When to add prednisone to colchicine (Colchicine) for the treatment of pericarditis?

When to Add Prednisone to Colchicine for Pericarditis

Prednisone should be added to colchicine for pericarditis only as a second-line therapy when there are contraindications to NSAIDs/aspirin or when there is an incomplete response to first-line therapy of NSAIDs/aspirin plus colchicine. 1

First-Line Therapy for Pericarditis

• Acute pericarditis: NSAIDs/Aspirin + colchicine + exercise restriction 1

  • Aspirin: 1500-3000 mg/day
  • Ibuprofen: 1200-2400 mg/day
  • Colchicine: 0.5mg twice daily (≥70kg) or 0.5mg daily (<70kg)

• Recurrent pericarditis: Same first-line approach as acute pericarditis 1

When to Add Prednisone

Indications for Adding Prednisone:

1. Contraindications to NSAIDs/aspirin 1

   • Peptic ulcer disease
   • Recent bleeding
   • Anticoagulation therapy
   • Renal failure

2. Incomplete response to NSAIDs/aspirin plus colchicine 1

   • Persistent symptoms despite adequate dosing
   • Continued elevation of inflammatory markers (CRP)

3. After exclusion of infectious causes 1

   • Particularly important to rule out tuberculous pericarditis before starting steroids

Prednisone Dosing Protocol

• Initial dose: 0.25-0.50 mg/kg/day 1

• Tapering schedule based on starting dose: 1

  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

• Only taper when patient is asymptomatic and CRP is normal 1

Important Considerations

Caution with Prednisone

• Prednisone may increase the risk of recurrence when used as first-line therapy 2
• Research suggests that prednisone may blunt the beneficial effects of colchicine 2
• A study showed higher recurrence rates in patients treated with prednisone and colchicine (40.5%) compared to those treated with NSAIDs/aspirin and colchicine (18.2%) 2

Monitoring During Treatment

• Track CRP levels to guide treatment duration 1
• Assess symptom resolution
• Follow ECG changes and echocardiogram findings
• Begin tapering only after CRP normalization and symptom resolution 1
• Taper gradually, removing one medication class at a time, starting with NSAIDs/aspirin while maintaining colchicine for the full duration 3

Supplementation with Corticosteroids

• Calcium intake: 1,200-1,500 mg/day 1
• Vitamin D: 800-1000 IU/day 1
• Consider bisphosphonates for bone loss prevention in men ≥50 years and postmenopausal women when long-term prednisone ≥5.0-7.5 mg/day is used 1

Treatment Algorithm for Refractory Cases

1. First line: NSAIDs/Aspirin + colchicine + exercise restriction
2. Second line: Low-dose corticosteroids (when first line is contraindicated or ineffective)
3. Third line: IV immunoglobulin or anakinra or azathioprine
4. Fourth line: Pericardiectomy 1

Treatment Duration

• Colchicine: Minimum 3-6 months, longer duration (>6 months) may be needed in some cases 1, 3
• Prednisone: Taper slowly based on clinical response and CRP levels 1
• Patients with multiple recurrences may benefit from extended colchicine therapy 3

Remember that corticosteroid use is associated with an increased risk of recurrence, so they should be used judiciously and only when clearly indicated.