Aspirin use in gout patients can be challenging. Indeed, aspirin embodies the yin and yang of medical practice. At low-doses, it can be cardioprotective but it also blocks urate excretion by the kidneys. At higher doses, it is more likely to cause GI problems but it is uricosuric.

While these factoids may fascinate physiologists and philosophers, do they have clinical implications in the real world?

Well, yes and no. A recent study in the Annals of Rheumatic Diseases looked at 724 gout patients over a one-year time period. Those taking aspirin for cardioprotection had twice the rate of gout attacks as those who did not take aspirin. And low-dose aspirin (81 mg) was associated with a higher rate of gout attacks than a dose of 325 mg daily. This is the yes part. However, gout patients on aspirin and allopurinol did not experience more frequent attacks than aspirin-free gout patients. This is the no part.

The take-home lesson here seems clear. When you initiate cardioprotective aspirin dosing in a patient with an established diagnosis of gout, keep a close eye on their uric acid level. If it goes up, consider adding or increasing their dose of allopurinol. If your gout patient who is already on low-dose aspirin is experiencing attacks, check their med profile to make sure allopurinol is on the list and that they are getting it refilled regularly.

In gout, prevention is particularly precious, not just to avoid the problematic pain of a gout flare, but because colchicine has become so costly, even in generic form.

Richard Fleming, MD