What is the treatment for pericarditis?

Treatment for Pericarditis

The first-line treatment for pericarditis consists of high-dose NSAIDs (such as ibuprofen 600 mg every 8 hours or aspirin 500-1000 mg every 6-8 hours) combined with colchicine (0.5-1.0 mg daily based on weight) for at least 3 months to control symptoms and prevent recurrence. 1, 2

First-Line Treatment Approach

NSAIDs/Aspirin

• Ibuprofen: 600 mg every 8 hours (1200-2400 mg/day)
• Aspirin: 500-1000 mg every 6-8 hours (1500-3000 mg/day)
• Indomethacin: 25-50 mg every 8 hours (75-150 mg/day)
• Continue at full dose until complete symptom resolution and normalization of C-reactive protein
• Gradually taper after symptoms resolve

Colchicine (as adjunctive therapy)

• For patients ≥70 kg: 0.5 mg twice daily
• For patients <70 kg: 0.5 mg once daily
• Duration: minimum 3 months for first episode, 6 months for recurrent cases
• Reduces recurrence rate from 30% to 8-15% 2, 3

Second-Line Treatment

Corticosteroids

• Only recommended when:
  • Incomplete response to NSAIDs + colchicine
  • Contraindications to NSAIDs
  • Specific autoimmune indications
• Prednisone: 0.2-0.5 mg/kg/day
• 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 2
• Important caution: Corticosteroids are not recommended in children due to severe side effects in growing children unless specifically indicated for autoimmune diseases 1

Treatment for Refractory Cases

Interleukin-1 Receptor Antagonists

• Anakinra or Rilonacept for corticosteroid-dependent or refractory cases
• Particularly effective in multiple recurrent pericarditis 4, 5
• May be considered in children with recurrent pericarditis, especially when corticosteroid-dependent 1

Other Immunosuppressants

• Azathioprine or Methotrexate may be considered in refractory cases 6
• Intravenous immunoglobulins for selected refractory cases 6

Treatment Based on Etiology

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

   • NSAIDs/Aspirin + colchicine
   • Good long-term prognosis
   • Recurrence risk: 15-30% without colchicine, 8-15% with colchicine 2

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

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

3. Bacterial Pericarditis:

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

4. Autoimmune/Neoplastic Pericarditis:

   • Treatment of underlying condition
   • Intermediate risk of constrictive pericarditis (2-5%) 2

Special Populations

Children

• NSAIDs at high doses are first-line therapy until complete symptom resolution
• Colchicine: <5 years: 0.5 mg/day; >5 years: 1.0-1.5 mg/day in 2-3 divided doses
• Anti-IL-1 drugs may be considered especially in corticosteroid-dependent cases
• Aspirin is contraindicated due to risk of Reye's syndrome 1
• Corticosteroids are not recommended unless specifically indicated for autoimmune diseases 1

Pregnancy

• Aspirin (low-moderate doses) preferred during first and second trimesters
• NSAIDs may be used until gestational week 20
• All NSAIDs except low-dose aspirin must be withdrawn by gestational week 32
• Prednisone at lowest effective doses may be used throughout pregnancy with calcium and vitamin D supplementation
• Colchicine is contraindicated during pregnancy and breastfeeding 1

Monitoring and Follow-up

• Schedule visits every 1-2 months until treatment completion
• Monitor for:
  • Symptom resolution
  • C-reactive protein normalization
  • Resolution of ECG changes
  • Resolution of pericardial effusion (if present) 2
• Continue colchicine for at least 3-6 months regardless of symptom resolution 2

Common Pitfalls

1. Premature discontinuation of therapy before complete resolution of inflammation
2. Rapid tapering of anti-inflammatory medications, especially corticosteroids
3. Failure to add colchicine to NSAIDs in initial therapy
4. Overuse of corticosteroids as first-line therapy
5. Inadequate rest and physical restriction, particularly with myopericardial involvement

Remember that hospitalization is recommended for diagnosis and monitoring of acute pericarditis, especially with high-risk features such as fever >38°C, large pericardial effusion, cardiac tamponade, or failure to respond to initial therapy 2.