First Line

• Medication usually more effective after initial onset vs. with chronic disease
• Condition often self-limited
• NSAIDs:
  • Indomethacin: 75–150 mg/d, divided t.i.d.
  • Naproxen (Naprosyn): 500–1,000 mg/d, divided b.i.d.
  • Aspirin: 325 mg 8–12 times per day; use enteric-coated to decrease GI upset. Titrate to blood levels.
• Contraindications:
  • Active or recent peptic ulcer disease
  • History of hypersensitivity to NSAIDs
• Precautions:
  • GI upset/bleeding
  • Fluid retention
  • Dose reduction in elderly, especially those with renal disease, diabetes, or heart failure
  • May mask fever
  • NSAIDs may elevate liver function tests
• Significant possible interactions:
  • May blunt antihypertensive effects of diuretics and β-blockers
  • NSAIDs can elevate plasma lithium levels.
  • Caution advised with naproxen or any highly protein-bound drug, because it may compete for albumin binding and elevate levels
• NSAIDs can cause significant elevation and prolongation of methotrexate levels.

• Potassium iodide 400–900 mg/d, divided 2–3 times a day for 3–4 weeks (for persistent lesions)
• Corticosteroids for severe, refractory cases
• Recent reports of improvement with colchicine 0.6–1.2 mg b.i.d.