What are the treatment options for acute pericarditis?

From the Guidelines

Treatment of acute pericarditis should involve a combination of nonsteroidal anti-inflammatory drugs (NSAIDs) and colchicine to reduce inflammation and prevent recurrence, with the most recent guidelines recommending this approach for optimal outcomes in terms of morbidity, mortality, and quality of life. The choice of NSAID, such as aspirin or ibuprofen, should be based on patient history, concomitant diseases, and physician expertise, with dosing as follows: aspirin 750-1000 mg every 8 hours or ibuprofen 600 mg every 8 hours for 1-2 weeks, followed by a gradual taper over 2-4 weeks 1.

Key Components of Treatment

• NSAIDs: Aspirin or ibuprofen are commonly used, with the dose and duration guided by symptoms and CRP levels.
• Colchicine: Added to NSAIDs at a dose of 0.5 mg twice daily (or 0.5 mg once daily for patients weighing less than 70 kg) for 3 months to reduce recurrence risk, as supported by recent guidelines 1.
• Gastrointestinal Protection: A proton pump inhibitor is recommended for patients on NSAIDs to prevent gastrointestinal complications.
• Corticosteroids: Should be considered as a second option for patients with contraindications to NSAIDs or refractory symptoms, but used with caution due to the risk of promoting chronic disease and drug dependence 1.

Management Considerations

• Restriction of Physical Activity: Patients should avoid strenuous physical activity until symptoms resolve and inflammatory markers normalize, typically for at least 2-4 weeks, with competitive athletes requiring closer monitoring and a gradual return to sports participation 1.
• Underlying Cause: Treatment should address the underlying cause if identified, such as antibiotics for bacterial infections or specific therapies for autoimmune disorders.
• Monitoring: Patients should be monitored for signs of recurrence or complications, with adjustments to treatment as necessary to optimize outcomes in terms of morbidity, mortality, and quality of life.

From the Research

Treatment Options for Acute Pericarditis

The treatment options for acute pericarditis include:

• Nonsteroidal anti-inflammatory drugs (NSAIDs) as the mainstay of therapy 2
• Aspirin as an alternative to NSAIDs 3
• Colchicine as an adjunct to NSAIDs or aspirin, especially for recurrences 3, 4
• Corticosteroids as a second choice for difficult cases requiring multi-drug therapies and specific medical conditions 3, 5, 6
• Immunosuppressive agents, such as azathioprine, methotrexate, and mycophenolate mofetil, for patients with idiopathic recurrent pericarditis unresponsive to corticosteroids 5
• Interleukin 1 (IL-1) blockers for selected patients with multiple recurrences as steroid-sparing therapy 4

Specific Treatment Regimens

• High-dose NSAIDs with doses tapered once chest pain has resolved and C-reactive protein level has normalized, typically over several weeks 4
• A 3-month course of colchicine to relieve symptoms and reduce the risk of recurrence 4
• Continuation of colchicine for at least 6 months with a first recurrence of pericarditis 4

Factors Predicting Treatment Failure

• Female sex, age, PR-segment depression, and a secondary cause of pericarditis are independent predictors of poor response to NSAIDs and switch to corticosteroid treatment 6