What is the treatment for pericarditis?

From the Guidelines

The treatment of pericarditis should primarily focus on relieving symptoms and addressing the underlying cause, with first-line therapy including nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or aspirin, along with colchicine, 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 or ibuprofen being commonly prescribed at doses of 750-1000 mg every 8 hours for 1-2 weeks, followed by gradual tapering over 2-4 weeks 1. Colchicine should be added to NSAIDs at a dose of 0.5 mg twice daily for patients >70 kg or 0.5 mg once daily for patients <70 kg, for 3 months in acute cases and 6 months for recurrent cases to reduce recurrence risk 1. Gastrointestinal protection with proton pump inhibitors like omeprazole 20 mg daily is recommended during NSAID treatment 1. For patients with contraindications to NSAIDs or refractory cases, corticosteroids like prednisone may be used, but should be tapered slowly to prevent recurrence, with a recommended dose of 0.25-0.5 mg/kg/day 1. Some key points to consider in the treatment of pericarditis include:

• Rest and activity restriction, particularly avoiding competitive sports until resolution of symptoms and normalization of inflammatory markers, is important 1.
• Treatment should be continued until complete resolution of symptoms and normalization of inflammatory markers (C-reactive protein) 1.
• Specific causes of pericarditis, such as bacterial infections, require targeted therapy with appropriate antibiotics 1.
• Colchicine therapy of longer duration (> 6 months) should be considered in some cases, according to clinical response 1.
• Exercise restriction for a minimum of 3 months should be considered for athletes with recurrent pericarditis until symptom resolution and normalization of CRP, ECG, and echocardiogram 1.

From the Research

Treatment Options for Pericarditis

• Aspirin and non-steroidal anti-inflammatory drugs (NSAIDs) are the mainstay of therapy for acute and recurrent pericarditis, with colchicine as a possible adjunct, 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.
• Low- to moderate-dose glucocorticoids are reserved for patients with a first recurrence for which NSAIDs and colchicine failed and/or who have an autoimmune disorder, with a slow tapering 3.

Role of Colchicine in Pericarditis Treatment

• Colchicine has been shown to reduce episodes of pericarditis in people with recurrent pericarditis over 18 months follow-up, with a number needed to treat (NNT) of 4 4.
• Colchicine also reduces recurrence in people with acute pericarditis, with moderate quality evidence 4.
• Colchicine is effective in reducing the number of pericarditis recurrences in patients with recurrent pericarditis or acute pericarditis, as adjunctive therapy to NSAIDs 4, 5.

Use of Glucocorticoids and Other Agents

• Glucocorticoids, especially at high-dose, have been associated with a higher recurrence rate, but low-dose glucocorticoids may be considered a successful and safe treatment for acute and recurrent idiopathic pericarditis 6.
• Anti-interleukin-1 agents, such as anakinra and rilonacept, are effective in reducing recurrences in patients with recurrent pericarditis refractory to conventional drugs 5.
• Immunoglobulins and immunosuppressive agents may also be considered in the treatment of pericarditis, although their efficacy is less well-established 5.

Treatment Approach

• Medical therapy of pericarditis should be individualized, providing the attack dose every 8 h to ensure full daily control of symptoms and till remission and C-reactive protein normalization, and then tapering should be considered 2.
• A correct pharmacological management of pericarditis is key to prevent recurrences, with colchicine as the mainstay of treatment in acute and recurrent pericarditis 5.