Is indomethacin (Nonsteroidal Anti-Inflammatory Drug (NSAID)) effective for treating pericarditis?

Indomethacin for Pericarditis

Indomethacin is effective for treating pericarditis but should be avoided in elderly patients due to its adverse effects on coronary blood flow; ibuprofen is the preferred NSAID for most patients. 1

First-Line NSAID Selection

Ibuprofen is the preferred NSAID for pericarditis treatment over indomethacin due to its superior safety profile, favorable impact on coronary flow, and wide dose range (600 mg every 8 hours, range 1200-2400 mg/day). 1, 2

Why Indomethacin is Less Preferred

• Indomethacin should be avoided in elderly patients because it reduces coronary blood flow, which poses particular risk in this population. 1
• When indomethacin is used, dosing is 25-50 mg every 8 hours (75-150 mg/day total), starting at the lower end to avoid headache and dizziness. 1
• The drug has a narrower therapeutic window and more frequent side effects compared to ibuprofen. 1

Complete Treatment Algorithm

Initial Therapy (All Patients)

NSAIDs plus colchicine is the recommended first-line combination for acute pericarditis. 2

• Aspirin 750-1000 mg every 8 hours OR Ibuprofen 600 mg every 8 hours (preferred) for 1-2 weeks with gastroprotection. 2
• Add colchicine at weight-adjusted doses: 0.5 mg once daily if <70 kg or 0.5 mg twice daily if ≥70 kg for 3 months. 2
• Continue treatment until symptoms resolve and C-reactive protein (CRP) normalizes. 2

Tapering Strategy

• Taper NSAIDs gradually: decrease aspirin by 250-500 mg every 1-2 weeks or ibuprofen by 200-400 mg every 1-2 weeks. 1, 2
• For indomethacin specifically, decrease by 25 mg every 1-2 weeks. 1
• Only attempt tapering when symptoms are absent and CRP is normal. 2

When Indomethacin May Be Considered

Despite being less preferred, indomethacin remains an acceptable NSAID option in younger patients without coronary disease when ibuprofen or aspirin are contraindicated or not tolerated. 1

Specific Dosing for Indomethacin

• Start at 25 mg every 8 hours and titrate upward to avoid headache and dizziness. 1
• Maximum dose: 50 mg every 8 hours (150 mg/day total). 1
• Continue for weeks to months based on clinical response. 1

Evidence Quality Considerations

The 2015 European Society of Cardiology guidelines (the most recent and authoritative source) explicitly state that ibuprofen is preferred over indomethacin, while the 2004 guidelines more strongly cautioned against indomethacin in elderly patients. 1 Both guideline iterations consistently recommend NSAIDs as Class I, Level B evidence for pericarditis treatment. 1

Research evidence supports NSAID efficacy broadly, with meta-analyses showing that colchicine plus NSAIDs reduces recurrence (OR 0.37; 95% CI 0.27-0.51). 3 However, no randomized trials have specifically compared indomethacin to other NSAIDs head-to-head. 3, 4

Critical Pitfalls to Avoid

• Do not use indomethacin as first-line in elderly patients or those with coronary artery disease due to coronary flow reduction. 1
• Do not use NSAIDs alone without colchicine as this increases recurrence risk from 30% to 15%. 2, 4
• Do not undertaper or stop treatment prematurely before CRP normalization, as inadequate treatment duration is the most common cause of recurrence. 2, 5
• In myopericarditis specifically, some experts recommend reducing NSAID dosages compared to pure pericarditis, though this remains controversial. 1

Special Populations

Uremic Pericarditis

Indomethacin showed no benefit for uremic pericarditis beyond fever reduction in a controlled trial; it did not affect chest pain duration, pericardial rub duration, effusion size, or need for surgical intervention. 6 This represents a specific contraindication to indomethacin use.

Myopericarditis

When myocardial involvement is present, consider dose reduction of all NSAIDs (including indomethacin) as animal models suggest potential harm, though human applicability is uncertain. 1