What is the recommended dosage and usage of Indomethacin (Nonsteroidal Anti-Inflammatory Drug (NSAID)) for treating inflammatory conditions?

Indomethacin Dosing and Administration for Inflammatory Conditions

For inflammatory conditions, indomethacin should be dosed at 25 mg two to three times daily initially, then increased as needed to a maximum of 150-200 mg daily, with the lowest effective dose used for the shortest duration possible to minimize adverse effects. 1

Dosing Recommendations by Condition

Rheumatoid Arthritis, Ankylosing Spondylitis, and Osteoarthritis

• Start with 25 mg two to three times daily 1
• If well tolerated, increase by 25-50 mg at weekly intervals based on symptom response 1
• Maximum recommended daily dose is 150-200 mg 1
• For persistent night pain/morning stiffness, up to 100 mg of the total daily dose can be given at bedtime 1

Acute Gout

• 50 mg three times daily until pain is tolerable 1, 2
• Once pain is controlled, rapidly reduce to complete cessation 1, 2
• Pain relief typically occurs within 2-4 hours, with tenderness and heat subsiding within 24-36 hours 1
• Swelling generally resolves within 3-5 days 1

Acute Painful Shoulder (Bursitis/Tendinitis)

• 75-150 mg daily in 3-4 divided doses 1
• Continue until inflammation is controlled for several days 1
• Typical treatment course is 7-14 days 1

Administration Considerations

• Take with food to minimize gastrointestinal side effects 3
• For patients with persistent symptoms, rectal administration (100 mg suppository at night) can be as effective as oral dosing 4
• Use the lowest effective dose for the shortest duration to minimize adverse effects 1

Safety Monitoring

• Baseline assessment recommended: blood pressure, BUN, creatinine, liver function tests, CBC, and fecal occult blood 3
• Follow-up monitoring every 3 months for long-term use 3
• Discontinue if:
  • BUN or creatinine doubles 3
  • Hypertension develops or worsens 3
  • Liver function tests increase to three times the upper limit of normal 3

Precautions and Contraindications

• Use with caution in:
  • Patients over 60 years of age 3
  • History of peptic ulcer disease 3
  • Significant alcohol use 3
  • Cardiovascular disease or risk factors 3
  • Renal or hepatic impairment 3
• Consider proton pump inhibitors for GI protection in high-risk patients 3
• NSAIDs including indomethacin increase risk of GI bleeding, particularly when combined with aspirin 2

Alternative Treatments for Inflammatory Conditions

For Acute Gout When NSAIDs Are Contraindicated

• Oral corticosteroids (prednisolone 30-35 mg for 5 days) are as effective as NSAIDs with fewer adverse effects 5, 2
• Intramuscular corticosteroids (e.g., triamcinolone acetonide 60 mg) are as effective as indomethacin with fewer side effects 6, 5
• Low-dose colchicine (1.2 mg followed by 0.6 mg one hour later) if started within 36 hours of symptom onset 2

Common Pitfalls and Caveats

• Adverse effects correlate with dose in most patients; use lowest effective dose 1
• Gastrointestinal effects (gastric upset, nausea, risk of peptic ulcer or GI bleeding) are common 3
• Long-term use may lead to renal effects (fluid retention, worsened renal function) and cardiovascular effects (hypertension) 3
• Indomethacin should generally not be prescribed for pediatric patients 14 years of age and under 1
• In elderly patients, use with greater care due to increased possibility of adverse reactions 1