What is the medication treatment for pericarditis?

Medication Treatment for Pericarditis

The first-line medication treatment for pericarditis consists of high-dose aspirin or NSAIDs plus colchicine, with treatment continued until complete symptom resolution and normalization of inflammatory markers. 1, 2

First-Line Treatment

NSAIDs/Aspirin

• Aspirin: 500-1000 mg every 6-8 hours (1.5-4 g/day)
• Ibuprofen: 600 mg every 8 hours (1200-2400 mg/day)
• Indomethacin: 25-50 mg every 8 hours (start at lower doses and titrate upward)
• Treatment duration: Weeks to months until symptoms resolve and CRP normalizes 1
• Tapering: Decrease doses gradually (e.g., aspirin by 250-500 mg every 1-2 weeks) 1

Colchicine (Add to NSAIDs/Aspirin)

• Dosing: 0.5 mg twice daily for patients ≥70 kg or 0.5 mg once daily for patients <70 kg 1
• Duration: At least 6 months 1
• Benefits: Reduces recurrence rate from 15-30% to 8-15% 2, 3
• No loading dose is recommended 1

Treatment Considerations by Etiology

1. Idiopathic/Viral Pericarditis (most common in developed countries):

   • NSAIDs/Aspirin + colchicine 2
   • Risk of constrictive pericarditis is <1% 1, 2

2. Tuberculous Pericarditis (most common in endemic areas):

   • Anti-tuberculosis therapy + corticosteroids 2, 3
   • Higher risk of constrictive pericarditis (20-30%) 1

3. Bacterial Pericarditis:

   • Urgent drainage + targeted antibiotics 2
   • High risk of constrictive pericarditis (20-30%) 1

4. Neoplastic/Autoimmune Pericarditis:

   • Treatment of underlying condition + anti-inflammatory therapy 2
   • Intermediate risk of constrictive pericarditis (2-5%) 1

Second-Line Treatment: Corticosteroids

• Only use when:

  • Incomplete response to aspirin/NSAIDs and colchicine
  • Contraindications to NSAIDs (allergy, recent peptic ulcer, high bleeding risk)
  • Specific indications (systemic inflammatory diseases, pregnancy) 1

• Dosing: Prednisone 0.2-0.5 mg/kg/day 1

• Important caveat: Corticosteroids should be added to aspirin/NSAIDs and colchicine as triple therapy, not replace them 1

• Tapering: Very slow decrements (1.0-2.5 mg) at intervals of 2-6 weeks, especially at the critical threshold of 10-15 mg/day 1

Treatment for Refractory Recurrent Pericarditis

• For multiple recurrences unresponsive to conventional therapy, IL-1 blockers have demonstrated efficacy 3, 4
• IL-1 blockers (anakinra, rilonacept) significantly reduce recurrences compared to placebo (10% vs 78%) 4

Monitoring and Follow-up

• Continue treatment until:

  1. Complete resolution of symptoms
  2. Normalization of CRP
  3. Resolution of ECG changes
  4. Resolution of pericardial effusion (if present) 2

• Follow-up visits: Every 1-2 weeks initially, then every 1-2 months until treatment completion 2

Common Pitfalls to Avoid

1. Premature discontinuation of treatment before symptoms and inflammatory markers normalize (leading cause of recurrence) 2

2. Inadequate dosing of NSAIDs - full anti-inflammatory doses should be given every 8 hours 2

3. Using corticosteroids as first-line therapy - associated with higher recurrence rates 1, 2

4. Rapid tapering of medications - particularly corticosteroids, which requires extremely slow tapering 1

5. Failure to add colchicine - doubles the risk of recurrence 1, 3