What treatment should be initiated for a patient with suspected pericarditis?

Treatment of Pericarditis

For a patient with suspected pericarditis, the first-line treatment should be high-dose NSAIDs (such as ibuprofen 600 mg every 8 hours) combined with colchicine (0.5-1.0 mg daily based on weight) for at least 3 months. 1

First-Line Treatment

NSAIDs

• Ibuprofen: 600 mg every 8 hours (1200-2400 mg/day)
• Aspirin: 500-1000 mg every 6-8 hours (1500-3000 mg/day)
• Continue until complete symptom resolution
• Provide gastrointestinal protection

Colchicine (add to NSAID therapy)

• For patients ≥70 kg: 0.5 mg twice daily
• For patients <70 kg: 0.5 mg once daily
• Continue for minimum of 3 months
• Reduces recurrence rate from 30% to 8-15% 1

Exercise Restriction

• Restrict physical activity beyond normal sedentary life until resolution of symptoms and normalization of inflammatory markers 2

Second-Line Treatment

If there are contraindications to NSAIDs/colchicine or incomplete response:

Corticosteroids

• Prednisone: Starting dose 0.25-0.50 mg/kg/day 2
• 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

Important: Only taper when patient is asymptomatic and C-reactive protein is normal 2

Third-Line Treatment (for refractory cases)

For corticosteroid-dependent recurrent pericarditis not responsive to colchicine:

• Intravenous immunoglobulin
• Anakinra (IL-1 receptor antagonist)
• Azathioprine 2, 3

Fourth-Line Treatment

• Pericardiectomy (only after thorough trial of unsuccessful medical therapy) 2

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) 1

Special Considerations

Pericardiocentesis

• Indicated for cardiac tamponade (life-saving)
• Consider for effusions >20 mm in echocardiography
• Useful for diagnostic purposes in smaller effusions 2

Hospitalization

• Warranted to determine etiology
• Observe for tamponade
• Monitor effect of treatment 2

Common Pitfalls to Avoid

1. Premature discontinuation of therapy: Continue colchicine for at least 3-6 months regardless of symptom resolution to prevent recurrence 1

2. Inappropriate corticosteroid use: Reserve systemic corticosteroids for specific indications (connective tissue diseases, autoreactive or uremic pericarditis) or when NSAIDs/colchicine are contraindicated 2

3. Failure to provide gastroprotection: Always provide gastrointestinal protection when prescribing NSAIDs 2

4. Inadequate tapering of corticosteroids: Follow the recommended tapering schedule to minimize side effects and prevent recurrence 2, 1

5. Missing concurrent conditions: Always rule out cardiac tamponade, which requires immediate intervention 2

By following this treatment algorithm and avoiding common pitfalls, you can effectively manage pericarditis and minimize the risk of recurrence, which affects 15-30% of patients after an initial episode 3.