From the Guidelines
The first-line medication treatment for pericarditis consists of a combination of aspirin or non-steroidal anti-inflammatory drugs (NSAIDs) plus colchicine, as recommended by the 2015 ESC guidelines 1.
Medication Details
- For NSAIDs, ibuprofen (600-800 mg every 8 hours) or indomethacin (25-50 mg every 8 hours) are commonly used, while aspirin can be given at 750-1000 mg every 8 hours.
- Colchicine should be added at 0.5-0.6 mg twice daily (or 0.5-0.6 mg once daily for patients <70 kg) for 3 months to reduce recurrence risk, as stated in the guidelines 1.
Key Considerations
- Gastric protection with a proton pump inhibitor should be considered when using NSAIDs or aspirin.
- These medications work by reducing inflammation in the pericardium - NSAIDs inhibit cyclooxygenase enzymes that produce inflammatory mediators, while colchicine disrupts microtubule formation and leukocyte function.
- For patients with contraindications to NSAIDs (such as renal failure, gastric ulcers, or bleeding disorders), acetaminophen can be used for pain control, and early consideration of low-dose corticosteroids may be necessary, though these are generally reserved for refractory cases or specific etiologies.
Treatment Duration and Monitoring
- Treatment should be continued until symptoms resolve, typically 1-2 weeks, followed by a gradual taper over 2-4 weeks.
- Serum CRP should be considered to guide the treatment duration and assess the response to therapy, as recommended in the guidelines 1.
From the Research
First Line Medication for Pericarditis
- High-dose nonsteroidal anti-inflammatory drugs (NSAIDs) are the first line of treatment for pericarditis, as they help to relieve symptoms and reduce inflammation 2, 3, 4, 5, 6
- Aspirin is also a common first-line treatment, especially in patients with coronary artery disease, heart failure, or renal disease 6
- Colchicine is often used in conjunction with NSAIDs to relieve symptoms and reduce the risk of recurrence 2, 3, 4, 5
- The choice of NSAID should be dictated by comorbid conditions, tolerability, and adverse effects, with options including ibuprofen, indometacin, and ketorolac 6
Treatment Duration and Tapering
- NSAIDs should be tapered once symptoms are controlled and C-reactive protein level has normalized, typically over several weeks 4
- Colchicine should be continued for at least 3-6 months to reduce the risk of recurrence 2, 4
- With a first recurrence of pericarditis, colchicine should be continued for at least 6 months 4
Special Considerations
- Corticosteroids are often used if pericarditis does not improve with NSAIDs and colchicine, or in patients with autoimmune disorders or contraindications to NSAIDs 2, 3, 4
- Interleukin 1 (IL-1) blockers 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 2, 4