Regimen of indomethacin therapy in acute gouty arthritis.

Though colchicine has been famed for centuries for its effect in acute gouty arthritis its relief of pain and inflammation in this condition is not invariable and may not be apparent for 24 hours or more. It was therefore not surprising that when phenylbutazone was introduced colchicine was largely replaced by this preparation, which was more certain in its action. Highdosage phenylbutazone therapy, however, was occasionally associated with marrow depression (Mauer, 1955). In 1963 indomethacin was reported to be an effective anti-inflammatory agent in a number of rheumatic diseases (Katz et al., 1963; Norcross, 1963 ; Rothermrich, 1963). In acute gouty arthritis Hart and Boardman (1963) reported favourable results with the use of 300 mg. of indomethacin given in divided doses during the first 24 hours, with a gradual subsequent reduction to 100-150 mg. daily. The dose was varied from day to day according to the response, and treatment was continued for at least five days, or longer if symptoms persisted. Smyth et al. (1963) also obtained good results with indomethacin in acute gouty arthritis, using doses of 600-900 mg. on the first day and 400 mg. daily in divided doses during the next three to five days. It therefore seemed that indomethacin was useful in acute gouty arthritis, but that dosage schedules varied widely and needed frequent review. Thus there seemed a need for a standardized regimen of treatment which would be uniformly successful but simple enough to leave in the hands either of patients or of nursing staff without constant supervision, and which would vary inherently with the severity of the gout and the response. Such a schedule might well be comparable to the usual schedule of oral colchicine treatment, in which the dosage varied with the response and toxic effects. The above considerations therefore led to the choice of the following therapeutic regimen: 100 mg. of indomethacin four-hourly until most pain was relieved, then 100 mg. eight-hourly for 24 hours, then 75 mg. eight-hourly for 24 hours, and then 50 mg. eighthourly for 24 hours. This regimen was tested for effectiveness in patients with acute gouty arthritis. At the same time undesirable side-effects were sought and opportunities were taken to determine whether improvement in the regimen, such as a reduction in dosage, was possible.