an acute gout attack. If your attacks are increasing in frequency, this may be an indication that you need other medications adjusted to reduce your uric acid levels (such as allopurinol, probenecid, febuxostat). Another wrinkle for you is that injections into the joints for patients on coumadin can be tricky given that there is a possiblility of causing bleeding into the joint after the procedure.