What is the recommended dose of Indocid (indomethacin) for an adult patient with acute gout?

Indomethacin Dosing for Acute Gout

For acute gout, start indomethacin 50 mg three times daily until pain is tolerable, then rapidly taper and discontinue once symptoms resolve, typically over 5-7 days total. 1, 2

Initial Dosing Regimen

• Start with 50 mg three times daily (150 mg/day total) and continue at this dose until pain becomes tolerable 2
• Once pain is tolerable, rapidly reduce the dose to complete cessation 2
• An alternative regimen uses 50 mg three times daily for 2-3 days, followed by 25 mg three times daily for an additional 3-5 days 1
• Total treatment duration is typically 5-7 days or until pain and inflammation completely resolve 1

Expected Timeline for Symptom Relief

• Definite pain relief typically occurs within 2-4 hours of initiating treatment 2
• Tenderness and heat usually subside within 24-36 hours 2
• Swelling gradually disappears over 3-5 days 2
• Complete resolution of all symptoms averages 8 days 3

Critical Contraindications

Avoid indomethacin in patients with: 4, 1, 5

• Severe renal impairment (CrCl <30 mL/min)
• History of gastrointestinal bleeding or active peptic ulcer disease
• Heart failure
• Cirrhosis
• Patients on anticoagulation therapy

Adverse Effects Profile

• Gastrointestinal adverse events occur in 55-63% of patients taking indomethacin, significantly higher than corticosteroid alternatives 4, 1
• Common side effects include abdominal discomfort, dyspepsia (55% of patients at 50 mg four times daily), headaches, and cognitive difficulties 6
• The high adverse event rate makes indomethacin less favorable compared to other treatment options 4

Superior Alternative Treatment Options

Oral corticosteroids (prednisolone 30-35 mg daily for 5 days) provide equivalent efficacy to indomethacin with significantly fewer adverse events 4, 1

• Corticosteroids should be considered first-line therapy in patients without contraindications due to their superior safety profile 1
• Low-dose colchicine (1.2 mg followed by 0.6 mg one hour later) is equally effective if started within 36 hours of symptom onset 1, 5
• Other NSAIDs (naproxen 500 mg twice daily) are equally effective with potentially fewer side effects 1, 5

Treatment Selection Algorithm

Before prescribing indomethacin, assess for: 1, 5

• Renal function: If CrCl <30 mL/min, use corticosteroids instead
• Cardiovascular disease or heart failure: Prefer corticosteroids over NSAIDs
• GI risk factors (history of bleeding, ulcers, anticoagulation): Use corticosteroids
• Diabetes or active infection: Avoid corticosteroids, consider NSAIDs if no other contraindications
• Cirrhosis: Avoid indomethacin entirely 1

Common Pitfalls to Avoid

• Do not continue high-dose indomethacin (50 mg three times daily) beyond 2-3 days, as this increases adverse effects without additional benefit 1
• Do not interrupt ongoing urate-lowering therapy during an acute attack 1
• Do not initiate urate-lowering therapy during the acute attack itself 1
• Failure to provide prophylaxis (colchicine 0.6 mg once or twice daily) when starting urate-lowering therapy after the acute attack resolves leads to recurrent flares 4, 1

Dosing in Special Populations

• Elderly patients require greater caution with indomethacin due to increased risk of adverse reactions 2
• The FDA label recommends using the lowest effective dose for the shortest duration in all patients 2
• Doses above 150-200 mg daily generally do not increase effectiveness 2