GLASGOW, Scotland — Whether anti-inflammatory drugs should always be used to prevent flares when initiating urate-lowering therapy (ULT) for gout remains an open question as experts discussed its relative pros and cons during a debate session at the British Society for Rheumatology (BSR) 2026 Annual Meeting.

“The last few decades have brought increasing awareness of the risk of flares after initiation of urate-lowering” therapy, said Philip Riches, MBChB, PhD, Lothian University Hospitals NHS Trust, Edinburgh, Scotland, who chaired the session.

There has also been increasing acknowledgement of “the importance of inflammation in driving cardiovascular events [CVEs] [and] the role of colchicine in preventing cardiovascular events,” but there are also challenges of polypharmacy and the risk for side effects from these drugs, Riches said.

Arguments Against a Blanket Approach

Edward Roddy, DM, consultant rheumatologist at Midlands Partnership University NHS Foundation Trust in Stoke-on-Trent, England, and professor of rheumatology at Keele University, Keele, England, argued that not all people initiating ULT need anti-inflammatory prophylaxis and prescribing perhaps needed to be more nuanced, particularly in primary care.

“There’s potential for drug harms, and there’s potential for drug interactions, which we still don’t fully understand,” Roddy said. “It’s difficult to identify people at risk of harm, good outcomes from ULT can be achieved without prophylaxis, and guideline recommendations have evolved to highlight the importance of the patient perspective,” he added.

He did not dispute that the drugs commonly used to prevent flares — colchicine, glucocorticoids, or nonsteroidal anti-inflammatory drugs (NSAIDs) — could be effective, but there was very little evidence with regards to the latter as to why they did.

“One in four people who aren’t given prophylaxis don’t flare, and we can identify the people at greatest risk of flaring,” Roddy said. Moreover, there is qualitative research to show that “people with gout have concerns about prophylaxis and don’t consider all flares to be the same.”

Co-Prescription Prevents Flares and CVEs

Abhishek Abhishek, MBBS, professor of rheumatology and honorary consultant rheumatologist the University of Nottingham in Nottingham, England, was of the contrary view that everyone starting ULT should get anti-inflammatory prophylaxis.

“Patients want prompt symptom control; you really don’t want to have a gout flare if you can avoid it,” he said. Notably, gout flares are associated with serious CVEs including myocardial infarction, stroke, and blood clots, and prophylaxis with colchicine is associated with lower risk for CVE in people with gout.

“Once a patient experiences a flare, I think you’ll miss the boat for them having a potential heart attack or a stroke or dying from them in the next few months. And I don’t want to miss that boat for any of my patients, so I do want to prevent those flares,” Abhishek argued.

‘Pill-in-the-Pocket’ Prescribing

There is an alternative to the blanket approach, Roddy argued. This is the so-called ‘pill-in-the-pocket approach’ where ULT and anti-inflammatory medicine is co-prescribed, but the anti-inflammatory medication is taken only when the patient feels that they are starting to flare.

This is not a new concept and was included in the 2016 updated EULAR evidence-based recommendations for the management of gout.

Roddy argued that there needed to be a “personalized approach in which we reach a shared treatment decision when discussing the possibility of co-prescribing prophylaxis that considers the patient’s comorbidities, their medications, and their risk of flaring.”

The pill-in-the-pocket approach “also considers their views about flares, their views of their own individual risk of flare, informed by what we advise them, and also their concerns about taking and views about taking prophylaxis.”

Robert Sandler, MBChB, a specialist registrar in rheumatology based at the Royal Hallamshire Hospital, part of Sheffield Teaching Hospitals NHS Foundation Trust in Sheffield, England, commented that the pill-in-the-pocket approach “would seem like a really reasonable halfway house.”

He told Medscape Medical News that rheumatologists of his generation, particularly those in training, were becoming more and more cautious over the use of NSAIDs and colchicine “because of the GI [gastrointestinal] and the renal issues,” he said.

“In terms of patients in secondary care, I’ve almost never prescribed an NSAID because there’s always a reason not to, and if their renal function is too bad for colchicine,” I’m going to prescribe glucocorticoids, he added.

However, patients with gout seen in secondary care were very different to those who present in primary care, Sandler observed. “People just suffer with gout at home” and may self-medicate even when they flare.

Another delegate pointed out the differences between patients with gout seen in primary and secondary care: “I totally get a nuanced approach to this; one size doesn’t fit all.”

He added: “Unfortunately…where I work, most of gout is managed in primary care. My patients are not very literate, and they are not the most compliant of people. I do need a ‘one size fits all’ sometimes because actually most of my treatment of gout is advice and guidance to GPs [general practitioners].”

Roddy said there is an even stronger case for more nuanced approach to anti-inflammatory prophylaxis alongside ULT in the primary care setting.

“I strongly feel that we should follow people up with gout until people are in remission, until we’ve achieved target. And I think you know that that should be a call to arms to all rheumatologists,” Roddy said.

“It’s our responsibility to show the way, to lead by example, and to educate our colleagues in primary care.”

Roddy disclosed being the lead for the British Society for Rheumatology Guideline for the Management of Gout and the BSR’s 2013/2014 national audit of primary care gout services, a topic advisor for the National Institute for Health and Care Excellence gout guideline, and a co-author of some of the research that he discussed. He also disclosed receiving speaker honorarium from the Irish Society for Rheumatology in 2023.

Abhishek disclosed receiving royalties from UpToDate, lecture fees from SOBI, and consulting fees from Eli Lilly, Novartis, and Alesta Pharmaceuticals.

Riches, Sandler, and all other persons mentioned in this article had no conflicts of interest.

Sara Freeman is a medical journalist based in London, England.