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Non-selective NSAID Pregnancy: Contraindicated in third trimester; avoid in first trimester; specialist supervision only in second trimester

Indomethacin

Brand names: Indocid

Adult dose

Dose: 25–50 mg two to three times daily; Acute gout: 50 mg TDS; HO prevention: 25 mg TDS for 6 weeks
Route: Oral or PR suppository
Frequency: Two to three times daily
Max: 200 mg/day
Take with food; PR route useful when oral not tolerated; HO prevention: start within 24 hours of arthroplasty; take for full prescribed course even if pain improves

Paediatric dose

Dose: 0.5–1 mg/kg
Route: Oral/PR
Frequency: Two to three times daily
Max: 3 mg/kg/day or 150–200 mg/day
IV indomethacin used neonatally for PDA closure — entirely different clinical context

Dose adjustments

Renal

Avoid if eGFR <30 mL/min; use with caution in mild-moderate impairment

Hepatic

Avoid in severe hepatic impairment

Paediatric weight-based calculator

IV indomethacin used neonatally for PDA closure — entirely different clinical context

Clinical pearls

  • Heterotopic ossification (HO) prevention post-THR: 25 mg TDS for 6 weeks started within 24 hours of surgery — most studied NSAID for this indication; alternative to radiation therapy; evidence from multiple RCTs; BSSH/BOA guidelines support use
  • Acute gout: 50 mg TDS is the traditional first-line NSAID — rapid onset; reduce to 25 mg TDS as symptoms resolve; typically 5–7 days; now often replaced by etoricoxib due to fewer GI side effects but indomethacin remains widely used
  • Highest GI toxicity among NSAIDs — use with PPI gastric protection especially in elderly, anticoagulant users, or patients with prior GI history; avoid in patients already on aspirin
  • CNS effects: headache, dizziness, and cognitive effects more common with indomethacin than other NSAIDs due to higher CNS penetration — warn patients about driving impairment
  • PR suppository 100 mg: bioequivalent to oral route — useful post-operatively when oral not tolerated; reduces first-pass variation

Contraindications

  • Active peptic ulcer
  • History of GI bleeding
  • Severe renal or hepatic impairment
  • NSAID hypersensitivity
  • Aspirin-sensitive asthma
  • Third trimester pregnancy

Side effects

  • GI upset (highest GI toxicity among NSAIDs)
  • Headache
  • Dizziness
  • GI bleeding
  • Renal impairment
  • Oedema
  • Elevated LFTs

Interactions

  • Anticoagulants — increased bleeding risk
  • ACE inhibitors/ARBs — AKI triad risk
  • Diuretics — reduced efficacy
  • Lithium — increased levels
  • Methotrexate — reduced renal clearance and toxicity

Monitoring

  • Renal function (U&E) if use exceeds 2 weeks
  • BP
  • GI symptoms
  • Haemoglobin if long-term
  • Pain score

Reference: BNFc; BNF 90; NICE CG177 (Gout); BOA/BSSH HO prevention guidelines; SPC Indocid; Cochrane Review (NSAIDs for HO prevention). Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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