What is the treatment for pericarditis?

From the Guidelines

The treatment of pericarditis should focus on relieving symptoms and addressing the underlying cause, with first-line therapy including nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin (500-1000 mg every 6-8 hours) or ibuprofen, and colchicine (0.5-0.6 mg once or twice daily) for 3 months, as recommended by the most recent guidelines 1.

Key Considerations

• The use of NSAIDs and colchicine is supported by the latest evidence, which emphasizes their role in reducing inflammation and preventing recurrence 1.
• Gastrointestinal protection with a proton pump inhibitor like omeprazole 20mg daily is recommended while on NSAIDs to prevent gastrointestinal complications.
• For patients with contraindications to NSAIDs or refractory symptoms, low-dose corticosteroids (prednisone 0.25-0.5mg/kg/day) may be used, but should be tapered slowly to prevent recurrence, as suggested by earlier guidelines 1.

Treatment Approach

• Rest and activity restriction, particularly avoiding competitive sports until resolution of symptoms and normalization of inflammatory markers, is important.
• Treatment of the underlying cause is essential in specific cases like infectious or autoimmune pericarditis.
• The identification of specific viral signatures may aid in understanding the pathogenetic mechanisms in pericarditis, but antiviral treatment is still under evaluation and rarely used 1.

Important Notes

• Corticosteroids are generally not indicated in viral pericarditis, as they can reactivate many virus infections and lead to ongoing inflammation 1.
• The latest guidelines prioritize the use of NSAIDs and colchicine, with corticosteroids reserved for specific cases with contraindications or refractory symptoms 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 the possible adjunct of colchicine, especially for recurrences 2, 3, 4, 5.
• 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, 6, 3, 4.
• Colchicine should be used in combination with first- or second-line treatments to reduce the risk of recurrence 3, 4, 5.
• Immunosuppressive agents, including azathioprine, methotrexate, and mycophenolate mofetyl, may be efficacious and well tolerated in patients with idiopathic recurrent pericarditis unresponsive to corticosteroids 6.
• Interleukin 1 (IL-1) blockers have demonstrated efficacy and may be preferred to corticosteroids in certain patients with multiple recurrences 4, 5.

Treatment Approach

• Medical therapy of pericarditis should be individualized as much as possible, 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 3-month course of colchicine should be given to relieve symptoms and reduce the risk of recurrence, and continued for at least 6 months with a first recurrence of pericarditis 4.
• Patients with a higher risk of complications should be admitted to the hospital for further workup and treatment 3.

Recurrence Prevention

• Colchicine is effective in the reduction of recurrent pericarditis, compared with standard treatment 5.
• Anti-interleukin-1 agents, such as anakinra and rilonacept, are effective in the reduction of recurrences, compared with placebo 5.