What is the dosing for indomethacin (Nonsteroidal Anti-Inflammatory Drug (NSAID)) for an acute gout flare?

From the Guidelines

For acute gout flare, indomethacin is typically dosed at 50 mg three times daily for 3-5 days, then tapered to 25 mg three times daily until the flare resolves completely (usually within 7-10 days total). This dosing regimen is based on the most recent and highest quality study available, which suggests that there is no evidence that indomethacin is more efficacious than other NSAIDs, such as naproxen and ibuprofen, for the treatment of acute gout 1.

Key Considerations

• Indomethacin should be taken with food to minimize gastrointestinal side effects, and patients should be advised to stay well-hydrated.
• Caution is warranted in patients with renal impairment, heart failure, or history of peptic ulcer disease, as indomethacin can worsen these conditions.
• Elderly patients may require lower doses due to increased risk of adverse effects.
• Common side effects include headache, dizziness, gastrointestinal upset, and fluid retention.
• Concurrent use of a proton pump inhibitor may be considered for patients at high risk for gastrointestinal complications.

Special Populations

• Patients with renal disease, heart failure, or cirrhosis may be contraindicated for NSAIDs, including indomethacin.
• Patients with a history of gastrointestinal issues, such as ulcers or bleeding, should be monitored closely while taking indomethacin.
• Patients taking potent cytochrome P450 3A4 inhibitors or P-glycoprotein inhibitors should be cautious when taking colchicine, as it may interact with these medications.

Monitoring and Follow-up

• Patients should be monitored for signs of gastrointestinal complications, such as bleeding or ulcers.
• Patients should be advised to seek medical attention if they experience any severe side effects, such as chest pain or difficulty breathing.
• Follow-up appointments should be scheduled to assess the effectiveness of the treatment and to monitor for any potential side effects.

From the FDA Drug Label

Acute gouty arthritis. Suggested Dosage: Indomethacin capsules 50 mg t.i.d. until pain is tolerable. The dose should then be rapidly reduced to complete cessation of the drug. The recommended dosing for indomethacin for acute gout flare is 50 mg t.i.d. until the pain is tolerable, then the dose should be rapidly reduced to complete cessation of the drug 2.

• The goal is to provide definite relief of pain, which has been reported within 2 to 4 hours.
• Tenderness and heat usually subside in 24 to 36 hours, and swelling gradually disappears in 3 to 5 days.

From the Research

Dosing for Indomethacin in Acute Gout Flare

• The dosing for indomethacin in acute gout flare is not explicitly stated in the provided studies, but its efficacy and comparison with other treatments are discussed 3, 4, 5, 6, 7.
• Indomethacin is mentioned as a common treatment for acute gout, often compared to other options such as systemic corticosteroids, colchicine, and interleukin-1 inhibitors 3, 4, 5, 7.
• In one study, oral indomethacin was compared to intramuscular triamcinolone acetonide, showing no significant difference in efficacy 4.
• Another study found that systemic corticosteroids were as effective as NSAIDs (including indomethacin) but safer 5.
• A clinical trial evaluated rilonacept added to indomethacin for the treatment of acute gout flares, but found no significant additional pain relief with the combination compared to indomethacin alone 7.
• The American College of Rheumatology recommends indomethacin as a first-line treatment for acute gout, but the specific dosing is not provided in the given studies.

Comparison with Other Treatments

• Indomethacin is often compared to other NSAIDs, colchicine, and corticosteroids in the treatment of acute gout 3, 4, 5, 6.
• Systemic corticosteroids, such as prednisolone and triamcinolone, have been shown to be effective in treating acute gout, with similar efficacy to indomethacin 4, 5.
• Colchicine, particularly at low doses, has been found to be effective and safer than high-dose colchicine, but its comparison to indomethacin is limited in the provided studies 3, 5.
• Interleukin-1 inhibitors, such as canakinumab, have been shown to be effective in treating acute gout, but their comparison to indomethacin is not extensively discussed in the given studies 3, 5, 7.