Indomethacin: Difference between revisions

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Non-steroidal anti-inflammatory (NSAID, potent non-selective), Analgesic

Indomethacin

Indocin (oral, IV, suppository), Tivorbex (low-dose), Indo-Lemmon

Experience

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Problems

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Titration strategies

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Effects

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Summary

Classes

Non-steroidal anti-inflammatory (NSAID, potent non-selective), Analgesic

Common uses

Acute gouty arthritis (FDA; the classic first-line indication)0, Moderate-to-severe rheumatoid arthritis (FDA)0, Osteoarthritis (FDA)0, Ankylosing spondylitis (FDA)0, Calcium pyrophosphate deposition disease (pseudogout, off-label)0, Acute migraine and hemicrania continua (off-label; the latter is a uniquely indomethacin-responsive headache syndrome)0, Patent ductus arteriosus closure in preterm neonates (FDA, IV; Indocin IV)0

Pharmacy

Starting dose

Acute gout: 50 mg PO TID until symptom relief, then taper; maximum 200 mg/day for 3-5 days. Rheumatoid arthritis / osteoarthritis: 25-50 mg PO BID-TID. Patent ductus arteriosus: 0.2 mg/kg IV, then 0.1-0.2 mg/kg every 12-24 hours for 2 doses

Preparations

Capsules 25, 50 mg; ER capsules 75 mg; oral suspension 25 mg/5 mL; suppositories 50 mg; injection 1 mg/vial (PDA closure)

US FDA Max

200 mg/day (typical adult oral)

Pharmacology

Routes

Oral, rectal, intravenous (PDA closure only)

Onset

30-60 minutes (oral); rapid relief in acute gout

Duration

4-6 hours (IR); 24 hours (ER)

Half-life

4-5 hours^[1]

Bioavailability

~100% (oral)^[1]

Pregnancy

Avoid from 20 weeks gestation onward per FDA's 2020 expanded NSAID warning; contraindicated from 30 weeks (risk of premature ductus arteriosus closure, which is paradoxically the basis of the neonatal PDA-closure indication)^[1]

Legal status

Rx-only in US

Purported mechanism

Non-selective COX-1 and COX-2 inhibitor with high potency relative to other NSAIDs, the basis of its acute-gout efficacy and the uniquely indomethacin-responsive hemicrania continua syndrome. The PDA closure indication uses prostaglandin inhibition therapeutically: the ductus arteriosus stays patent via prostaglandin E1, and inhibiting its synthesis closes the shunt.0 Among the higher-cardiovascular-risk NSAIDs, with elevated GI bleeding risk compared to the class average. Notable for CNS adverse effects uncommon with other NSAIDs: paradoxical headache, dizziness, depression, and confusion in elderly patients (Beers-list concerns)^[1].

References

↑ ^1.0 ^1.1 ^1.2 ^1.3 FDA Prescribing Information, Indocin (indomethacin), Iroko/Egalet, current revision. https://www.accessdata.fda.gov/drugsatfda_docs/label/2016/018332s044lbl.pdf

[indocin-label-1] 1.0 ^1.1 ^1.2 ^1.3 FDA Prescribing Information, Indocin (indomethacin), Iroko/Egalet, current revision. https://www.accessdata.fda.gov/drugsatfda_docs/label/2016/018332s044lbl.pdf

[1]

@@ Line 1: / Line 1: @@
-{{Stub}}
 {{MedTemplate
-| generic = Indomethacin
+| generic           = Indomethacin
-| brand   = Indocin
+| brand             = Indocin (oral, IV, suppository), Tivorbex (low-dose), Indo-Lemmon
-| classes = NSAID
+| structure         =
-| intro   = Indomethacin is a potent non-selective non-steroidal anti-inflammatory drug (NSAID), used for inflammatory conditions such as gout and certain forms of arthritis.
+| classes           = [[:Category:NSAIDs|Non-steroidal anti-inflammatory (NSAID, potent non-selective)]], [[:Category:Analgesics|Analgesic]]
+| uses              = <vote slug="acute-gouty-arthritis-use">Acute gouty arthritis (FDA; the classic first-line indication)</vote>, <vote slug="rheumatoid-arthritis-use">Moderate-to-severe rheumatoid arthritis (FDA)</vote>, <vote slug="osteoarthritis-use">Osteoarthritis (FDA)</vote>, <vote slug="ankylosing-spondylitis-use">Ankylosing spondylitis (FDA)</vote>, <vote slug="pseudogout-use">Calcium pyrophosphate deposition disease (pseudogout, off-label)</vote>, <vote slug="acute-migraine-indomethacin-use">Acute migraine and hemicrania continua (off-label; the latter is a uniquely indomethacin-responsive headache syndrome)</vote>, <vote slug="pda-closure-use">Patent ductus arteriosus closure in preterm neonates (FDA, IV; Indocin IV)</vote>
+| starting_dose     = Acute gout: 50 mg PO TID until symptom relief, then taper; maximum 200 mg/day for 3-5 days. Rheumatoid arthritis / osteoarthritis: 25-50 mg PO BID-TID. Patent ductus arteriosus: 0.2 mg/kg IV, then 0.1-0.2 mg/kg every 12-24 hours for 2 doses
+| preparations      = Capsules 25, 50 mg; ER capsules 75 mg; oral suspension 25 mg/5 mL; suppositories 50 mg; injection 1 mg/vial (PDA closure)
+| fda_max           = 200 mg/day (typical adult oral)
+| pill_id           =
+| routes            = Oral, rectal, intravenous (PDA closure only)
+| onset             = 30-60 minutes (oral); rapid relief in acute gout
+| duration          = 4-6 hours (IR); 24 hours (ER)
+| halflife          = 4-5 hours<ref name="indocin-label">FDA Prescribing Information, Indocin (indomethacin), Iroko/Egalet, current revision. https://www.accessdata.fda.gov/drugsatfda_docs/label/2016/018332s044lbl.pdf</ref>
+| bioavailability   = ~100% (oral)<ref name="indocin-label" />
+| pregnancy         = Avoid from 20 weeks gestation onward per FDA's 2020 expanded NSAID warning; contraindicated from 30 weeks (risk of premature ductus arteriosus closure, which is paradoxically the basis of the neonatal PDA-closure indication)<ref name="indocin-label" />
+| legal             = [[USLegal:Prescription only|Rx-only]] in US
+| mechanism         = <vote slug="indomethacin-mech-claim">Non-selective COX-1 and COX-2 inhibitor with '''high potency''' relative to other NSAIDs, the basis of its acute-gout efficacy and the uniquely indomethacin-responsive hemicrania continua syndrome. The PDA closure indication uses prostaglandin inhibition therapeutically: the ductus arteriosus stays patent via prostaglandin E1, and inhibiting its synthesis closes the shunt.</vote> Among the higher-cardiovascular-risk NSAIDs, with elevated GI bleeding risk compared to the class average. Notable for '''CNS adverse effects''' uncommon with other NSAIDs: paradoxical headache, dizziness, depression, and confusion in elderly patients (Beers-list concerns)<ref name="indocin-label" />.
 }}
+== References ==
+<references />
+[[Category:NSAIDs]]
+[[Category:Analgesics]]

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