From the Guidelines
Indomethacin should not be prescribed for long-term use due to its significant side effect profile, and instead, the lowest effective dose for the shortest duration possible should be considered, as recommended by recent guidelines 1. When considering long-term use, it's essential to weigh the benefits against the risks, including gastrointestinal bleeding, kidney damage, cardiovascular complications, and fluid retention, which increase with age, higher doses, and longer duration of treatment. The most recent and highest quality study, published in 2016, suggests that the choice of NSAID should be based on consideration of the patient’s past history of NSAID use, risk factors for adverse effects, and comorbidities 1. Some key points to consider when prescribing indomethacin for long-term use include:
- Typical dosing ranges from 25-50 mg 2-3 times daily
- Extended use beyond a few weeks requires careful medical supervision
- Regular monitoring of kidney function, blood pressure, and gastrointestinal symptoms is essential
- Alternatives with better safety profiles, such as celecoxib, or using the lowest effective dose of indomethacin with protective medications like proton pump inhibitors, may be recommended by doctors. It's also important to note that the American College of Rheumatology recommends treatment with NSAIDs over no treatment with NSAIDs for adults with active ankylosing spondylitis, but also suggests that the decision to use NSAIDs continuously may vary depending on the severity and intermittency of symptoms, comorbidities, and patient preferences 1. Overall, while indomethacin can be effective for certain conditions, its use should be carefully considered and monitored to minimize the risk of adverse effects, as supported by the evidence from the 2016 study 1.
From the FDA Drug Label
Indomethacin has been shown to be an effective anti-inflammatory agent, appropriate for long-term use in rheumatoid arthritis, ankylosing spondylitis, and osteoarthritis
- Long-term use: Indomethacin can be used for long-term treatment of certain conditions, such as rheumatoid arthritis, ankylosing spondylitis, and osteoarthritis.
- Precautions: However, long-term administration of NSAIDs, including indomethacin, has resulted in renal papillary necrosis and other renal injury, and may increase the risk of gastrointestinal adverse events, such as ulceration, bleeding, and perforation.
- Monitoring: Patients on long-term treatment with indomethacin should be carefully monitored for signs and symptoms of adverse events, and the lowest effective dose should be used for the shortest possible duration 2.
- Key considerations: The decision to prescribe indomethacin for long-term use should be made with caution, taking into account the potential risks and benefits, and alternative therapies should be considered for high-risk patients 2.
From the Research
Long-term Indomethacin Prescription
- Indomethacin is a non-steroidal anti-inflammatory drug (NSAID) that can be prescribed for long-term use, but its tolerability and efficacy must be carefully evaluated 3, 4.
- A retrospective study of 67 patients with moderate to severe rheumatoid arthritis, osteoarthritis, or ankylosing spondylitis found that long-term daily administration of indomethacin was well-tolerated and effective, with only 13% of patients experiencing side effects 3.
- Another study of 26 patients with chronic paroxysmal hemicrania or hemicrania continua found that prolonged indomethacin treatment had a good safety and tolerability profile, with 42% of patients experiencing a decrease in the required dose over time 4.
Gastrointestinal Risks
- NSAIDs, including indomethacin, are associated with an increased risk of gastrointestinal (GI) complications, such as ulcers and bleeding 5, 6, 7.
- The risk of GI events can be reduced by using COX-2 selective inhibitors, such as celecoxib, which have been shown to have a better GI safety profile than non-selective NSAIDs 5, 6, 7.
- Patients with a history of ulcer or GI complications, advanced age, concomitant anticoagulation therapy or corticosteroid use, and high-dose or multiple NSAID therapy are at increased risk of GI events 6, 7.