From the Guidelines
The treatment for uncomplicated pericarditis primarily involves anti-inflammatory medications to reduce inflammation and relieve symptoms, with a combination of colchicine and a non-steroidal anti-inflammatory drug (NSAID) as first-line therapy. The choice of NSAID should be based on the patient's history, concomitant diseases, and physician expertise, with ibuprofen (600 mg every 8 hours) or aspirin (750-1000 mg every 8 hours) being preferred options, given for 1-2 weeks then tapered over 1-2 additional weeks 1. Colchicine should be administered at 0.5 mg twice daily (or 0.5 mg once daily for patients <70 kg) for 3 months to reduce the risk of recurrence, as recommended by the 2015 ESC guidelines 1.
Key Considerations
- Gastrointestinal protection with a proton pump inhibitor like omeprazole 20 mg daily is recommended while taking NSAIDs to prevent gastrointestinal complications 1.
- For patients with contraindications to NSAIDs (such as renal failure, gastric ulcers, or bleeding disorders), acetaminophen can be used for pain control 1.
- Corticosteroids (prednisone 0.25-0.5 mg/kg/day) should be reserved for cases that are refractory to NSAIDs and colchicine, or for specific indications like autoimmune pericarditis, due to the risk of favouring the chronic evolution of the disease and promoting drug dependence 1.
- Rest and activity restriction, particularly avoiding strenuous physical activity, is advised until symptoms resolve and inflammatory markers normalize, typically for 3 months, with a minimal restriction of 3 months recommended for athletes 1.
Treatment Rationale
The treatment approach is based on the pathophysiology of pericarditis, with NSAIDs blocking prostaglandin synthesis and colchicine disrupting microtubule assembly and leukocyte function to suppress the inflammatory response in the pericardium 1. The use of colchicine as an adjunct to aspirin/NSAID therapy is supported by the 2015 ESC guidelines, which recommend its use to improve the response to medical therapy and prevent recurrences 1.
From the Research
Treatment Options for Uncomplicated Pericarditis
- Aspirin and non-steroidal anti-inflammatory drugs (NSAIDs) are the mainstay of therapy for uncomplicated pericarditis, with colchicine as a possible adjunct, especially for recurrences 2, 3, 4, 5.
- Corticosteroids are considered a second choice for difficult cases requiring multi-drug therapies and specific medical conditions, such as systemic autoimmune diseases, postpericardiotomy syndrome, and pregnancy 2, 3, 4, 6.
- Colchicine is necessary to relieve symptoms and reduce the rate of recurrences, and should be continued for at least 3-6 months 3, 4.
- Interleukin-1 blockers, such as anakinra, rilonacept, and goflikicept, may be used as a third-line option in patients who cannot come off glucocorticoids or as second-line therapy after NSAIDs and colchicine in patients with contraindications to glucocorticoids or high-risk features 3, 4.
Treatment Approach
- Medical therapy of pericarditis should be individualized, providing the attack dose every 8 hours to ensure full daily control of symptoms and till remission and C-reactive protein normalization, and then tapering should be considered 2.
- Treatment with NSAIDs and colchicine leads to a favorable prognosis in most patients, although 15% to 30% of patients develop recurrence 4.
- Patients with multiple recurrent pericarditis can have a disease duration of several years or more, and may be treated with corticosteroids, with IL-1 blockers as a possible alternative 4, 6.
Specific Considerations
- Low- to moderate-dose glucocorticoids may be reserved for patients with a first recurrence for which NSAIDs and colchicine failed and/or who have an autoimmune disorder, with slow tapering 3, 4.
- Steroids at low dose may not act as an independent risk factor for recurrences, and therefore may be considered a successful and safe treatment for acute and recurrent idiopathic pericarditis 6.