Is indomethacin (Nonsteroidal Anti-Inflammatory Drug (NSAID)) a good option for treating pericarditis, considering potential gastrointestinal side effects and renal impairment?

Is Indomethacin a Good Option for Pericarditis?

Indomethacin is NOT recommended as a first-line NSAID for pericarditis and should be avoided entirely in elderly patients and those with coronary artery disease due to its adverse effects on coronary blood flow. 1, 2

First-Line NSAID Selection

Ibuprofen is the preferred NSAID for pericarditis treatment due to its superior safety profile, favorable impact on coronary flow, and wide dosing range (600 mg every 8 hours, total 1200-2400 mg/day). 2 Aspirin (750-1000 mg every 8 hours) is an acceptable alternative, particularly in post-myocardial infarction or post-cardiac surgery settings. 3, 4

Why Indomethacin Should Be Avoided

• Indomethacin reduces coronary blood flow, creating particular risk in elderly patients and those with coronary artery disease. 1, 2
• The 2015 European Society of Cardiology guidelines explicitly state that "indomethacin is not indicated" in elderly patients. 1
• While indomethacin can be dosed at 25-50 mg every 8 hours (75-150 mg/day total), it should only be considered in younger patients without coronary disease when ibuprofen or aspirin are contraindicated or not tolerated. 2

Gastrointestinal and Renal Considerations

Gastrointestinal Risk

All NSAIDs, including indomethacin, carry significant GI risks:

• NSAIDs cause serious GI adverse events including bleeding, ulceration, and perforation that can be fatal and occur without warning. 5
• Upper GI ulcers, gross bleeding, or perforation occur in approximately 1% of patients treated for 3-6 months and 2-4% treated for one year. 5
• Gastroprotection with H2 blockers or proton pump inhibitors is mandatory when using any NSAID for pericarditis. 1, 3
• Patients with prior peptic ulcer disease or GI bleeding have a greater than 10-fold increased risk for GI bleeding. 5

Renal Impairment

• NSAIDs can cause dose-dependent reduction in renal blood flow and precipitate acute renal decompensation in patients with compromised renal function. 5
• Long-term NSAID administration has resulted in renal papillary necrosis and other renal injury. 5
• In patients with moderate-to-severe renal impairment, aspirin becomes the preferred NSAID with appropriate dose adjustments, and colchicine requires substantial dose reduction (0.5 mg once daily for CrCl 30-50 mL/min; 0.3 mg once daily for CrCl <30 mL/min). 3, 4

Recommended Treatment Algorithm

Standard Approach (No Contraindications)

1. Ibuprofen 600 mg every 8 hours PLUS colchicine (0.5 mg once daily if <70 kg or twice daily if ≥70 kg) for 3 months. 3, 2
2. Add gastroprotection with H2 blocker or proton pump inhibitor. 1, 3
3. Continue until symptoms resolve and CRP normalizes. 3
4. Taper ibuprofen by 200-400 mg every 1-2 weeks only after complete symptom resolution. 2

With Renal Impairment

1. Aspirin 750-1000 mg every 8 hours with gastroprotection PLUS renally-adjusted colchicine. 3, 4
2. Monitor renal function closely throughout treatment. 5

With NSAID Contraindications

1. Low-dose corticosteroids (prednisone 0.2-0.5 mg/kg/day) as second-line therapy after excluding infectious causes. 3, 4
2. Corticosteroids are NOT first-line due to increased risk of chronicity and recurrence. 3, 2

Critical Pitfalls to Avoid

• Never use indomethacin in elderly patients or those with coronary disease due to coronary flow reduction. 1, 2
• Never use NSAIDs alone without colchicine, as this increases recurrence risk (colchicine reduces recurrence with OR 0.37; 95% CI 0.27-0.51). 2, 6
• Never taper NSAIDs before CRP normalization and complete symptom resolution, as inadequate treatment duration is the most common cause of recurrence. 3, 2
• Never use corticosteroids as first-line therapy unless NSAIDs are contraindicated, as they promote chronicity and increase recurrence rates. 3, 2
• Monitor for cardiovascular thrombotic events, as NSAIDs increase risk of myocardial infarction and stroke, particularly in post-MI patients. 5