What is the role of indomethacin (Nonsteroidal Anti-Inflammatory Drug, NSAID) in the treatment of gout?

From the Guidelines

Indomethacin should not be considered as the first-line treatment for gout due to its potential adverse effects and lack of evidence showing its superiority over other NSAIDs or corticosteroids. According to the American College of Physicians guideline 1, corticosteroids are recommended as first-line therapy in patients without contraindications because they are generally safer and a low-cost treatment option. The guideline states that moderate-quality evidence showed no difference between different types of NSAIDs, including indomethacin, and that adverse effects associated with NSAIDs include dyspepsia and potential gastrointestinal perforations, ulcers, and bleeding.

Some key points to consider when treating gout include:

• Corticosteroids, such as prednisolone, are effective and have fewer adverse effects compared to NSAIDs 1
• Indomethacin is commonly considered for treatment of acute gout, but there is no evidence that it is more efficacious than other NSAIDs, such as naproxen and ibuprofen 1
• Patients with renal disease, heart failure, or cirrhosis may be contraindicated for NSAIDs, including indomethacin 1
• Colchicine is an alternative treatment option, but it is more expensive than NSAIDs or corticosteroids and has its own set of adverse effects, including gastrointestinal issues 1

In terms of treatment, it is essential to weigh the benefits and risks of each medication and consider the individual patient's needs and contraindications. Corticosteroids, such as prednisolone, are a safer and more effective option for most patients, and indomethacin should only be considered when other options are contraindicated or ineffective 1.

From the FDA Drug Label

Indomethacin capsules have been found effective in relieving the pain, reducing the fever, swelling, redness, and tenderness of acute gouty arthritis Indomethacin capsules have been found effective in active stages of the following: ... Acute gouty arthritis.

Gout treatment with indomethacin is effective in relieving the pain, reducing the fever, swelling, redness, and tenderness of acute gouty arthritis.

• Key points:
  • Indomethacin is used to treat acute gouty arthritis.
  • It relieves pain, reduces fever, swelling, redness, and tenderness. 2 2

From the Research

Gout Treatment with Indomethacin

• Indomethacin is a nonsteroidal anti-inflammatory drug (NSAID) commonly used to treat acute gout attacks 3, 4, 5, 6
• Studies have compared indomethacin with other treatments, such as systemic corticosteroids, colchicine, and interleukin-1 inhibitors, in the management of acute gout 3, 4, 5, 6
• A study published in 2008 found that systemic corticosteroids, such as triamcinolone acetonide, were as effective as indomethacin in treating acute gout, with no significant differences in outcome measurements, including pain and joint status 3
• Another study from 1993 compared triamcinolone acetonide with indomethacin in the treatment of acute gouty arthritis and found that both treatments were effective, with no significant differences in resolution of symptoms or side effects 4
• A systematic review published in 2014 found that NSAIDs, including indomethacin, were effective in treating acute gout attacks, but noted that patients with comorbidities may require alternative treatments due to potential contraindications 5
• A review of systematic literature, including Cochrane reviews, found that indomethacin was effective in treating acute gout, but highlighted the need for further research to determine the optimal treatment strategy and to compare the efficacy and safety of different treatments, including indomethacin, systemic corticosteroids, and colchicine 6

Efficacy and Safety of Indomethacin

• Indomethacin has been shown to be effective in reducing pain and inflammation in acute gout attacks 3, 4, 5, 6
• However, indomethacin may be associated with adverse effects, such as gastrointestinal toxicity and renal impairment, particularly in patients with comorbidities 5, 6
• Systemic corticosteroids, such as triamcinolone acetonide, may be a safer alternative to indomethacin in patients with contraindications to NSAIDs 3, 4
• Colchicine, another treatment option for acute gout, has been shown to be effective in reducing pain and inflammation, but may be associated with adverse effects, such as gastrointestinal toxicity, particularly at high doses 7, 5, 6

Comparison with Other Treatments

• Indomethacin has been compared with other treatments, including systemic corticosteroids, colchicine, and interleukin-1 inhibitors, in the management of acute gout 3, 4, 5, 6
• Systemic corticosteroids, such as triamcinolone acetonide, have been shown to be as effective as indomethacin in treating acute gout, with no significant differences in outcome measurements, including pain and joint status 3
• Colchicine has been shown to be effective in reducing pain and inflammation in acute gout attacks, but may be associated with adverse effects, particularly at high doses 7, 5, 6
• Interleukin-1 inhibitors, such as canakinumab, have been shown to be effective in treating acute gout attacks, particularly in patients with contraindications to NSAIDs or colchicine 5, 6