What is the recommended indomethacin dosing regimen for an adult experiencing an acute gout flare?

Indomethacin Dosing for Adult Acute Gout Flare

For an adult experiencing an acute gout flare, indomethacin should be dosed at 50 mg three times daily for 2–3 days, then reduced to 25 mg three times daily for an additional 3–5 days until symptoms resolve, with treatment initiated within 24 hours of symptom onset. 1

Standard Dosing Regimen

• Initial high-dose phase: Indomethacin 50 mg orally three times daily for the first 2–3 days of the acute attack. 1
• Taper phase: Reduce to 25 mg orally three times daily for an additional 3–5 days until pain and inflammation completely resolve. 1
• Total treatment duration: Typically 5–7 days, continuing until complete symptom resolution. 1

Timing and Efficacy Considerations

• Initiate therapy within 24 hours of symptom onset to achieve optimal pain relief; delays beyond this window markedly reduce effectiveness of all anti-inflammatory agents. 1
• Significant clinical improvement typically occurs within 24–36 hours of starting indomethacin therapy. 1
• Do not continue high-dose indomethacin (50 mg three times daily) beyond 2–3 days, as this increases the risk of adverse effects without providing additional therapeutic benefit. 1

Comparative Efficacy and Safety Profile

• Indomethacin provides pain relief equivalent to other NSAIDs (naproxen, ibuprofen) for acute gout, with no single NSAID demonstrating superior efficacy. 1
• Gastrointestinal adverse events occur in 55–63% of patients treated with indomethacin, significantly higher than the 27% rate observed with corticosteroid alternatives such as prednisolone 30–35 mg daily for 5 days. 1
• Oral corticosteroids provide similar pain relief efficacy to indomethacin but with a markedly more favorable adverse-event profile. 2, 1

Absolute Contraindications to Indomethacin

• Severe renal impairment (eGFR < 30 mL/min): NSAIDs can precipitate or worsen acute kidney injury and are absolutely contraindicated in this population. 2, 1
• Active or recent gastrointestinal bleeding or peptic ulcer disease: NSAIDs carry unacceptable bleeding risk. 2, 1
• Heart failure or established cardiovascular disease: NSAIDs increase cardiovascular risk and fluid retention. 2, 1
• Cirrhosis or hepatic impairment: NSAIDs are contraindicated due to hepatotoxicity risk. 2, 1
• Concurrent anticoagulation therapy: NSAIDs significantly increase bleeding risk in anticoagulated patients. 2

Alternative First-Line Therapies When Indomethacin Is Contraindicated

Oral Corticosteroids (Preferred Alternative)

• Prednisone 30–35 mg orally once daily for 5 days (no taper required for short courses), or alternatively 0.5 mg/kg/day for 5–10 days. 2, 1
• Corticosteroids are the safest first-line option in patients with renal impairment, cardiovascular disease, gastrointestinal risk factors, or cirrhosis. 2, 1
• Level A evidence supports equivalent efficacy to NSAIDs with significantly fewer adverse events (27% vs 63%). 2

Low-Dose Colchicine

• Loading dose: 1.2 mg orally at first sign of flare, followed 1 hour later by 0.6 mg (total 1.8 mg). 3, 1
• Maintenance: After a 12-hour pause, resume 0.6 mg once or twice daily until the attack resolves. 3
• Critical timing window: Colchicine must be started within 36 hours of symptom onset; efficacy declines sharply after this window. 3, 1
• Contraindications: Severe renal impairment (CrCl < 30 mL/min) and concurrent use of strong CYP3A4 or P-glycoprotein inhibitors (clarithromycin, cyclosporine, ketoconazole, ritonavir, verapamil). 3

Parenteral Corticosteroids

• Intramuscular triamcinolone acetonide 60 mg as a single injection for patients unable to take oral medications. 2, 4
• Intra-articular corticosteroid injection (triamcinolone 40 mg for knee, 20–30 mg for ankle) for monoarticular gout involving one or two large, accessible joints. 2

Management of Ongoing Urate-Lowering Therapy

• Do not discontinue existing allopurinol or febuxostat during an acute gout flare; continue the urate-lowering therapy uninterrupted while treating the acute attack. 3, 1, 5
• Do not initiate new urate-lowering therapy during an acute flare; wait until the attack has completely resolved before starting allopurinol or febuxostat. 1

Prophylaxis When Initiating Urate-Lowering Therapy

• When starting allopurinol or febuxostat after the acute flare resolves, prescribe colchicine 0.6 mg once or twice daily for at least 6 months to prevent recurrent flares triggered by urate mobilization. 3, 1
• Failure to provide prophylaxis when initiating urate-lowering therapy markedly increases the risk of gout flares during the first 6 months. 1

Common Clinical Pitfalls to Avoid

• Do not delay treatment initiation beyond 24 hours of symptom onset, as therapeutic effectiveness declines sharply. 1
• Do not continue indomethacin 50 mg three times daily beyond 2–3 days, as prolonged high-dose therapy increases adverse effects without additional benefit. 1
• Do not prescribe indomethacin to patients with severe renal impairment, heart failure, cirrhosis, or active peptic ulcer disease, as these are absolute contraindications. 2, 1
• Do not use NSAIDs in elderly patients with multiple comorbidities without carefully assessing renal function, cardiovascular status, and gastrointestinal risk; corticosteroids are safer in this population. 2, 1