From the Guidelines
The treatment of pericarditis should primarily focus on reducing inflammation and managing symptoms, with first-line therapy consisting of a combination of colchicine and an NSAID, such as ibuprofen or aspirin, for 1-2 weeks, followed by gradual tapering over 2-3 weeks, as recommended by the 2015 ESC guidelines 1. The choice of NSAID should be based on the patient's history, concomitant diseases, and physician expertise, with aspirin being preferred in patients with coronary artery disease. Colchicine should be continued for a total of 3 months for first episodes and 6 months for recurrent cases to prevent relapse.
- Key considerations in the management of pericarditis include:
- Restricting physical activity until symptoms resolve and inflammatory markers normalize
- Monitoring treatment efficacy through symptom improvement and normalization of inflammatory markers like C-reactive protein
- Using low-dose corticosteroids in patients with contraindications to NSAIDs, such as renal failure or gastrointestinal bleeding, and tapering them slowly to prevent recurrence
- Considering the use of drugs such as IVIG, anakinra, and azathioprine in cases of corticosteroid-dependent recurrent pericarditis
- Exercise restriction for a minimum of 3 months in athletes with recurrent pericarditis until symptom resolution and normalization of CRP, ECG, and echocardiogram. The medications used in the treatment of pericarditis work by inhibiting inflammatory pathways, with NSAIDs blocking cyclooxygenase enzymes and colchicine disrupting microtubule formation and reducing neutrophil activity in the inflamed pericardium 1.
From the Research
Treatment Options for Pericarditis
- The mainstay of therapy for acute and recurrent pericarditis includes aspirin and non-steroidal anti-inflammatory drugs (NSAID), with the possible adjunct of colchicine, especially for recurrences 2.
- Corticosteroids are a second choice for difficult cases requiring multi-drug therapies and specific medical conditions, such as systemic autoimmune diseases, postpericardiotomy syndrome, and pregnancy 2.
- Colchicine has been shown to be effective in reducing the number of pericarditis recurrences in patients with recurrent pericarditis or acute pericarditis, and is often used in conjunction with NSAIDs 3.
- 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 4.
Treatment Approach
- The treatment approach for pericarditis should be individualized, with the goal of providing full daily control of symptoms and achieving remission and C-reactive protein normalization 2.
- High-dose NSAIDs are typically used to treat acute pericarditis, with doses tapered rapidly once symptoms are controlled 5, 4.
- Colchicine is often continued for at least 3-6 months to reduce the rate of recurrences 5, 4.
- 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 a slow tapering 4.
Recurrence Prevention
- Colchicine has been shown to reduce the risk of recurrence in patients with acute and recurrent pericarditis 3.
- The use of colchicine in addition to NSAIDs has been shown to reduce the rate of recurrences at 6,12, and 18 months 3.
- Interleukin-1 blockers may be used to prevent recurrences in patients with multiple resistant recurrences 4.