Is indomethacin or colchicine more effective for treating acute gout (gouty arthritis) flare-ups?

From the Guidelines

Colchicine is generally preferred over indomethacin as first-line therapy for treating gout flares due to its efficacy and lower risk of gastrointestinal side effects. According to the American College of Physicians guideline 1, colchicine is typically given as 1.2 mg initially, followed by 0.6 mg one hour later, then 0.6 mg once or twice daily until the flare resolves. This modern dosing regimen offers good efficacy with fewer gastrointestinal side effects than older high-dose protocols.

Some key points to consider when choosing between colchicine and indomethacin include:

• Colchicine works by preventing neutrophil activation and migration to affected joints, while indomethacin reduces inflammation through prostaglandin inhibition.
• Indomethacin, a potent NSAID, is typically prescribed at 50 mg three times daily for acute flares, then tapered over 7-10 days as symptoms improve.
• Indomethacin carries higher risks of gastrointestinal, renal, and cardiovascular side effects compared to colchicine, making it less suitable for elderly patients or those with comorbidities.
• The choice between these medications should consider the patient's age, kidney function, cardiovascular status, and history of gastrointestinal issues.
• For patients with contraindications to both medications, corticosteroids may be an alternative option, as they have been shown to be as effective as NSAIDs for managing gout, with fewer adverse effects 1.

It's also important to note that the American College of Physicians recommends using low-dose colchicine when treating acute gout, as it is associated with fewer gastrointestinal adverse effects 1. Additionally, there is no evidence that indomethacin is more efficacious than other NSAIDs, such as naproxen and ibuprofen 1.

Overall, when considering morbidity, mortality, and quality of life, colchicine is the preferred treatment option for gout flares due to its efficacy and safety profile.

From the FDA Drug Label

Indomethacin capsules have been found effective in relieving the pain, reducing the fever, swelling, redness, and tenderness of acute gouty arthritis The recommended dose of Colchicine Tablets, USP for treatment of a gout flare is 1.2 mg (two tablets) at the first sign of the flare followed by 0. 6 mg (one tablet) one hour later.

• Indomethacin is effective in relieving the pain and reducing the fever, swelling, redness, and tenderness of acute gouty arthritis.
• Colchicine is recommended for treatment of a gout flare at a dose of 1.2 mg at the first sign of the flare followed by 0.6 mg one hour later. Based on the information provided, indomethacin and colchicine are both effective for treating gout flares, but the FDA drug label does not provide a direct comparison of the two medications to determine which one is better. 2 3

From the Research

Comparison of Indomethacin and Colchicine for Gout Flare

• Indomethacin is a non-steroidal anti-inflammatory drug (NSAID) commonly used to treat gout flares, while colchicine is a tricyclic alkaloid that interrupts multiple inflammatory response pathways 4.
• A study comparing low-dose colchicine to placebo found that colchicine was effective in treating acute gout flare, with a significant reduction in pain within 24 hours of initiating treatment 4.
• Another study found that low-dose colchicine was associated with a lower rate of adverse events compared to regular-dose colchicine, while still preventing gout flares effectively 5.
• A review of the pharmacotherapy of gout found that standard treatments for gout flares include colchicine, NSAIDs, and oral or intramuscular corticosteroids, with IL-1 inhibitors as an option for flare refractory to standard therapies 6.
• A Cochrane review found low-quality evidence that low-dose colchicine may be an effective treatment for acute gout when compared to placebo, and that its benefits may be similar to NSAIDs 7.
• A study comparing systemic corticosteroids to indomethacin found no clinically relevant differences between the two treatments, and no important safety problems attributable to the corticosteroids were reported 8.

Efficacy and Safety

• The efficacy of indomethacin and colchicine in treating gout flares is supported by various studies, although the quality of evidence varies 4, 6, 7, 8.
• Colchicine has been shown to be effective in preventing gout flares, especially when used in combination with urate-lowering therapy 4, 5.
• The safety profile of colchicine is generally favorable, with a lower rate of adverse events associated with low-dose colchicine compared to regular-dose colchicine 5.
• Indomethacin, as an NSAID, may have a higher risk of adverse events, such as gastrointestinal problems and renal impairment, especially with long-term use 8.

Treatment Considerations

• The choice between indomethacin and colchicine for gout flare treatment should be based on individual patient factors, such as comorbidities, renal function, and patient preference 6.
• Colchicine may be a better option for patients with renal impairment or those who are at risk of NSAID-related adverse events 4, 5.
• Indomethacin may be a better option for patients who require rapid pain relief and have no contraindications to NSAID use 8.