What is the typical dosing of indomethacin (Nonsteroidal Anti-Inflammatory Drug (NSAID)) for an adult patient with conditions such as gout or rheumatoid arthritis?

Indomethacin Dosing for Acute Gout

For acute gout, start indomethacin 50 mg three times daily until pain becomes tolerable, then rapidly taper and discontinue—typically within 5-7 days total. 1

Standard Dosing Regimen

The FDA-approved dosing for acute gouty arthritis is:

• Initial phase: 50 mg three times daily (150 mg/day total) until pain is tolerable 1
• Taper phase: Rapidly reduce dose once pain improves, then complete cessation 1
• Expected timeline: Pain relief typically occurs within 2-4 hours, tenderness and heat subside in 24-36 hours, and swelling gradually disappears in 3-5 days 1
• Total treatment duration: Usually 5-7 days 2

An alternative regimen supported by guidelines is 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 2.

Treatment Initiation and Monitoring

• Timing: Initiate treatment as soon as possible after symptom onset, ideally within 24 hours for optimal efficacy 2
• Response assessment: Significant improvement typically occurs within 24-36 hours 2
• Do not interrupt ongoing urate-lowering therapy during the acute attack 2

Critical Contraindications

Avoid indomethacin in patients with:

• Severe renal impairment (eGFR <30 mL/min)—NSAIDs can exacerbate or cause acute kidney injury 3, 2
• History of GI bleeding or active peptic ulcer disease 2
• Heart failure—NSAIDs carry cardiovascular risks 2
• Cirrhosis or hepatic impairment 2
• Patients on anticoagulation 2

Adverse Effects Profile

Gastrointestinal adverse events are common with indomethacin, occurring in 55-63% of patients—significantly higher than corticosteroid alternatives 2, 4. In comparative studies, 55% of indomethacin-treated patients reported gastrointestinal adverse events at the 50 mg four times daily dose 3.

Other reported side effects include headaches and difficulty with mentation 4.

Preferred Alternative Therapies

When indomethacin is contraindicated or poorly tolerated:

• Oral corticosteroids: Prednisolone 30-35 mg daily for 5 days provides similar efficacy with fewer adverse events (27% vs 63% adverse event rate) 3, 2
• Low-dose colchicine: 1.2 mg loading dose followed by 0.6 mg one hour later (only if started within 36 hours of symptom onset) 2
• Other NSAIDs: Naproxen or ibuprofen are equally effective as indomethacin with potentially fewer side effects 2

Common Pitfalls to Avoid

• Do not continue high-dose indomethacin beyond 2-3 days—this increases adverse effect risk without additional benefit 2
• Do not use standard NSAID doses in renal impairment—switch to corticosteroids as first-line therapy 3, 2
• Do not initiate urate-lowering therapy during an acute attack—wait until the flare resolves 2
• Do not fail to provide prophylaxis when starting urate-lowering therapy—this prevents recurrent flares 2

Clinical Decision Algorithm

1. Confirm acute gout diagnosis and assess for NSAID contraindications (renal impairment, GI risk, heart failure, cirrhosis) 2
2. If contraindications present: Use oral corticosteroids (prednisone 0.5 mg/kg/day for 5-10 days) instead 5, 2
3. If no contraindications: Start indomethacin 50 mg three times daily 1
4. Monitor response at 24-36 hours: Expect significant improvement in pain, tenderness, and heat 2, 1
5. Taper rapidly once pain tolerable: Reduce dose and discontinue within 5-7 days total 1
6. For recurrent gout (≥2 episodes/year): Discuss urate-lowering therapy after acute attack resolves 2