What is the recommended dosage and treatment approach for Indomethacin (Nonsteroidal Anti-Inflammatory Drug (NSAID)) in patients with conditions like gout, osteoarthritis, and rheumatoid arthritis?

Indomethacin Dosing and Treatment Approach

Acute Gout

For acute gout, use indomethacin 50 mg three times daily until pain is tolerable, then rapidly taper to complete cessation, with definite pain relief expected within 2-4 hours and complete resolution typically within 3-5 days. 1

Specific Dosing Protocol

• Initial dose: 50 mg three times daily until pain becomes tolerable 1
• Tapering: Rapidly reduce dose once pain is tolerable, then discontinue completely 1
• Expected timeline: Pain relief within 2-4 hours, tenderness and heat subside in 24-36 hours, swelling resolves in 3-5 days 1

Critical Timing Considerations

• Initiate treatment within 24 hours of symptom onset for optimal outcomes 2, 3
• Earlier treatment (within 12-24 hours) provides superior pain relief 2

Important Caveats

• Gastrointestinal adverse events are significantly more common with indomethacin compared to corticosteroids (63% vs 27% in one trial, 55% experiencing GI side effects at 50 mg four times daily in another) 4, 5
• Consider adding a proton pump inhibitor if history of GI bleeding, ulcers, or concurrent corticosteroid use 2
• Avoid if history of NSAID-induced acute kidney injury 2

Alternative First-Line Options

The American College of Rheumatology does not rank indomethacin above other NSAIDs, corticosteroids, or colchicine for acute gout 4. Consider:

• Oral prednisone 30-35 mg daily for 3-5 days as first-line alternative if NSAIDs contraindicated 2
• Colchicine 1.2 mg immediately, followed by 0.6 mg one hour later if started within 36 hours of symptom onset 2, 3
• Naproxen or other NSAIDs show equivalent efficacy with potentially better tolerability 4

Concurrent Urate-Lowering Therapy

• Do not interrupt ongoing urate-lowering therapy during acute attacks 2, 3
• Continue current dose without modification 2, 3

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Rheumatoid Arthritis

For rheumatoid arthritis, start indomethacin 25 mg two to three times daily, increasing by 25-50 mg weekly intervals as tolerated until satisfactory response, up to a maximum of 150-200 mg daily. 1

Dosing Algorithm

• Initial dose: 25 mg twice or three times daily 1
• Titration: Increase by 25 mg (or 50 mg if needed) at weekly intervals until satisfactory response 1
• Maximum dose: 150-200 mg daily; doses above this do not increase effectiveness 1
• Night dosing option: Up to 100 mg at bedtime for patients with persistent night pain or morning stiffness 1

Monitoring and Adjustment

• If minor adverse effects develop during titration, rapidly reduce to tolerated dose 1
• If severe adverse reactions occur, stop the drug immediately 1
• Once acute phase is controlled, repeatedly attempt to reduce to smallest effective dose 1

Efficacy Considerations

• Responders to indomethacin show improvement in 8 of 9 clinical parameters compared to placebo, while nonresponders do not improve 6
• No correlation exists between plasma indomethacin concentration and clinical response 6
• Indomethacin 100 mg nightly (oral or rectal) produces significant improvements in morning and afternoon assessments 7

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Osteoarthritis

For osteoarthritis, use the same dosing approach as rheumatoid arthritis: start 25 mg two to three times daily, titrating by 25-50 mg weekly to a maximum of 150-200 mg daily based on response. 1

Treatment Principles

• Use the lowest effective dose for the shortest duration consistent with treatment goals 1
• Adjust dose and frequency to suit individual patient needs after observing initial response 1
• Adverse reactions correlate with dose size in most patients, so determine the smallest effective dosage 1

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Acute Painful Shoulder (Bursitis/Tendinitis)

For acute shoulder conditions, use 75-150 mg daily in 3-4 divided doses, discontinuing after signs and symptoms of inflammation are controlled for several days, with usual treatment duration of 7-14 days. 1

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Special Population Considerations

Elderly Patients

• Use with greater care as advancing age increases risk of adverse reactions 1
• Start at lower end of dosing range and titrate cautiously 1

Pediatric Patients

• Indomethacin should not ordinarily be prescribed for patients 14 years of age and under 1