What is the recommended dose of indomethacin (Non-Steroidal Anti-Inflammatory Drug (NSAID)) for treating pericarditis?

Indomethacin Dosing for Pericarditis

For pericarditis, start indomethacin at 25 mg every 8 hours (75 mg/day total) and titrate upward to a maximum of 50 mg every 8 hours (150 mg/day total) as needed for symptom control, but recognize that ibuprofen is the preferred NSAID due to indomethacin's adverse effect on coronary blood flow. 1, 2

Initial Dosing Strategy

• Start at the lower end of the dosing range (25 mg every 8 hours) to minimize side effects, particularly headache and dizziness which are common with indomethacin 1, 2
• Titrate upward toward 50 mg every 8 hours only if symptoms are not adequately controlled at the lower dose 1, 2
• The total daily dose range is 75-150 mg/day divided into three doses 2

Treatment Duration and Tapering

• Continue treatment for weeks to months until symptoms resolve and C-reactive protein (CRP) normalizes 1
• Taper by decreasing the dose by 25 mg every 1-2 weeks once symptoms are absent and CRP is normal 1, 2
• Longer tapering periods may be necessary for difficult or resistant cases 1
• Never attempt tapering while symptoms persist or CRP remains elevated, as premature discontinuation is a major cause of recurrence 1, 2, 3

Critical Considerations: Why Indomethacin Is NOT First-Line

• Indomethacin reduces coronary blood flow and should be avoided in elderly patients and those with coronary artery disease 2
• The European Society of Cardiology explicitly recommends ibuprofen (600 mg every 8 hours) as the preferred NSAID due to its superior safety profile and favorable impact on coronary flow 2, 3
• Indomethacin may only be considered in younger patients without coronary disease when ibuprofen or aspirin are contraindicated or not tolerated 2

Mandatory Adjunctive Therapy

• Always add colchicine to any NSAID regimen at weight-adjusted doses: 0.5 mg once daily if <70 kg or 0.5 mg twice daily if ≥70 kg for at least 3 months 1, 2, 3
• Colchicine reduces recurrence risk from 37.5% to 16.7% (absolute risk reduction 20.8%) when added to NSAIDs 4, 5
• Use gastroprotection with all NSAID therapy 3

Common Pitfalls to Avoid

• Do not use indomethacin as first-line therapy—ibuprofen is safer and equally effective 2
• Do not use NSAIDs as monotherapy without colchicine, as this dramatically increases recurrence rates 2, 3
• Do not stop treatment before CRP normalization, even if symptoms improve, as inadequate treatment duration is the most common cause of recurrence 2, 3
• Do not use indomethacin in elderly patients or those with known coronary disease due to coronary flow reduction 2

When to Escalate Therapy

• If symptoms persist despite appropriate NSAID doses and colchicine, consider adding low-dose corticosteroids (prednisone 0.2-0.5 mg/kg/day) as triple therapy rather than replacing NSAIDs 1
• Corticosteroids should not be first-line as they promote chronicity and increase recurrence rates 1, 3