Initial Treatment for Pericarditis
The initial treatment for pericarditis should be a combination of NSAIDs (such as ibuprofen or aspirin) and colchicine as first-line therapy, with treatment duration until complete symptom resolution and CRP normalization. 1
First-Line Treatment Regimen
NSAIDs
Ibuprofen (preferred due to favorable side effect profile):
- Dosage: 600 mg every 8 hours (1200-2400 mg/day)
- Duration: Weeks to months until symptoms resolve and CRP normalizes 1
- Caution: Reduce or avoid in moderate to severe renal impairment
Aspirin (preferred when antiplatelet therapy is required or ischemic heart disease is present):
- Dosage: 750-1000 mg every 8 hours (1500-4000 mg/day)
- Duration: Same as ibuprofen 1
Colchicine (to be given concurrently with NSAIDs)
- Weight-based dosing:
- <70kg: 0.5mg once daily
- ≥70kg: 0.5mg twice daily
- Duration: 3 months for first episode, 6 months for recurrent cases 1
- Significantly reduces recurrence rates from 15-30% to 8-15% 1, 2
Treatment Tapering Protocol
- Continue full-dose treatment until complete symptom resolution and CRP normalization
- Taper NSAIDs by decreasing dose by 250-500 mg every 1-2 weeks
- Maintain colchicine at full dose until other medications are tapered 1
Monitoring Treatment Response
- Initial follow-up: 1-2 weeks after starting treatment
- Subsequent follow-up: Every 1-2 months until treatment completion
- Monitor:
- Symptom resolution
- CRP normalization (essential to guide treatment duration)
- ECG changes resolution
- Resolution of pericardial effusion (if present) 1
Second-Line Treatment
- Corticosteroids should only be used when:
- Contraindications to NSAIDs/colchicine exist
- Infectious causes have been excluded
- Incomplete response to first-line therapy 1
- Starting dose: 0.25-0.50 mg/kg/day of prednisone
- Taper carefully: Reduce by 10mg/day every 1-2 weeks for doses >50mg 1
- Caution: Overuse of corticosteroids is associated with higher recurrence rates 1, 2
Special Considerations
High-Risk Features Requiring Hospitalization
- Fever >38°C
- Subacute course
- Large pericardial effusion
- Cardiac tamponade
- Failure to respond to NSAIDs
- Immunosuppression 1
Specific Etiologies
- Bacterial pericarditis: Requires urgent drainage plus targeted antibiotics 1
- Tuberculous pericarditis: Requires anti-tuberculosis therapy plus corticosteroids 1, 3
- Myopericarditis/perimyocarditis: Similar treatment to uncomplicated pericarditis, with additional rest and exercise restriction 1
Common Pitfalls to Avoid
- Failure to add colchicine (doubles recurrence risk)
- Inadequate treatment duration (leads to recurrences)
- Overuse of corticosteroids (increases recurrence rates)
- Missing high-risk features requiring hospitalization
- Potential adverse effects to monitor:
- Gastrointestinal effects
- Hepatotoxicity
- Neuromuscular toxicity
- Myelosuppression 1
Treatment Outcomes
- Successful treatment is indicated by:
- Resolution of symptoms
- Normalization of CRP levels
- Resolution of ECG changes
- Resolution of pericardial effusion (if present initially) 1
- With appropriate treatment, 70-85% of patients have a benign course 2
- Risk of constrictive pericarditis is <1% in idiopathic/viral cases with appropriate colchicine therapy 1