Is indomethacin (Nonsteroidal Anti-Inflammatory Drug (NSAID)) safe for treating gout in a patient with stable ischemic heart disease (IHD) and mildly impaired renal function (Glomerular Filtration Rate (GFR) of 74)?

Safety of Indomethacin for Gout in Patients with Stable Ischemic Heart Disease and Mild Renal Impairment

Indomethacin should be avoided for gout treatment in patients with stable ischemic heart disease, even with only mildly impaired renal function (GFR 74), due to increased cardiovascular and renal risks. 1

First-Line Treatment Recommendations for This Patient

Preferred Options:

1. Colchicine (if within 12-24 hours of flare onset):

   • Loading dose of 1 mg followed 1 hour later by 0.5 mg on day 1
   • Then 0.5-1 mg daily until attack resolves 2, 3
   • Dose adjustment not required with GFR 74

2. Oral corticosteroids:

   • Prednisone 0.5 mg/kg per day for 5-10 days 3
   • No dose adjustment needed for mild renal impairment
   • Safe alternative in patients with cardiovascular disease 1

3. Intra-articular corticosteroid injection:

   • Highly effective and safe treatment for acute gout affecting one or few joints 2
   • Particularly appropriate for patients with cardiovascular comorbidities 1

Why Avoid Indomethacin in This Patient?

Cardiovascular Risks:

• All NSAIDs, including indomethacin, increase cardiovascular risk in patients with pre-existing heart disease 1, 4
• NSAIDs should be avoided in patients with cardiovascular disease or heart failure 1

Renal Concerns:

• Even with mild renal impairment (GFR 74), NSAIDs can cause:
  • Dose-dependent reduction in renal blood flow
  • Risk of acute kidney injury
  • Hyperkalemia 5, 6
• Indomethacin specifically has been associated with azotemia and hyperkalemia, even in patients with mild renal impairment 6

Specific Risks of Indomethacin:

• May exacerbate heart failure through sodium retention
• Can increase blood pressure through inhibition of prostaglandin synthesis
• May interfere with the efficacy of antihypertensive medications
• Higher risk of gastrointestinal complications compared to some other NSAIDs 5

Long-Term Management Considerations

If this patient has recurrent gout attacks, consider urate-lowering therapy:

• Allopurinol is the preferred first-line agent for patients with cardiovascular disease 1
• Start at low dose (100 mg daily) and titrate upward every 2-4 weeks 2
• Target serum uric acid level <6 mg/dL (<5 mg/dL for severe gout) 2, 3
• Provide prophylaxis against flares during the first 6 months of urate-lowering therapy with low-dose colchicine 2

Common Pitfalls to Avoid

• Using NSAIDs like indomethacin in patients with cardiovascular disease
• Failing to consider cardiovascular risk when selecting gout treatments
• Overlooking the potential for drug interactions with cardiovascular medications
• Interrupting urate-lowering therapy during acute flares (should be continued) 3

By selecting colchicine or corticosteroids instead of indomethacin, you can effectively treat the gout flare while minimizing cardiovascular and renal risks in this patient with stable ischemic heart disease and mild renal impairment.