Is indomethacin or naproxen (Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)) more effective for acute gouty arthritis pain management?

From the Guidelines

Naproxen is as effective as indomethacin for treating gout pain, and its use may be preferred due to a potentially more favorable side effect profile. When considering the management of acute gout, both indomethacin and naproxen are viable options, but the choice between them should be guided by the individual patient's risk factors and tolerance for potential side effects 1. Indomethacin has traditionally been considered a first-line NSAID for acute gout, but there is no strong evidence to suggest it is more efficacious than other NSAIDs like naproxen. The dosage for indomethacin is typically 50 mg three times daily for acute attacks, while naproxen is usually prescribed at 500 mg twice daily.

Key considerations in choosing between these medications include their side effect profiles. Indomethacin is known for its potential to cause gastrointestinal side effects such as dyspepsia, and it may also lead to more severe gastrointestinal issues like ulcers and bleeding, especially in patients with risk factors such as renal disease, heart failure, or cirrhosis 1. Naproxen, while also an NSAID and thus carrying similar risks, may have a slightly more favorable profile in some patients, making it a reasonable alternative for those who cannot tolerate indomethacin's side effects.

It's crucial for patients to take these medications with food to minimize stomach irritation and to stay well-hydrated. The duration of use should be limited to the shortest period needed to control symptoms, typically 3-5 days for acute attacks. Given the lack of evidence showing indomethacin to be more effective than naproxen for gout pain management, and considering the potential for adverse effects, the decision between indomethacin and naproxen should prioritize the patient's specific health context and potential risks associated with each medication 1.

From the FDA Drug Label

In clinical studies in patients with rheumatoid arthritis, osteoarthritis, and juvenile arthritis, naproxen has been shown to be comparable to aspirin and indomethacin in controlling the aforementioned measures of disease activity, but the frequency and severity of the milder gastrointestinal adverse effects (nausea, dyspepsia, heartburn) and nervous system adverse effects (tinnitus, dizziness, lightheadedness) were less in naproxen-treated patients than in those treated with aspirin or indomethacin. In patients with acute gout, a favorable response to naproxen was shown by significant clearing of inflammatory changes (e.g., decrease in swelling, heat) within 24 to 48 hours, as well as by relief of pain and tenderness. Indomethacin capsules have been found effective in relieving the pain, reducing the fever, swelling, redness, and tenderness of acute gouty arthritis

Comparison of Naproxen and Indomethacin for Gout Pain:

• Both naproxen and indomethacin have been shown to be effective in treating gout pain.
• Naproxen has been found to have fewer gastrointestinal and nervous system adverse effects compared to indomethacin.
• The choice between naproxen and indomethacin for gout pain should be based on individual patient needs and medical history, considering the potential benefits and risks of each medication 2, 3.
• Naproxen may be preferred due to its more favorable side effect profile.

From the Research

Comparison of Indomethacin and Naproxen for Gout Pain

• The provided studies do not directly compare indomethacin and naproxen for gout pain, but they do discuss the efficacy of non-steroidal anti-inflammatory drugs (NSAIDs) in general for treating acute gout 4, 5, 6, 7, 8.
• A systematic review and meta-analysis found that etoricoxib, a selective cyclo-oxygenase-2 inhibitor, was comparable to indomethacin in terms of pain relief, but better than diclofenac 50 mg three times a day 8.
• Another study found that NSAIDs, including indomethacin and naproxen, are effective agents for the treatment of acute gout attacks, but it did not compare the two directly 5.
• The studies suggest that NSAIDs, including indomethacin and naproxen, are probably equally beneficial in terms of pain relief, but may have different side effect profiles 4, 7.
• Overall, the evidence suggests that both indomethacin and naproxen may be effective for treating gout pain, but the choice between them may depend on individual patient factors and side effect profiles 4, 5, 6, 7, 8.

Efficacy of NSAIDs for Gout Pain

• The studies found that NSAIDs are effective for treating acute gout pain, with moderate-certainty evidence showing that they probably result in little to no difference in pain relief compared to other treatments, such as glucocorticoids 4, 7.
• Low-certainty evidence suggests that NSAIDs may improve pain at 24 hours and may have little to no effect on function, inflammation, or adverse events for treatment of acute gout 4.
• The studies also found that NSAIDs may increase withdrawals due to adverse events and total adverse events, particularly gastrointestinal events 4, 7.

Safety and Side Effects

• The studies found that NSAIDs, including indomethacin and naproxen, may have different side effect profiles, with some NSAIDs increasing the risk of gastrointestinal events and other adverse effects 4, 7, 8.
• The choice of NSAID may depend on individual patient factors, such as comorbidities and concomitant medications, as well as the specific side effect profile of the medication 6.