What is the treatment protocol for pericarditis?

Treatment Protocol for Pericarditis

The primary treatment for acute pericarditis consists of high-dose NSAIDs/aspirin plus colchicine for 3-6 months, with treatment continuing until complete symptom resolution and normalization of inflammatory markers (CRP). 1

Diagnostic Criteria

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

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

First-Line Treatment for Acute Pericarditis

1. NSAIDs/Aspirin

   • Administer at high doses every 8 hours until symptoms resolve and CRP normalizes
   • Examples:
     • Ibuprofen: 600-800 mg every 8 hours
     • Aspirin: 750-1000 mg every 8 hours
     • Indomethacin: 25-50 mg every 8 hours
     • Ketorolac (IV option): with appropriate dosing limits

2. Colchicine (in addition to NSAIDs/Aspirin)

   • Adults: 0.5-1.0 mg daily
   • Children: <5 years: 0.5 mg/day; >5 years: 1.0-1.5 mg/day in 2-3 divided doses
   • Continue for 3 months for first episode, 6 months for recurrences
   • Reduces recurrence rate from 30-37% to 15-17% 1, 2

3. Activity Restriction

   • Restrict physical activity beyond ordinary sedentary life until symptoms resolve and CRP normalizes
   • Athletes: minimum restriction of 3 months
   • Non-athletes: until remission of symptoms
   • For myopericarditis: rest and avoidance of physical activity for at least 6 months 1

Second-Line Treatment

Corticosteroids (when NSAIDs/colchicine are contraindicated or ineffective)

• Starting doses based on severity:
  • Moderate dose: 0.25-0.5 mg/kg/day of prednisone
• Tapering protocol:

  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

Third-Line Treatment for Recurrent/Refractory Cases

Interleukin-1 blockers (anakinra, rilonacept, goflikicept)

• Used when patients cannot taper off glucocorticoids
• Can be second-line in patients with contraindications to glucocorticoids
• Highly effective in reducing recurrences (10% vs 78% with placebo) 2, 3

Treatment for Specific Types of Pericarditis

Idiopathic/Viral Pericarditis

• NSAIDs/Aspirin and colchicine as described above
• Recurrence rate: 15-30% without colchicine, reduced to 8-15% with colchicine 1

Tuberculous Pericarditis

• Anti-tuberculosis therapy plus corticosteroids
• Higher risk of constrictive pericarditis (20-30%) 1

Bacterial Pericarditis

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

Constrictive Pericarditis

• Pericardiectomy is the definitive treatment
• Medical therapy (diuretics, anti-inflammatory medications) is supportive and temporary
• Delayed surgery associated with worse outcomes 1

Special Populations

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

Children

• Aspirin is contraindicated due to risk of Reye's syndrome
• Colchicine dosing: <5 years: 0.5 mg/day; >5 years: 1.0-1.5 mg/day in 2-3 divided doses 1

Treatment Monitoring and Follow-up

• Track CRP levels to guide treatment duration
• 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
• Regular echocardiographic assessment to evaluate pericardial thickness, ventricular filling patterns, and development of tamponade
• Repeat echocardiogram if symptoms worsen or new symptoms develop 1

Important Considerations

• Aspirin is preferred over other NSAIDs in patients with coronary artery disease, heart failure, or renal disease 4
• Avoid aspirin in patients with asthma and nasal polyps who are naïve to aspirin therapy
• Ibuprofen is an inexpensive option for patients without CAD, heart failure, or renal disease
• Indomethacin has a relatively higher incidence of CNS adverse effects
• Ketorolac is an IV option but has maximum dosing limitations 4
• Tapering should only begin after complete symptom resolution and normalization of inflammatory markers