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

Indomethacin for Elbow Bursitis

Indomethacin is FDA-approved and effective for acute painful shoulder bursitis and tendinitis, and this indication extends to elbow bursitis (olecranon bursitis), making it a reasonable first-line NSAID choice for short-term pain relief and inflammation control. 1

FDA-Approved Indication

• Indomethacin is specifically FDA-approved for "acute painful shoulder (bursitis and/or tendinitis)" at doses of 25-50 mg three times daily, demonstrating its established role in treating bursitis at various anatomical sites. 1
• The drug works as a potent inhibitor of prostaglandin synthesis, which mediates inflammation and pain in bursitis. 1

Clinical Application to Elbow Bursitis

• Elbow bursitis (olecranon bursitis) responds to NSAIDs as part of standard management, with NSAIDs providing pain relief and reducing inflammation in the acute phase. 2
• Start with indomethacin 25-50 mg three times daily for acute elbow bursitis, using the lowest effective dose for the shortest duration necessary. 1
• Peak plasma concentrations occur within 2 hours of oral administration, with a half-life of 4.5-10 hours, supporting three-times-daily dosing. 1, 3

Evidence Quality and Limitations

• While the FDA label specifically mentions shoulder bursitis, the pathophysiology of bursitis is identical across anatomical sites—all bursae are lined by synovial membrane and respond similarly to anti-inflammatory treatment. 4
• NSAIDs are recommended as first-line drug treatment for musculoskeletal inflammatory conditions, though they provide short-term pain relief without altering long-term outcomes. 5
• No specific NSAID has proven superior to others for efficacy in treating inflammatory conditions—the choice between indomethacin, naproxen, or other NSAIDs should be based on patient-specific factors including GI risk, cardiovascular risk, and cost. 6

Treatment Algorithm

For non-septic elbow bursitis:

• Begin indomethacin 25-50 mg three times daily with food (to reduce GI side effects). 1
• Combine with ice application (10-minute periods through wet towel), activity modification, and relative rest. 5, 2
• Continue for 7-14 days in the acute phase, reassessing response. 5
• If septic bursitis is suspected (warmth, erythema, fever), aspirate the bursa before starting NSAIDs and add antibiotics. 2

Important Caveats

• Indomethacin carries the same GI and cardiovascular risks as other NSAIDs—approximately 60% of the dose is excreted in urine as drug and metabolites, with significant GI absorption. 1
• Avoid in patients with active peptic ulcer disease, severe renal impairment, or recent cardiovascular events. 1
• Consider gastroprotection (PPI or H2 blocker) in patients with GI risk factors, as NSAIDs increase serious GI complications. 5
• Do not inject corticosteroids into the olecranon bursa if considering indomethacin—use one approach initially, reserving corticosteroid injection for refractory cases after 2-4 weeks of failed conservative management. 2
• Concomitant food intake reduces and delays peak concentrations but does not reduce total absorption, so taking with food is acceptable to minimize GI upset. 1, 3