Steroid Dosing for Pericarditis
For pericarditis, corticosteroids should be used at low to moderate doses (prednisone 0.2-0.5 mg/kg/day) only when there is incomplete response to first-line therapy or specific contraindications to NSAIDs exist. 1
Treatment Algorithm
First-Line Therapy (Always Try First)
- NSAIDs/Aspirin + Colchicine + Exercise Restriction
Second-Line Therapy (Only When First-Line Fails or Contraindicated)
- Corticosteroids (Prednisone)
Steroid Tapering Schedule
When using steroids, follow this precise tapering schedule to minimize recurrence risk:
| Starting Dose | Tapering Protocol |
|---|---|
| >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 |
Critical threshold for recurrences is 10-15 mg/day of prednisone. At this threshold, use very slow decrements (1.0-2.5 mg) at intervals of 2-6 weeks. 1
Important Considerations
Indications for Steroids
Steroids should be restricted to patients with:
- Incomplete response to NSAIDs + colchicine
- Specific indications (systemic inflammatory diseases, post-pericardiotomy syndromes, pregnancy)
- NSAID contraindications (allergy, recent peptic ulcer, GI bleeding, high bleeding risk with anticoagulants) 1
Cautions with Steroid Use
- Avoid high-dose steroids (>0.5 mg/kg/day) as they are associated with more side effects, recurrences, and hospitalizations 3
- Higher doses (1.0 mg/kg/day) have a hazard ratio of 3.61 for adverse outcomes compared to lower doses 3
- Always exclude infections, particularly bacterial and TB, before starting steroids 1
Steroid Adjuncts
When using steroids, always provide:
- Calcium supplementation: 1,200-1,500 mg/day
- Vitamin D: 800-1000 IU/day
- Bisphosphonates for men ≥50 years and postmenopausal women when prednisone ≥5.0-7.5 mg/day 1
Special Situations
Tuberculous Pericarditis
- Higher steroid doses may be needed: Prednisone 1-2 mg/kg/day for 5-7 days
- Taper progressively over 6-8 weeks
- Always combine with appropriate anti-tuberculous therapy 4
Recurrent Pericarditis
- Maintain the same low-dose steroid approach (0.2-0.5 mg/kg/day)
- Ensure even slower tapering with each recurrence
- Consider third-line therapies (azathioprine, IVIG, or anakinra) for steroid-dependent cases 1, 2
Remember that corticosteroids, while effective for symptom control, are associated with increased risk of recurrence and should be used judiciously with the lowest effective dose and careful tapering.