What is the recommended dose of prednisone (corticosteroid) for acute pericarditis?

Prednisone Dosing for Acute Pericarditis

For acute pericarditis, prednisone should be used at a starting dose of 0.25-0.50 mg/kg/day, with higher doses avoided except in special cases, and only for a few days with rapid tapering to 25 mg/day. 1

First-Line Therapy Considerations

• Corticosteroids should NOT be first-line therapy for acute pericarditis
• First-line treatment includes:
  • NSAIDs/Aspirin (high doses)
  • Colchicine (0.5mg twice daily for patients ≥70kg or 0.5mg daily for patients <70kg)
• Prednisone should only be considered as second-line therapy when:
  • NSAIDs/colchicine are contraindicated
  • First-line therapy is ineffective
  • Specific indications exist (e.g., autoimmune causes, tuberculous pericarditis)

Prednisone Dosing Protocol

When prednisone is indicated, follow this evidence-based regimen:

1. Initial dose: 0.25-0.50 mg/kg/day 1
2. Tapering schedule based on starting dose:

   • 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

Critical Considerations for Tapering

• A critical threshold for recurrences is 10-15 mg/day of prednisone 1
• At this threshold, very slow decrements (1.0-2.5 mg) at intervals of 2-6 weeks are essential
• Only taper when:
  • Patient is completely asymptomatic
  • C-reactive protein (CRP) is normal

Important Cautions with Corticosteroid Use

• Higher doses and prolonged use of corticosteroids are associated with:
  • Increased risk of recurrences 2
  • More side effects
  • Risk of steroid dependence
• Corticosteroids may attenuate the beneficial effects of colchicine in preventing recurrences 2
• If recurrence occurs during tapering:
  • Avoid increasing the dose
  • Avoid reinstating corticosteroids if possible 1

Adjunctive Measures

When using prednisone, implement these protective measures:

• Calcium supplementation: 1,200-1,500 mg/day (supplement plus oral intake)
• Vitamin D supplementation: 800-1000 IU/day
• Consider bisphosphonates for:
  • Men ≥50 years
  • Postmenopausal women
  • When long-term treatment with prednisone ≥5.0-7.5 mg/day is anticipated

Monitoring and Follow-up

• Regular assessment of CRP levels
• Clinical evaluation for symptom resolution
• Consider cardiac magnetic resonance imaging (CMR) to guide therapy, as CMR-guided management has been shown to decrease:
  • Pericarditis recurrence
  • Overall steroid exposure 3

Special Situations

For steroid-dependent or refractory cases:

• Consider immunosuppressive agents (azathioprine, methotrexate, mycophenolate mofetil) 4
• These agents have shown efficacy in reducing recurrence frequency from 0.22 (±0.34) with corticosteroids alone to 0.01 (±0.04) with immunosuppressive agents 4

Remember that the goal is to use the lowest effective dose of prednisone for the shortest duration possible to minimize side effects while effectively treating pericarditis.