What is the initial treatment for pericarditis?

Initial Treatment for Pericarditis

The initial treatment for acute pericarditis should consist of NSAIDs (such as ibuprofen 600 mg every 8 hours) as first-line therapy, combined with colchicine as an adjunctive treatment to reduce recurrence rates. 1

First-Line Treatment Algorithm

1. NSAIDs:

   • Ibuprofen 600 mg every 8 hours (range 1200-2400 mg/day) 1, 2
   • OR Aspirin 750-1000 mg every 8 hours (range 1500-4000 mg/day) 3, 1
   • Continue until symptoms resolve and CRP normalizes 1
   • Administer with meals or milk if gastrointestinal complaints occur 2

2. Colchicine (always combined with NSAIDs, never as monotherapy):

   • Weight-adjusted dosing is critical:
     • 0.5 mg once daily for patients <70 kg
     • 0.5 mg twice daily for patients ≥70 kg 3, 1
   • Duration: 3 months for first episode 1
   • No loading dose required 3

Monitoring Response

• Monitor C-reactive protein (CRP) levels to guide treatment duration 1
• Continue treatment until symptoms resolve and CRP normalizes 1
• Begin tapering NSAIDs after symptom resolution and CRP normalization 3
• Tapering schedule for NSAIDs:
  • Ibuprofen: Decrease by 200-400 mg every 1-2 weeks
  • Aspirin: Decrease by 250-500 mg every 1-2 weeks 3

Second-Line Treatment

If there is incomplete response to NSAIDs and colchicine:

• Corticosteroids may be considered, but only when:

  • There are contraindications to NSAIDs (allergy, recent peptic ulcer, high bleeding risk)
  • Patient shows intolerance to NSAIDs
  • Persistent disease despite appropriate doses of NSAIDs and colchicine 3, 1
  • Specific indications exist (systemic inflammatory diseases, post-pericardiotomy syndromes, pregnancy) 3

• Corticosteroid dosing:

  • Prednisone 0.2-0.5 mg/kg/day 3
  • Add to NSAIDs and colchicine as triple therapy, not as replacement 3
  • Avoid if infections, particularly bacterial and TB, cannot be excluded 3

Important Considerations

• Risk stratification: Patients with high-risk features (fever, subacute onset, large pericardial effusion, cardiac tamponade, immunosuppression) require hospitalization and full evaluation 1

• Activity restrictions: Restrict physical activity until symptoms resolve and CRP normalizes; minimum of 3 months for athletes 1

• Prognosis: With appropriate treatment, most patients (70-85%) have a benign course 4

• Complications to monitor:

  • Risk of constrictive pericarditis is <1% in idiopathic/viral cases with appropriate colchicine therapy 1
  • Cardiac tamponade is rare in idiopathic pericarditis (<3%) 1, 4
  • Recurrence rates: 15-30% without colchicine, reduced to 8-15% with colchicine 1, 4

• Caution: Corticosteroids provide rapid symptom control but favor chronicity and increase recurrence rates 3, 1

Special Situations

• For bacterial pericarditis: Urgent pericardial drainage plus appropriate antibiotics is mandatory 5
• For tuberculous pericarditis: Specific anti-tuberculous therapy is required 4, 5
• For pericarditis complicating acute myocardial infarction: Use aspirin instead of other NSAIDs 6

Remember that the combination of NSAIDs and colchicine provides the best outcomes for most patients with acute pericarditis, significantly reducing recurrence rates and improving quality of life 1.