What is the recommended dosing for indomethacin (Nonsteroidal Anti-Inflammatory Drug) in the treatment of acute gout?

Indomethacin Dosing for Acute Gout

For acute gout attacks, indomethacin should be dosed at 50 mg three times daily for 2-3 days, followed by 25 mg three times daily for an additional 3-5 days until symptoms resolve. 1, 2

Recommended Dosing Regimen

• Initial dose: 50 mg three times daily (150 mg total daily dose) 1
• Duration of initial dose: 2-3 days 2, 1
• Maintenance dose: 25 mg three times daily (75 mg total daily dose) 2
• Total treatment duration: 5-7 days or until pain and inflammation resolve 1

Efficacy and Considerations

• Indomethacin provides effective pain relief in acute gout attacks, with significant improvement typically observed within 24-36 hours 2
• Complete resolution of symptoms generally occurs within 3-5 days 1
• Treatment should be initiated as soon as possible after symptom onset, ideally within 24 hours 2
• Ongoing urate-lowering therapy should not be interrupted during an acute gout attack 2

Adverse Effects and Cautions

• Gastrointestinal adverse events are common with indomethacin (reported in 55-63% of patients), significantly higher than with corticosteroid alternatives (27%) 2
• Use the lowest effective dose for the shortest duration to minimize adverse effects 1
• Indomethacin should be used with greater caution in elderly patients due to increased risk of adverse reactions 1
• Contraindications include severe renal impairment, history of GI bleeding or ulceration, and heart failure 3

Alternative Treatment Options

• Oral corticosteroids (prednisolone 30-35 mg daily for 5 days) provide similar efficacy to indomethacin with fewer adverse events 2
• Low-dose colchicine (1.2 mg followed by 0.6 mg one hour later) is effective if started within 36 hours of symptom onset 2, 3
• Intramuscular triamcinolone acetonide (60 mg) is as effective as indomethacin with fewer side effects 4

Treatment Algorithm

1. Confirm diagnosis of acute gout (clinical presentation or crystal identification) 2
2. Assess for contraindications to NSAIDs (renal impairment, GI risk, heart failure) 3
3. If no contraindications:
   • Start indomethacin 50 mg three times daily for 2-3 days 1, 2
   • Continue with 25 mg three times daily until symptoms resolve (typically 3-5 additional days) 2, 1
4. If contraindications to indomethacin exist:
   • Use prednisolone 30-35 mg daily for 5 days 2 OR
   • Consider intramuscular triamcinolone acetonide 60 mg as a single dose 4 OR
   • Use low-dose colchicine if within 36 hours of symptom onset 2

Common Pitfalls to Avoid

• Continuing high-dose indomethacin (50 mg TID) beyond 2-3 days increases risk of adverse effects without additional benefit 2, 1
• Inadequate duration of therapy may lead to symptom recurrence; continue until complete resolution 1
• Failure to provide prophylaxis when initiating urate-lowering therapy 2
• Using doses above 200 mg daily does not increase effectiveness but significantly increases toxicity 1