What is the initial treatment for pericarditis?

Initial Treatment for Pericarditis

The initial treatment for pericarditis should consist of high-dose nonsteroidal anti-inflammatory drugs (NSAIDs) or aspirin as first-line therapy, combined with colchicine for a minimum of 3-6 months. 1

First-Line Therapy

NSAIDs/Aspirin

• The European Society of Cardiology recommends aspirin as the NSAID of choice for pericarditis treatment (Class I, Level C) 1
• Ibuprofen can be used at 600mg every 8 hours (1800mg daily) until symptom resolution and normalization of inflammatory markers 1, 2
• NSAIDs should be administered with meals or milk to reduce gastrointestinal side effects 2
• Aspirin is preferred during first and second trimesters of pregnancy and in cases of pericarditis complicating acute myocardial infarction 1
• Important: Aspirin is contraindicated in children with pericarditis due to risk of Reye's syndrome 1

Colchicine

• Should be added to NSAIDs/aspirin as part of initial therapy, especially in severely symptomatic cases 1, 3
• Weight-based dosing:
  • ≥70 kg: 0.5 mg twice daily
  • <70 kg: 0.5 mg once daily 1
• Minimum treatment duration: 3-6 months regardless of symptom resolution 1
• Reduces recurrence rate from 30% to 8-15% 1, 4

Treatment Monitoring and Tapering

1. Monitor C-reactive protein (CRP) levels to guide treatment duration 1
2. Begin tapering only after:
   • Complete symptom resolution
   • Normalization of CRP levels
   • Resolution of ECG changes 1
3. Tapering protocol:
   • Remove one medication class at a time
   • Start by tapering NSAIDs/aspirin while maintaining colchicine for the full duration 1
   • Taper NSAIDs gradually after symptom control is achieved 5

Second-Line Therapy

Corticosteroids

• Not recommended as first-line treatment (Class III, Level B) 1
• Consider only when:
  • NSAIDs and colchicine are contraindicated
  • Incomplete response to first-line therapy 1
• If required, use low-dose prednisone (0.25-0.50 mg/kg/day) 1
• Strict tapering schedule to minimize side effects and reduce recurrence risk:

  • 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 1

Third-Line Therapy

For corticosteroid-dependent recurrent pericarditis:

• Anakinra (2 mg/kg/day up to 100 mg subcutaneously for at least 6 months, then tapered)
• Rilonacept (loading dose of 320 mg SC followed by 160 mg weekly) 1, 5

Special Considerations

• Idiopathic/Viral Pericarditis: NSAIDs/Aspirin + colchicine; good prognosis 1
• Tuberculous Pericarditis: Anti-tuberculosis therapy + corticosteroids; higher risk of constrictive pericarditis (20-30%) 1
• Bacterial Pericarditis: Urgent drainage + targeted antibiotics; high risk of constrictive pericarditis (20-30%) 1
• Neoplastic/Autoimmune Pericarditis: Treatment of underlying condition; intermediate risk of constrictive pericarditis (2-5%) 1

Common Pitfalls and Caveats

• Avoid premature discontinuation of colchicine (continue for full 3-6 months)
• Avoid high-dose corticosteroids as initial therapy due to increased risk of recurrence 1, 6
• Do not taper medications before CRP normalization and symptom resolution 1
• Provide gastrointestinal protection when prescribing NSAIDs 1
• NSAIDs except low-dose aspirin must be withdrawn by gestational week 32 in pregnant patients 1
• Colchicine is contraindicated during pregnancy and breastfeeding 1

Most patients with pericarditis have a favorable prognosis when treated appropriately, with serious complications being rare in idiopathic recurrent pericarditis (constrictive pericarditis <1%) 1, 4.