Indomethacin (indomethacin)
Also sold as: Indocid, Indoflam, Intagesic, Indocin
Pregnancy
Cat C
Lactation
Caution
Schedule
H
Forms
Capsules 25 mg +4
Indications
- Acute gout attack — highly effective acute treatment
- Ankylosing spondylitis — chronic anti-inflammatory therapy
- Rheumatoid arthritis — acute flares and chronic management
- Osteoarthritis — pain and inflammation (short-term)
- Bursitis and tendinitis — acute musculoskeletal inflammation
- Patent ductus arteriosus (PDA) — IV formulation in neonates
- Pericarditis (refractory cases — off-label adjunct)
Adult Dosing
Acute gout attack
50 mg orally three times daily
For 3–5 days until acute attack resolves; then taper to 25 mg TDS for 2–3 days
One of the most potent NSAIDs for acute gout. Take with food to minimise GI side effects. Avoid in elderly, peptic ulcer disease, renal impairment, or cardiovascular disease. Naproxen or celecoxib preferred in patients at higher GI/CV risk.
Ankylosing spondylitis
25–50 mg orally three times daily; or sustained-release 75 mg once to twice daily
Long-term; use minimum effective dose
Indomethacin is particularly effective in ankylosing spondylitis (AS) — one of the few NSAIDs with evidence for slowing radiographic progression in AS. Monitor renal function, blood pressure, and GI status on long-term therapy. Add a PPI for GI protection.
Osteoarthritis and rheumatoid arthritis
25–50 mg orally two to three times daily
Shortest duration at lowest effective dose; reassess regularly
Reserved for cases not responding to less potent NSAIDs (ibuprofen, naproxen) due to higher toxicity profile.
Pediatric Dosing
Hold if urine output <0.6 mL/kg/hr. Monitor renal function. Not for standard paediatric use.
Renal Dose Adjustment
| CrCl / eGFR | Dose Adjustment |
|---|---|
| CrCl <30 mL/min | Avoid — NSAIDs reduce renal prostaglandin synthesis and can cause acute renal injury, sodium and water retention, and hyperkalaemia |
| CrCl ≥30 mL/min | Short-course use only (3–5 days) in mild CKD with close renal monitoring; avoid long-term use in any CKD |
Hepatic Adjustment
Use with caution in hepatic impairment — indomethacin is extensively hepatically metabolised. Avoid in severe hepatic disease. Risk of hepatotoxicity and fluid retention in decompensated cirrhosis.
Pregnancy & Lactation
Pregnancy: Category C
Category C in first and second trimesters — avoid if possible; use only when benefit clearly outweighs risk. Category D/X in the third trimester — premature closure of the ductus arteriosus; also associated with oligohydramnios (reduces fetal renal perfusion), fetal renal toxicity, and delayed parturition. Contraindicated after 30 weeks gestation. Before 30 weeks: short-term use only with fetal monitoring.
Lactation: Caution
Indomethacin is excreted in breast milk. Isolated reports of neonatal seizures in breastfed infants (neonates have reduced ability to metabolise indomethacin). Ibuprofen is preferred for nursing mothers as it has lower milk transfer and better safety data.
Top Drug Interactions
| Interacting Drug | Effect | Severity |
|---|---|---|
| Warfarin and anticoagulants | Indomethacin inhibits platelet aggregation and may cause GI bleeding; combined with anticoagulants, this significantly increases haemorrhagic risk. Also displaces warfarin from protein binding — raises INR. Monitor INR closely; avoid combination if possible | Major |
| Lithium | NSAIDs reduce renal prostaglandin synthesis, decrease lithium excretion, and increase serum lithium levels by 25–60% — lithium toxicity risk (tremor, confusion, arrhythmia). Monitor lithium levels closely or use sulindac (least interaction among NSAIDs) | Major |
| Aspirin (concurrent anti-platelet dose) | Indomethacin competes with aspirin for COX-1 binding, reducing the antiplatelet effect of aspirin. Combined use also significantly increases GI bleeding risk | Major |
| ACE inhibitors and ARBs | NSAIDs blunt the antihypertensive effect (prostaglandin-mediated renal mechanism) and combined with ACEi/ARB increase nephrotoxicity risk — avoid in CKD; monitor blood pressure and renal function | Moderate |
| SSRIs (fluoxetine, sertraline, escitalopram) | Additive risk of GI bleeding — SSRIs deplete platelet serotonin (impair platelet aggregation) and combined with NSAID GI toxicity significantly increases upper GI haemorrhage risk; add PPI if combination unavoidable | Moderate |
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Side Effects
Common
- Gastrointestinal upset, nausea, dyspepsia (most common — take with food)
- Headache (including frontal headache — indomethacin-specific; may be dose-limiting)
- Dizziness and lightheadedness
- Fluid retention and ankle oedema
- Elevated blood pressure
- Peptic ulceration (with long-term or high-dose use)
Serious / Discontinue If
- Gastrointestinal bleeding and peptic ulceration — high GI toxicity (one of the highest among NSAIDs); use PPI concomitantly
- Acute kidney injury — especially in volume-depleted patients, elderly, and CKD
- Cardiovascular events (MI, stroke) — all NSAIDs carry CV risk; higher with indomethacin at high doses or prolonged use
- Hypersensitivity reactions — bronchospasm, anaphylaxis (especially in aspirin-sensitive asthma patients)
- CNS effects — headache, dizziness, confusion, psychiatric disturbances (indomethacin crosses blood-brain barrier more than other NSAIDs)
- Hepatotoxicity (rare)
- Neonatal PDA use: renal impairment, oliguria, necrotising enterocolitis, intracranial haemorrhage (monitor closely)
Contraindications
- Active peptic ulcer disease or GI bleeding history
- Aspirin-exacerbated respiratory disease (NSAID-sensitive asthma, urticaria)
- Severe renal impairment (CrCl <30 mL/min)
- After 30 weeks of pregnancy (premature ductus arteriosus closure)
- Severe heart failure
- Post-operative pain management in CABG surgery
- Hypersensitivity to indomethacin or any NSAID
- Concurrent anticoagulant use (relative contraindication — avoid if possible)
Available Indian Brands
| Brand | Manufacturer | Price (approx) |
|---|---|---|
| Indocid 25 mg Capsules | MSD India | ₹28/10 capsules |
| Indoflam 25 mg Capsules | Cipla | ₹22/10 capsules |
| Intagesic 25 mg Capsules | Elder Pharmaceuticals | ₹18/10 capsules |
Monitoring Required
- Renal function (serum creatinine, eGFR, urine output) — before starting, after 1–2 weeks, and periodically during use
- Blood pressure — NSAIDs can raise blood pressure; monitor especially in hypertensive patients
- Haematocrit and faecal occult blood — for GI bleeding (especially with long-term use)
- Liver function tests — with prolonged use
- Electrolytes (potassium) — NSAIDs can cause hyperkalaemia, especially with ACEi/ARB or in CKD
- Neonatal PDA monitoring: urine output (hold if <0.6 mL/kg/hour), serum creatinine, BUN, platelet count, blood glucose
- Gout uric acid levels — indomethacin controls the attack but does not lower uric acid; initiate urate-lowering therapy separately
Patient Counseling Points
- Always take indomethacin with food or immediately after a meal — this reduces stomach upset and irritation.
- Do not lie down for at least 30 minutes after taking this medicine.
- Take this medicine for the shortest time needed — it is particularly strong and has more side effects than other pain medicines.
- Avoid alcohol while taking indomethacin — it greatly increases the risk of stomach bleeding.
- Tell your doctor immediately if you notice black tarry stools, vomit that looks like coffee grounds, or severe stomach pain — these may be signs of internal bleeding.
- Do not take aspirin or other pain medicines (ibuprofen, diclofenac) at the same time as indomethacin without your doctor's advice.
- If you have high blood pressure, heart disease, or kidney problems, discuss with your doctor before taking this medicine.
- For swallowing difficulty: the suppository (rectal) form is available and avoids stomach irritation.
- Indomethacin treats the pain of a gout attack but does not lower your uric acid levels — you will need a separate medicine (allopurinol/febuxostat) for long-term gout management.
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Clinically reviewed by: Dr. Pradeep Sharma, MD (Medicine), DM (Rheumatology), Consultant Rheumatologist
Last reviewed: 2026-04-15
References
- Schumacher HR Jr, et al. Randomised double-blind trial of etoricoxib and indomethacin in treatment of acute gouty arthritis. BMJ. 2002;324(7352):1488–1492.
- Zochling J, et al. ASAS/EULAR recommendations for the management of ankylosing spondylitis. Ann Rheum Dis. 2006;65(4):442–452.
- Van Overmeire B, et al. A comparison of ibuprofen and indomethacin for closure of patent ductus arteriosus. N Engl J Med. 2000;343(10):674–681.
- MSD India. Indocid prescribing information. 2024.