What is the recommended dose of indomethacin (Non-Steroidal Anti-Inflammatory Drug (NSAID)) for an adult patient with acute gout?

Indomethacin Dosing for Acute Gout

For acute gout, start indomethacin at 50 mg three times daily until pain is tolerable, then rapidly reduce and discontinue the drug, with definite pain relief typically occurring within 2-4 hours and complete resolution in 7-14 days. 1

FDA-Approved Dosing Regimen

• The FDA label specifies indomethacin 50 mg three times daily for acute gouty arthritis, continuing until pain becomes tolerable, then rapidly tapering to complete cessation. 1
• Definite relief of pain occurs within 2-4 hours, tenderness and heat subside in 24-36 hours, and swelling gradually disappears in 3-5 days. 1
• The total daily dose should not exceed 200 mg under any circumstances. 1

Alternative Dosing Strategy from Guidelines

• The American College of Physicians recommends an initial dose of 50 mg three times daily for 2-3 days, followed by 25 mg three times daily for an additional 3-5 days until symptoms resolve, with total treatment duration of 5-7 days. 2
• Treatment should be initiated within 24 hours of symptom onset for optimal effectiveness. 2, 3

When to Avoid Indomethacin

• Absolute contraindications include severe renal impairment (eGFR <30 mL/min), history of GI bleeding or ulceration, heart failure, cirrhosis, and active peptic ulcer disease. 2, 3
• NSAIDs can exacerbate or cause acute kidney injury in patients with renal impairment. 4

Adverse Effects Profile

• Gastrointestinal adverse events occur in 55-63% of patients receiving indomethacin, significantly higher than corticosteroid alternatives (27%). 5, 2
• In comparative trials, 22 of 40 patients (55%) experienced abdominal discomfort or dyspepsia, 15 had headaches, and 12 had difficulty with mentation. 6
• Continuing high-dose indomethacin beyond 2-3 days increases risk of adverse effects without additional benefit. 2

Preferred Alternative Therapies

• Oral corticosteroids (prednisolone 30-35 mg daily for 5 days) provide equivalent efficacy to indomethacin with significantly fewer adverse events (27% vs 63%). 5, 2
• Corticosteroids are explicitly preferred as first-line therapy in patients with renal impairment, cardiovascular disease, heart failure, cirrhosis, peptic ulcer disease, or those on anticoagulation. 4, 2
• Low-dose colchicine (1.2 mg followed by 0.6 mg one hour later) is effective if started within 36 hours of symptom onset. 2, 3

Treatment Algorithm

1. Confirm diagnosis of acute gout (ideally with crystal confirmation) and assess timing of symptom onset. 2
2. Screen for contraindications: Check renal function (eGFR), history of GI bleeding, heart failure status, liver disease, and current anticoagulation. 2, 3
3. If no contraindications exist: Start indomethacin 50 mg three times daily until pain is tolerable (typically 2-4 hours), then rapidly taper and discontinue. 1
4. If contraindications present: Use oral prednisone 0.5 mg/kg per day (30-35 mg for average adults) for 5-10 days instead. 4, 2
5. Do not interrupt ongoing urate-lowering therapy during the acute attack. 2, 3

Common Pitfalls to Avoid

• Delaying treatment beyond 24 hours of symptom onset significantly reduces effectiveness. 2, 3
• Using indomethacin in patients with renal impairment, where corticosteroids are the safest first-line option. 4
• Continuing high-dose indomethacin beyond 2-3 days unnecessarily increases adverse event risk. 2
• Failing to provide prophylaxis (low-dose colchicine or prednisone <10 mg/day) when initiating urate-lowering therapy after the acute attack resolves. 2

Comparative Efficacy Evidence

• Multiple head-to-head trials demonstrate no clinically significant differences in efficacy between different NSAIDs for acute gout. 5, 3
• Other NSAIDs (naproxen, ibuprofen) are equally effective as indomethacin with potentially fewer side effects. 2
• Single-dose intramuscular triamcinolone acetonide 60 mg achieved symptom resolution in an average of 7 days compared to 8 days with indomethacin 50 mg three times daily, with no side effects in the corticosteroid group. 7