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

Indomethacin Dosing for Inflammatory Conditions

For acute gout, start indomethacin 50 mg three times daily for 2-3 days, then reduce to 25 mg three times daily for an additional 3-5 days until symptoms resolve. 1, 2

Acute Gout Treatment

Initial Dosing Regimen

• Begin with 50 mg three times daily as soon as possible after symptom onset, ideally within 24 hours 1, 2
• Continue this high dose for only 2-3 days to minimize adverse effects while achieving rapid pain control 1
• Rapidly taper to 25 mg three times daily for an additional 3-5 days until pain and inflammation completely resolve 1, 2
• Total treatment duration typically ranges from 5-7 days 1

Expected Clinical Response

• Definite pain relief occurs within 2-4 hours of initiating therapy 2
• Tenderness and heat typically subside within 24-36 hours 1, 2
• Swelling gradually disappears over 3-5 days 2

Critical Treatment Principles

• Do not interrupt ongoing urate-lowering therapy during an acute gout attack 1
• Once pain is tolerable, rapidly reduce the dose to complete cessation 3, 2
• Avoid continuing high-dose indomethacin beyond 2-3 days, as this increases adverse event risk without additional benefit 1

Chronic Inflammatory Arthritis (Rheumatoid Arthritis, Osteoarthritis, Ankylosing Spondylitis)

Starting Dose

• Begin with 25 mg two or three times daily 2
• If well tolerated, increase by 25-50 mg at weekly intervals based on symptom response 2
• Maximum daily dose is 150-200 mg; doses above this do not increase effectiveness 2

Dosing Adjustments

• For patients with persistent night pain or morning stiffness, give up to 100 mg of the total daily dose at bedtime 2
• The typical maintenance dose for long-term therapy is 75-100 mg daily in 81% of patients 4
• Once acute inflammation is controlled, attempt to reduce to the smallest effective dose 2

Acute Painful Shoulder (Bursitis/Tendinitis)

• Dose: 75-150 mg daily in 3-4 divided doses 2
• Discontinue after signs and symptoms of inflammation are controlled for several days 2
• Usual treatment course is 7-14 days 2

Safety Monitoring and Contraindications

Absolute Contraindications

• Severe renal impairment 1
• History of gastrointestinal bleeding or ulceration 1
• Heart failure 1

Baseline and Monitoring Requirements

• Before initiating therapy: Check blood pressure, BUN, creatinine, liver function tests, CBC, and fecal occult blood 5
• During long-term use: Monitor these parameters every 3 months 5
• Discontinue immediately if: BUN or creatinine doubles, hypertension develops or worsens, or liver enzymes increase to three times the upper limit of normal 5

High-Risk Populations Requiring Extra Caution

• Patients over 60 years of age 5
• History of peptic ulcer disease or significant alcohol use 5
• Cardiovascular disease or risk factors 5
• Renal or hepatic impairment 5

Adverse Effects Profile

Gastrointestinal Toxicity (Most Common)

• GI adverse events occur in 55-63% of patients, significantly higher than corticosteroid alternatives 3, 1
• Consider proton pump inhibitors for GI protection in high-risk patients 5
• Taking indomethacin with food may minimize GI side effects 5

Other Common Adverse Effects

• Fluid retention and worsened renal function 5
• Hypertension 5
• Headache (reported in long-term studies) 4

Superior Alternative Options for Acute Gout

Given the high adverse event rate with indomethacin, consider these equally effective alternatives:

Oral Corticosteroids (Preferred in Many Patients)

• Prednisolone 30-35 mg daily for 5 days provides similar efficacy with fewer adverse events (27% vs 63% adverse event rate) 3, 1
• No dose tapering required 3

Low-Dose Colchicine

• 1.2 mg loading dose followed by 0.6 mg one hour later, effective if started within 36 hours of symptom onset 3, 1
• Dramatically fewer adverse effects than high-dose colchicine regimens (23% vs 77% diarrhea rate) 3

Common Pitfalls to Avoid

• Never continue 50 mg three times daily beyond 2-3 days in acute gout—this is the most common dosing error 1
• Do not use indomethacin in elderly patients with renal impairment without dose adjustment and close monitoring 5
• Failure to provide prophylaxis when initiating urate-lowering therapy leads to recurrent flares 1
• Combining indomethacin with aspirin increases GI bleeding risk more than 10-fold 3