From the Guidelines
Indomethacin should be avoided in patients with heart failure who have acute gout. Instead, consider using colchicine (0.6 mg twice daily for 1-2 days, then once daily for 7-10 days) or prednisolone (30-40 mg daily for 3-5 days, followed by a taper over 7-10 days) as first-line treatments, as recommended by the American College of Physicians 1. Indomethacin, like other NSAIDs, can worsen heart failure by causing sodium and fluid retention, reducing renal blood flow, and decreasing the effectiveness of heart failure medications such as ACE inhibitors and diuretics. These effects can lead to acute decompensation of heart failure. Some key points to consider when treating acute gout in patients with heart failure include:
- The use of low-dose colchicine, which has been shown to be as effective as higher doses at reducing pain and is associated with fewer gastrointestinal adverse effects 1.
- The potential benefits and harms of urate-lowering therapy, which may not be necessary in cases where the patient would have no or infrequent recurrences 1.
- The importance of weight management and avoidance of high-purine foods and alcohol to prevent future attacks that would require anti-inflammatory treatment. If colchicine cannot be used due to renal impairment or drug interactions, and corticosteroids are contraindicated, consider intra-articular steroid injections for single-joint involvement or a consultation with rheumatology for alternative approaches.
From the FDA Drug Label
Carefully consider the potential benefits and risks of indomethacin and other treatment options before deciding to use indomethacin. Use the lowest effective dose for the shortest duration consistent with individual patient treatment goals (see WARNINGS) Acute gouty arthritis. Suggested Dosage: Indomethacin capsules 50 mg t.i. d. until pain is tolerable. The dose should then be rapidly reduced to complete cessation of the drug.
The use of indomethacin in acute gout is supported by the drug label. However, caution is advised when using indomethacin in patients with heart failure, as the label recommends careful consideration of the potential benefits and risks.
- The label does not provide specific guidance on the use of indomethacin in patients with heart failure.
- Heart failure is not mentioned as a contraindication or precaution in the provided drug label text. The decision to use indomethacin in a patient with heart failure and acute gout should be made with caution and careful consideration of the individual patient's condition 2.
From the Research
Treatment of Acute Gout in Patients with Heart Failure
- The use of nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided in patients with cardiovascular disease (CVD) or heart failure (HF) 3.
- Colchicine is considered safe and potentially reduces the risk of myocardial infarction in patients with CVD or HF who present with an acute gout flare 3, 4.
- Short durations of low-dose glucocorticoids are efficacious and may be safe for patients who cannot tolerate colchicine 3.
- Indomethacin, an NSAID, is not recommended for patients with heart failure due to the increased risk of adverse cardiovascular events 3.
- There is no direct evidence to support the use of indomethacin in acute gout in patients with heart failure, and its use is generally discouraged in this population 3, 5, 6.
Alternative Treatment Options
- Colchicine is a suitable alternative for the treatment of acute gout in patients with heart failure, with low-dose colchicine being preferred due to its better tolerability profile 3, 7, 5.
- Glucocorticoids can be used as an alternative to colchicine in patients who cannot tolerate it, but their use should be limited to short durations and low doses 3.
- Other treatment options, such as canakinumab and anakinra, may be considered in patients with refractory gout, but their use is limited by high cost and potential side effects 3, 5.