Is indomethacin (nonsteroidal anti-inflammatory drug (NSAID)) or ibuprofen (NSAID) more effective for treating acute gout pain?

Indomethacin vs. Ibuprofen for Gout Pain

Both indomethacin and ibuprofen are effective for acute gout pain, with no significant difference in efficacy between these NSAIDs, though indomethacin has FDA approval specifically for gout treatment while ibuprofen does not. 1

Treatment Selection for Acute Gout

The American College of Physicians and American College of Rheumatology guidelines indicate that NSAIDs are one of three first-line treatment options for acute gout, alongside colchicine and corticosteroids 2, 1. When choosing an NSAID:

• FDA-approved NSAIDs for gout:

  • Indomethacin (Evidence A) 2
  • Naproxen (Evidence A) 2
  • Sulindac (Evidence B) 2

• Non-FDA approved NSAIDs for gout:

  • Ibuprofen and other NSAIDs may be equally effective (Evidence B-C) 2

Dosing Recommendations

• Indomethacin: 50 mg three times daily at full anti-inflammatory dose until attack resolves 2, 3
• Ibuprofen: Full anti-inflammatory dosing (typically 600-800 mg three to four times daily)

Efficacy Considerations

The 2025 American College of Physicians guideline specifically states that there is moderate-quality evidence showing no difference in efficacy between different NSAIDs, including indomethacin, naproxen, and ibuprofen for acute gout treatment 1. This is the most recent and authoritative guidance on the comparison.

A 1982 study noted that indomethacin was considered a standard treatment for acute gout, but suggested that newer NSAIDs like ibuprofen might prove equally effective with fewer gastrointestinal side effects 4. However, this older research has been superseded by more recent guidelines.

Safety Profile Considerations

When choosing between indomethacin and ibuprofen, consider:

• Indomethacin:

  • Higher incidence of adverse effects, particularly GI and CNS side effects 5
  • In studies, indomethacin showed higher rates of:
    • Abdominal discomfort/dyspepsia (55% of patients)
    • Headaches (38% of patients)
    • Cognitive effects (30% of patients) 5

• Ibuprofen:

  • Generally considered to have a more favorable side effect profile than indomethacin
  • May be preferred in patients with higher risk for GI or CNS side effects

Treatment Algorithm

1. For uncomplicated acute gout with mild-moderate pain (≤6/10) affecting 1-3 small joints or 1-2 large joints:

   • Either indomethacin or ibuprofen is appropriate as monotherapy
   • Choose indomethacin if rapid, potent effect is desired and patient has no contraindications
   • Choose ibuprofen if patient has history of GI or CNS side effects with indomethacin

2. For severe pain or polyarticular attacks:

   • Consider combination therapy (NSAID plus another agent) 2
   • If using NSAID monotherapy, indomethacin may be preferred due to its FDA approval for gout

3. Continue treatment at full dose until attack completely resolves 2

Contraindications and Cautions

Both medications should be avoided in:

• Renal disease
• Heart failure
• Cirrhosis
• History of GI ulcers or bleeding

In these cases, corticosteroids are preferred 1.

Key Points to Remember

• Start treatment as early as possible (within 24 hours of symptom onset)
• Use full anti-inflammatory doses until attack resolves
• Do not interrupt urate-lowering therapy during acute attacks
• Monitor for adverse effects, particularly in elderly patients or those with comorbidities

The choice between indomethacin and ibuprofen should be based primarily on individual patient factors including comorbidities, prior response, and tolerance rather than differences in efficacy.