What is the recommended treatment for recurrent pericarditis?

Treatment for Recurrent Pericarditis

The recommended treatment for recurrent pericarditis is a stepwise approach starting with NSAIDs (preferably ibuprofen) plus colchicine as first-line therapy, followed by corticosteroids as second-line therapy, and then consideration of immunosuppressants (azathioprine), IVIG, or IL-1 blockers (anakinra, rilonacept) for refractory cases, with pericardiectomy as a last resort for treatment-resistant cases. 1, 2, 3

First-Line Treatment

• NSAIDs plus colchicine:
  • Ibuprofen 300-800mg every 6-8 hours (preferred for its favorable coronary flow impact and wide dose range) 1
  • Aspirin can be used as an alternative (except in children due to risk of Reye's syndrome) 4
  • Colchicine 0.5mg twice daily in addition to NSAIDs 1, 2
  • Continue treatment until complete symptom resolution and normalization of inflammatory markers (CRP) 5
  • Colchicine should be continued for at least 6 months for recurrent cases 6

Clinical Pearl: Gastrointestinal protection must be provided with NSAID therapy to prevent complications 1.

Second-Line Treatment

• Corticosteroids (when NSAIDs/colchicine are contraindicated or ineffective):
  • Low to moderate doses (prednisone 0.2-0.5mg/kg/day) 2, 4
  • Should be tapered gradually according to this protocol 5:

    • 50mg: Reduce by 10mg/day every 1-2 weeks

    • 50-25mg: Reduce by 5-10mg/day every 1-2 weeks
    • 25-15mg: Reduce by 2.5mg/day every 2-4 weeks
    • <15mg: Reduce by 1.25-2.5mg/day every 2-6 weeks

Important: Corticosteroids should not be used as first-line therapy due to increased risk of recurrence with their use 3.

Third-Line Treatments for Refractory Cases

For the approximately 5% of patients who develop corticosteroid-dependence and colchicine resistance 2:

1. Azathioprine as an immunosuppressant option 2, 4
2. Intravenous immunoglobulin (IVIG) 2, 4
3. IL-1 blockers (anakinra, rilonacept, goflikicept) - particularly effective for patients who cannot be weaned off corticosteroids 3

Last Resort

• Pericardiectomy (surgical removal of the pericardium) for cases refractory to all medical therapy 2, 4
• Should be performed only in experienced centers 2

Monitoring and Follow-up

• Regular monitoring of CRP levels to guide treatment duration 5
• Echocardiographic assessment to evaluate pericardial thickness and ventricular filling patterns 5
• Physical activity restriction beyond ordinary sedentary life until symptoms resolve and CRP normalizes (minimum 3 months for athletes) 5
• Tapering should begin only after CRP normalization and symptom resolution 5

Special Considerations

• Pregnancy: Aspirin (low-moderate doses) preferred during first and second trimesters; NSAIDs may be used until gestational week 20; prednisone at lowest effective doses may be used throughout pregnancy with calcium and vitamin D supplementation 5

• Children: Colchicine dosing 5:

  • <5 years: 0.5mg/day

  • 5 years: 1.0-1.5mg/day in 2-3 divided doses

Prognosis

Despite significant impairment of quality of life, most common forms of recurrent pericarditis have good long-term outcomes with negligible risk of developing constrictive pericarditis and rarely cardiac tamponade during follow-up 4.