What is the treatment for pericarditis?

Treatment of Pericarditis

The first-line treatment for acute pericarditis consists of aspirin or NSAIDs (particularly ibuprofen) plus colchicine, with exercise restriction until symptoms resolve and CRP normalizes. 1, 2

First-Line Treatment

NSAIDs/Aspirin

• Ibuprofen: 600 mg every 8 hours (1200-2400 mg/day) for weeks to months
  • Preferred due to favorable side effect profile and impact on coronary blood flow
• Aspirin: 500-1000 mg every 6-8 hours (1500-4000 mg/day) for weeks to months
  • Preferred when antiplatelet therapy is required or ischemic heart disease is a concern
• Indomethacin: 25-50 mg every 8 hours (start at lower doses to avoid headache/dizziness)

Colchicine (Mandatory Adjunctive Therapy)

• Weight-based dosing:
  • <70 kg: 0.5 mg once daily
  • ≥70 kg: 0.5 mg twice daily
• Duration:
  • First episode: 3 months
  • Recurrent pericarditis: at least 6 months

Treatment Monitoring and Tapering

• Continue full-dose treatment until complete symptom resolution AND CRP normalization
• Tapering protocol:
  • Aspirin/NSAIDs: Decrease by 250-500 mg (aspirin) or 200-400 mg (ibuprofen) every 1-2 weeks
  • Colchicine: Generally maintained at full dose until other medications are tapered, then gradually discontinued

Second-Line Treatment

• Corticosteroids: Only when:

  1. Contraindications to aspirin/NSAIDs exist
  2. Infectious causes have been excluded
  3. Incomplete response to first-line therapy

• Prednisone dosing:

  • Starting dose: 0.25-0.50 mg/kg/day
  • Careful tapering schedule:

    • 50 mg: reduce by 10 mg/day every 1-2 weeks

    • 50-25 mg: reduce by 5-10 mg/day every 1-2 weeks
    • 25-15 mg: reduce by 2.5 mg/day every 2-4 weeks
    • <15 mg: reduce by 1.25-2.5 mg/day every 2-6 weeks

Treatment for Recurrent Pericarditis

1. First line: Same as acute pericarditis (aspirin/NSAIDs + colchicine + exercise restriction)
2. Second line: Low-dose corticosteroids (with cautions as above)
3. Third line: Immunomodulatory agents for corticosteroid-dependent cases:
   • IV immunoglobulin
   • Anakinra (IL-1 receptor antagonist)
   • Azathioprine
4. Fourth line: Pericardiectomy (last resort after thorough trial of medical therapy)

Special Considerations

Specific Etiologies

• Bacterial pericarditis: Requires urgent drainage plus targeted antibiotics
• Tuberculous pericarditis: Anti-tuberculosis therapy plus corticosteroids

Risk Stratification

• High-risk features requiring hospitalization:
  • Fever >38°C
  • Subacute onset
  • Large pericardial effusion
  • Cardiac tamponade
  • Immunosuppression

Common Pitfalls to Avoid

1. Using corticosteroids as first-line therapy: This increases risk of chronicity and recurrence 1, 2
2. Inadequate treatment duration: Continue until complete symptom resolution AND CRP normalization
3. Rapid tapering: Follow recommended gradual tapering schedules
4. Inadequate colchicine use: Always add colchicine to reduce recurrence rates
5. Failure to restrict physical activity: Restrict until symptoms resolve and CRP normalizes

Follow-up

• Initial follow-up: 1-2 weeks after starting treatment
• Subsequent follow-up: Every 1-2 months until treatment completion
• Monitor:
  • Symptom resolution
  • CRP normalization
  • ECG changes resolution
  • Resolution of pericardial effusion (if present)

With appropriate treatment, most patients (70-85%) have a favorable course 3, with constrictive pericarditis (<0.5%) and pericardial tamponade (<3%) being rare complications in idiopathic/viral cases.