What are the treatment guidelines for pericarditis?

Treatment Guidelines for Pericarditis

First-line treatment for pericarditis includes high-dose NSAIDs/Aspirin plus colchicine for 3-6 months, with specific dosing based on patient weight and characteristics. 1

Diagnosis

Pericarditis is diagnosed when at least 2 of the following are present:

• Sharp, pleuritic chest pain that worsens when supine (≈90% of cases)
• ECG changes: widespread ST-segment elevation and PR depression (25-50% of cases)
• New or increased pericardial effusion (≈60% of cases)
• Pericardial friction rub (<30% of cases) 2

First-Line Treatment

NSAIDs/Aspirin (Class I, Level A recommendation)

• Dosing:
  • Aspirin: 1500-3000 mg/day
  • Ibuprofen: 1200-2400 mg/day
  • Indomethacin: 75-150 mg/day 1
• Administer every 8 hours to ensure full daily symptom control 3
• Continue until symptom resolution and CRP normalization, then taper gradually 1

Colchicine (Class I, Level A recommendation)

• Dosing:
  • Adults ≥70kg: 0.5mg twice daily
  • Adults <70kg: 0.5mg once daily
  • Children <5 years: 0.5 mg/day
  • Children >5 years: 1.0-1.5 mg/day in 2-3 divided doses 1
• Duration: 3 months for first episode, 6+ months for recurrent cases 1, 2
• Reduces recurrence risk from 37.5% to 16.7% 2

Second-Line Treatment

Corticosteroids (Class III, Level B for first-line use)

• Only when NSAIDs/colchicine are contraindicated or ineffective
• Low-dose: 0.25-0.50 mg/kg/day
• 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 1

Advanced Therapies for Refractory Cases

• IL-1 blockers have demonstrated efficacy in multiple recurrences and may be preferred to long-term corticosteroids 2, 4
• IL-1 agents reduce recurrences compared to placebo (10% vs 78%) 4

Treatment by Etiology

Idiopathic/Viral Pericarditis

• NSAIDs/Aspirin + colchicine
• Recurrence rate: 15-30% without colchicine, reduced to 8-15% with colchicine 1

Tuberculous Pericarditis

• Anti-tuberculosis therapy (rifampicin, isoniazid, pyrazinamide, ethambutol) for ≥6 months
• Adjunctive corticosteroids to reduce risk of constrictive pericarditis (from >80% to <10%)
• Higher risk of constrictive pericarditis (20-30%) 1

Bacterial Pericarditis

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

Neoplastic/Autoimmune Pericarditis

• Treatment of underlying cancer/condition
• Intermediate risk of constrictive pericarditis (2-5%) 1

Treatment Monitoring

• Track CRP levels to guide treatment duration
• Assess symptom resolution
• Follow ECG changes and echocardiogram findings
• Begin tapering only after CRP normalization and symptom resolution
• Taper gradually, removing one medication class at a time, starting with NSAIDs/aspirin while maintaining colchicine for the full duration 1

Special Considerations

Constrictive Pericarditis

• Initial medical therapy includes diuretics for symptom management
• Pericardiectomy is the only definitive treatment for chronic constrictive pericarditis
• Medical therapy should not unnecessarily delay surgical intervention in advanced cases 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 1

Myopericarditis

• Rest, avoidance of physical activity, and restriction of exercise for at least 6 months
• Return to sports only after complete effusion resolution, normalization of inflammatory markers, and comprehensive cardiologic evaluation 1

Common Pitfalls and Caveats

1. Delayed diagnosis: Pericarditis accounts for up to 5% of emergency department visits for non-ischemic chest pain 2
2. Inappropriate corticosteroid use: Corticosteroids should not be first-line therapy as they increase recurrence risk 1
3. Inadequate treatment duration: Premature discontinuation before CRP normalization increases recurrence risk 1
4. Failure to use colchicine: Colchicine significantly reduces recurrence risk and should be standard therapy 5, 4
5. Gastrointestinal intolerance: Most common side effect of colchicine, may require dose adjustment 5
6. Delayed referral for pericardiectomy: Medical therapy should not unnecessarily delay surgical intervention in advanced constrictive cases 1