What is the recommended dose of indomethacin (nonsteroidal anti-inflammatory drug (NSAID)) for an elderly patient with acute gout and impaired renal function?

Indomethacin Dosing for Acute Gout in Elderly Patients with Renal Impairment

Indomethacin should be avoided entirely in elderly patients with impaired renal function—use oral prednisone 30-35 mg daily for 3-5 days instead. 1, 2

Why Indomethacin is Contraindicated

• NSAIDs, including indomethacin, are explicitly contraindicated in severe renal impairment (eGFR <30 mL/min) because they can exacerbate or cause acute kidney injury. 1, 2, 3

• Even in mild to moderate renal insufficiency, indomethacin has been documented to cause reversible acute renal failure and life-threatening hyperkalemia. 4

• The elderly are at particularly high risk for NSAID-related complications, including peptic ulcer disease, renal failure, uncontrolled hypertension, and cardiac failure. 5

• Short-acting NSAIDs like diclofenac or ketoprofen are preferred over indomethacin in elderly patients if NSAIDs must be used, but even these should be avoided in renal impairment. 5

Recommended First-Line Treatment: Oral Corticosteroids

Prednisone 30-35 mg daily for 3-5 days is the safest and most effective first-line treatment for acute gout in elderly patients with renal impairment. 1, 2, 6

Dosing Algorithm:

• Start with prednisone 0.5 mg/kg per day (approximately 30-35 mg for most adults) for 5-10 days at full dose, then stop abruptly. 2
• Alternatively, give full dose for 2-5 days, then taper over 7-10 days for patients at higher risk of rebound flares (including those with renal impairment or severe attacks). 2
• No dose adjustment is required for any level of renal impairment, including dialysis patients. 6

Evidence Supporting Corticosteroids:

• The American College of Rheumatology provides Level A evidence that oral corticosteroids are equally effective as NSAIDs for acute gout treatment, with fewer adverse effects. 2
• Direct comparison studies show 27% of prednisolone patients experienced adverse events compared to 63% in the indomethacin group. 2
• Corticosteroids are explicitly preferred over NSAIDs in patients with severe renal impairment, cardiovascular disease, heart failure, cirrhosis, or peptic ulcer disease. 2

Alternative Treatment Options

Intra-articular Corticosteroid Injection:

• For monoarticular gout involving 1-2 large joints, intra-articular corticosteroid injection is highly effective with minimal systemic effects. 2, 6
• This approach is particularly useful when systemic therapy is contraindicated. 6

Intramuscular Corticosteroids:

• Triamcinolone acetonide 60 mg intramuscularly is as safe and effective as indomethacin, with resolution of symptoms in an average of 7 days. 2, 7
• This route is particularly indicated when patients cannot take oral medications. 2

Why Not Colchicine?

Colchicine should be avoided in elderly patients with severe renal impairment (eGFR <30 mL/min) due to fatal toxicity risk. 1, 6, 3

• Colchicine toxicity is significantly increased in chronic kidney disease, particularly neurotoxicity and muscular toxicity. 1, 2
• If mild to moderate renal impairment (CrCl 30-80 mL/min), standard dosing can be used with close monitoring, but this is not recommended in the elderly with multiple comorbidities. 6
• Colchicine is poorly tolerated in the elderly and is best avoided. 5
• Colchicine must not be given to patients receiving strong P-glycoprotein or CYP3A4 inhibitors (cyclosporin, clarithromycin, ketoconazole, ritonavir, verapamil). 1, 6

Common Pitfalls to Avoid

• Never use indomethacin or any NSAID in elderly patients with renal impairment—the risk of acute kidney injury and hyperkalemia is unacceptable. 3, 4
• Do not use high-dose prednisone (>10 mg/day) for prolonged prophylaxis during urate-lowering therapy initiation. 2
• Avoid combining NSAIDs with systemic corticosteroids due to synergistic gastrointestinal toxicity. 8
• Do not interrupt ongoing urate-lowering therapy during an acute gout attack. 2

Long-Term Management Considerations

• Initiate urate-lowering therapy after the acute flare resolves, with a target serum uric acid <6 mg/dL. 6
• Prophylaxis with low-dose prednisone (<10 mg/day) can be used for 3-6 months when initiating urate-lowering therapy if colchicine and NSAIDs are contraindicated. 2, 6
• In severe renal impairment, febuxostat is preferred over allopurinol as it does not require dose adjustment. 6