What is the initial treatment for pericarditis?

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 until complete symptom resolution and CRP normalization. 1

First-Line Treatment Algorithm

1. NSAIDs:

   • Ibuprofen: 600 mg every 8 hours (1200-2400 mg/day) - preferred due to favorable side effect profile 1
   • Aspirin: 500-1000 mg every 6-8 hours (1500-4000 mg/day) - preferred when antiplatelet therapy is required or in patients with ischemic heart disease 1

2. Colchicine (added to NSAIDs):

   • Weight <70kg: 0.5mg once daily
   • Weight ≥70kg: 0.5mg twice daily
   • Duration: 3 months for first episode, 6 months for recurrent cases 1

3. Treatment Duration:

   • Continue full-dose treatment until complete symptom resolution AND CRP normalization
   • Then taper NSAIDs by decreasing 250-500 mg every 1-2 weeks
   • Maintain colchicine at full dose until other medications are tapered 1

Adding colchicine to NSAIDs is crucial as it significantly reduces recurrence rates from 37.5% to 16.7% (absolute risk reduction of 20.8%) 2. The most recent evidence from JAMA (2024) confirms this approach, emphasizing the importance of continuing treatment until both symptoms resolve and inflammatory markers normalize 2.

Monitoring and 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, and resolution of pericardial effusion (if present) 1

Second-Line Treatment

Corticosteroids should only be used as second-line therapy when:

• Contraindications to NSAIDs/colchicine exist
• Infectious causes have been excluded
• There is an incomplete response to first-line therapy 1

If corticosteroids are necessary:

• 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

Special Considerations

• High-risk features requiring hospitalization: fever >38°C, subacute course, large pericardial effusion, cardiac tamponade, failure to respond to NSAIDs, and immunosuppression 1
• Tuberculous pericarditis: Requires anti-tuberculosis therapy plus corticosteroids 1
• Bacterial pericarditis: Requires urgent drainage plus targeted antibiotics 1

Common Pitfalls to Avoid

1. Overuse of corticosteroids - associated with higher recurrence rates 1
2. Inadequate treatment duration - leads to recurrences 1
3. Failure to add colchicine - doubles recurrence risk 1
4. Missing high-risk features requiring hospitalization 1
5. Drug interactions - avoid co-administration of P-glycoprotein/CYP3A4 inhibitors with colchicine or reduce colchicine dose 1

The evidence strongly supports this approach, with the European Society of Cardiology guidelines emphasizing that proper initial treatment with NSAIDs plus colchicine significantly improves outcomes and quality of life by reducing recurrence rates from 15-30% to approximately 8-15% 1. The risk of constrictive pericarditis is <1% in idiopathic/viral cases with appropriate colchicine therapy 1.