What is the recommended dosage of indomethacin (Nonsteroidal Anti-Inflammatory Drug (NSAID)) for rheumatoid arthritis in adults?

Indomethacin Dosage for Rheumatoid Arthritis

For moderate to severe rheumatoid arthritis, start indomethacin at 25 mg twice or three times daily, then increase by 25-50 mg weekly as tolerated until reaching 150-200 mg daily in divided doses, with the maximum effective dose typically being 150 mg/day. 1

Initial Dosing Strategy

• Begin with indomethacin 25 mg two or three times daily (50-75 mg/day total) 1
• This conservative starting approach allows assessment of tolerability before dose escalation 1
• If well tolerated after the first week, proceed with dose titration 1

Dose Escalation Protocol

• Increase the daily dose by 25 mg or 50 mg at weekly intervals based on symptom response and tolerability 1
• Continue escalation until achieving satisfactory symptom control or reaching the maximum daily dose of 150-200 mg 1
• Doses above 200 mg daily generally do not increase effectiveness and should not be exceeded 1

Optimal Maintenance Dosing

• The typical effective maintenance dose ranges from 75-150 mg daily in divided doses 1, 2
• For 81% of patients in long-term studies, the average effective daily dose was 75-100 mg 2
• Divided dosing (2-3 times daily) maintains more consistent therapeutic levels throughout the day 1

Special Dosing Considerations for Symptom Patterns

• For patients with persistent night pain or morning stiffness: Give up to 100 mg of the total daily dose at bedtime to provide overnight relief 1
• This bedtime loading strategy can significantly improve morning symptoms while keeping total daily dose at or below 200 mg 1
• A single 100 mg dose at night has demonstrated equivalent efficacy to divided daytime dosing for controlling morning symptoms 3

Dose Adjustment During Acute Flares

• During acute exacerbations of chronic rheumatoid arthritis, increase the dose by 25-50 mg daily as needed 1
• If minor adverse effects develop during escalation, rapidly reduce to the previously tolerated dose and observe closely 1
• If severe adverse reactions occur, stop the drug immediately 1

Dose Optimization and De-escalation

• Once acute inflammation is controlled, attempt to reduce the daily dose repeatedly to find the smallest effective maintenance dose 1
• The goal is to maintain disease control at the lowest possible dose to minimize long-term adverse effects 1
• Studies show that doses above 150 mg daily rarely provide additional therapeutic benefit 1, 2

Alternative Dosing Strategy for Lower Risk

• Consider combining low-dose indomethacin 50 mg/day with paracetamol 4 g/day as an alternative to high-dose indomethacin (150 mg/day) 4
• This combination provides equivalent analgesia with fewer and milder side effects compared to indomethacin 150 mg/day alone 4
• This approach is particularly appropriate when higher indomethacin doses cause intolerable adverse effects 4

Sustained-Release Formulations

• Sustained-release indomethacin 75 mg twice daily is equivalent in efficacy to conventional 50 mg three times daily 5
• The sustained-release formulation may improve adherence with less frequent dosing while maintaining therapeutic levels 5
• Both formulations have comparable safety profiles and incidence of adverse effects 5

Critical Safety Monitoring

• Elderly patients require greater caution and potentially lower doses due to increased risk of adverse reactions 1
• Careful individual patient observation is essential to prevent serious, irreversible, and potentially fatal adverse reactions 1
• The drug should not ordinarily be prescribed for pediatric patients 14 years of age and under 1

Common Pitfalls to Avoid

• Do not exceed 200 mg daily, as higher doses do not improve efficacy and substantially increase toxicity risk 1
• Avoid rapid dose escalation without adequate assessment periods (minimum 1 week between increases) 1
• Do not continue ineffective doses for prolonged periods—if no response occurs at 150 mg daily after adequate trial, consider alternative therapy 1
• Long-term tolerability is best predicted by the first 10-14 days of therapy; patients experiencing significant early adverse effects are unlikely to tolerate chronic use 2