What are the guidelines for treating pericarditis?

Guidelines for Treatment of Pericarditis

First-line treatment for pericarditis should be aspirin or NSAIDs combined with colchicine, with corticosteroids reserved only for specific cases where first-line therapy fails or is contraindicated. 1

Diagnostic Approach

Before initiating treatment, confirm the diagnosis of pericarditis based on:

• Physical examination
• ECG findings (typical ST elevation)
• Chest X-ray
• Echocardiogram
• C-reactive protein (CRP) and troponin levels

Treatment Algorithm

Acute Pericarditis (First Episode)

1. First-line therapy (Class I, Level A evidence) 1:

   • Aspirin (750-1000 mg every 8h) or NSAIDs (ibuprofen 600 mg every 8h) for 1-2 weeks
   • PLUS colchicine (0.5 mg once daily if <70 kg or 0.5 mg twice daily if ≥70 kg) for 3 months
   • Always provide gastroprotection when using aspirin/NSAIDs

2. Treatment duration and tapering:

   • Continue initial dosing until symptoms resolve and CRP normalizes
   • Taper aspirin/NSAIDs by decreasing doses gradually (250-500 mg for aspirin or 200-400 mg for ibuprofen every 1-2 weeks)
   • Colchicine tapering is not mandatory but can be done in the last weeks

3. For patients not responding to first-line therapy:

   • Consider hospital admission and etiology search
   • Low-dose corticosteroids (0.2-0.5 mg/kg/day of prednisone) only if:
     • Aspirin/NSAIDs and colchicine have failed or are contraindicated
     • Infectious causes have been excluded
     • Specific indications exist (e.g., autoimmune disease)

Recurrent Pericarditis

1. First-line therapy 1:

   • Aspirin/NSAIDs at higher doses (aspirin 500-1000 mg every 6-8h or ibuprofen 600 mg every 8h)
   • PLUS colchicine (0.5 mg twice daily or 0.5 mg daily if <70 kg) for at least 6 months

2. Second-line therapy (for refractory cases):

   • Low to moderate dose corticosteroids (prednisone 0.2-0.5 mg/kg/day)
   • Very slow tapering: decrease by 1.0-2.5 mg at intervals of 2-6 weeks

3. Third-line therapy (for corticosteroid-dependent or resistant cases) 2:

   • Immunosuppressive agents (azathioprine, methotrexate, or mycophenolate mofetil)
   • Anti-IL-1 agents (anakinra, rilonacept) for cases refractory to conventional drugs 3

Activity Restrictions

• Non-athletes: Restrict exercise until symptoms resolve and CRP, ECG, and echocardiogram normalize 1
• Athletes: Restrict exercise for at least 3 months and until symptoms resolve with normalization of CRP, ECG, and echocardiogram 1

Monitoring and Follow-up

• Use CRP to guide treatment duration and assess response (Class IIa, Level C) 1
• Monitor for side effects, particularly gastrointestinal intolerance with colchicine 4
• Follow patients for potential recurrence (15-30% risk after first episode, up to 50% after first recurrence without colchicine) 1

Important Caveats

• Avoid corticosteroids as first-line therapy (Class III recommendation) as they increase risk of recurrence and chronicity 1, 5
• Colchicine reduces recurrence rates by approximately 50% when added to standard therapy 3
• Tapering of anti-inflammatory medications should be gradual to prevent rebound inflammation
• Risk of constrictive pericarditis varies by etiology: low (<1%) for idiopathic/viral, intermediate (2-5%) for autoimmune/neoplastic, and high (20-30%) for bacterial causes 1
• For myopericarditis, colchicine as adjunct to aspirin/NSAIDs has shown favorable effects on electrocardiographic parameters 6

Remember that treatment should be guided by the specific etiology when identified, with the above approach primarily for idiopathic or viral pericarditis, which represents the majority of cases in developed countries.