What is the role of indomethacin (Nonsteroidal Anti-Inflammatory Drug (NSAID)) in treating pericarditis?

Role of Indomethacin in Treating Pericarditis

Indomethacin is an effective NSAID for treating pericarditis, but should be avoided in elderly patients due to its coronary flow reduction effects, with ibuprofen being the preferred NSAID for pericarditis treatment. 1

First-Line Treatment Options for Pericarditis

NSAIDs are the mainstay of treatment for acute pericarditis, with specific recommendations:

• Preferred NSAID options:

  • Ibuprofen: 1200-2400 mg/day (preferred due to rare side effects, favorable impact on coronary flow, and flexible dosing) 1, 2
  • Aspirin: 1500-3000 mg/day (especially indicated in post-myocardial infarction pericarditis) 2, 3
  • Indomethacin: 75-150 mg/day 2

• Important dosing considerations:

  • Initial high doses may be required (e.g., ibuprofen 300-800 mg every 6-8 hours) 1
  • Continue treatment until effusion disappears 1
  • Always provide gastrointestinal protection 1

Limitations of Indomethacin Use

Despite being effective, indomethacin has specific limitations:

• Contraindicated in elderly patients due to its reduction of coronary blood flow 1
• May have more side effects compared to ibuprofen 1, 3
• Should be used with caution in patients with coronary artery disease 1

Comprehensive Treatment Approach

For optimal management of pericarditis:

1. First-line therapy: NSAIDs (preferably ibuprofen) plus colchicine

   • Colchicine (0.5 mg twice daily for patients ≥70kg or 0.5 mg daily for patients <70kg) should be added to NSAIDs or used as monotherapy 1, 2
   • Colchicine is effective for both initial attack and prevention of recurrences 1

2. Treatment duration:

   • Continue until complete symptom resolution and normalization of CRP 2
   • Maintain therapy until pericardial effusion disappears 1
   • Taper medications gradually, removing NSAIDs first while maintaining colchicine for the full duration 2

3. For refractory cases:

   • Corticosteroids should be restricted to specific cases (connective tissue diseases, autoreactive or uremic pericarditis) 1
   • Intrapericardial application of corticosteroids can avoid systemic side effects 1
   • For frequent symptomatic recurrences, consider balloon pericardiotomy or pericardiectomy 1

Monitoring and Follow-up

• Regular echocardiographic assessment to evaluate pericardial thickness and ventricular filling patterns 2
• Track CRP levels to guide treatment duration 2
• Monitor for recurrences or development of constrictive pericarditis 1

Special Considerations

• Hospitalization is warranted for determining etiology and observing for tamponade 1
• Pericardiocentesis is indicated for cardiac tamponade (life-saving) and for effusions >20 mm in echocardiography 1, 2
• In cases with myocardial involvement, rest and avoidance of physical activity for at least 6 months is recommended 2

Pitfalls to Avoid

• Premature discontinuation of therapy before complete resolution of symptoms and normalization of inflammatory markers
• Using corticosteroids as first-line therapy (associated with higher recurrence rates) 2, 3
• Failing to add colchicine to NSAIDs (increases risk of recurrence from 15-30% to 8-15%) 2
• Using indomethacin in elderly patients or those with coronary artery disease 1