What is the treatment for pericarditis?

Treatment of Pericarditis

First-line treatment for pericarditis is a combination of aspirin or NSAIDs plus colchicine, with treatment duration guided by symptom resolution and normalization of CRP. 1

Acute Pericarditis Treatment Algorithm

First-Line Therapy

• NSAIDs/Aspirin (Class I, Level A evidence) 1

  • Aspirin: 750-1000 mg every 8 hours for 1-2 weeks
  • Ibuprofen: 600 mg every 8 hours for 1-2 weeks
  • Indomethacin: 25-50 mg every 8 hours (for recurrent cases)
  • Provide gastroprotection with all NSAID therapy
  • Taper by decreasing doses gradually after symptom resolution and CRP normalization

• Add Colchicine (Class I, Level A evidence) 1, 2

  • Weight-adjusted dosing:
    • <70 kg: 0.5 mg once daily
    • ≥70 kg: 0.5 mg twice daily
  • Duration: 3 months for first episode, 6 months for recurrent cases
  • Reduces recurrence rate from 37.5% to 16.7% (NNT = 4) 3

Second-Line Therapy

• Low-dose corticosteroids (only if NSAIDs/colchicine contraindicated or failed, and infection excluded) 1
  • Prednisone 0.2-0.5 mg/kg/day (not 1.0 mg/kg/day)
  • Maintain until symptom resolution and CRP normalization, then taper slowly
  • Caution: Corticosteroids increase risk of recurrence and chronicity 1

For Refractory/Recurrent Cases

• Triple therapy (NSAIDs + colchicine + low-dose corticosteroids)
• For corticosteroid-dependent cases: Consider IL-1 blockers (anakinra) or immunosuppressants 3

Treatment Based on Etiology

Idiopathic/Viral Pericarditis (Most Common in Developed Countries)

• Standard therapy as above
• Good prognosis (<1% risk of constriction) 1, 4

Bacterial Pericarditis

• Urgent pericardial drainage
• Appropriate antibiotics based on culture results
• Higher risk of constriction (20-30%) 1, 5

Tuberculous Pericarditis

• Anti-tuberculosis therapy
• Consider adding corticosteroids 5

Activity Restrictions

• Non-athletes: Restrict physical activity until symptom resolution and normalization of CRP, ECG, and echocardiogram 1
• Athletes: Restrict for at least 3 months and until normalization of all parameters 1

Monitoring and Follow-up

• Use C-reactive protein (CRP) to guide treatment duration and assess response 1
• Continue therapy until complete symptom resolution and CRP normalization
• Monitor for recurrence (occurs in 15-30% of cases without colchicine) 1, 3

Important Considerations and Pitfalls

• Avoid corticosteroids as first-line therapy - they increase risk of recurrence and chronicity 1
• Proper tapering is essential - too rapid tapering of anti-inflammatory drugs can lead to recurrence
• Colchicine reduces recurrence by >50% - should be added to all first-line regimens 2
• Treatment duration should be symptom and CRP-guided - don't stop therapy prematurely
• Recognize different types of pericarditis:
  • Acute: new-onset
  • Incessant: symptoms persisting >4-6 weeks
  • Chronic: lasting >3 months
  • Recurrent: symptom-free interval of ≥4-6 weeks followed by recurrence 1

Most patients with idiopathic/viral pericarditis have excellent long-term prognosis with appropriate treatment, with rare progression to tamponade (<3%) or constrictive pericarditis (<0.5%) 3, 4.