What are the recommended anti-inflammatory regimens for pericarditis?

Anti-inflammatory Regimens for Pericarditis

The recommended first-line anti-inflammatory regimen for pericarditis consists of high-dose NSAIDs (preferably ibuprofen 300-800mg every 6-8 hours) plus colchicine (0.5mg twice daily) for 3-6 months. 1

First-Line Treatment Approach

NSAIDs + Colchicine

• NSAIDs:
  • Ibuprofen 300-800mg every 6-8 hours (preferred agent)
  • Must be given with gastrointestinal protection
  • Continue at full dose until symptom resolution and normalization of C-reactive protein
  • Then taper gradually
• Colchicine:
  • 0.5mg twice daily for adults
  • Children dosing: <5 years: 0.5 mg/day; >5 years: 1.0-1.5 mg/day in 2-3 divided doses
  • Continue for 3-6 months
  • Reduces recurrence rate from 15-30% to 8-15% 1

Second-Line Treatment

Corticosteroids

• Only when NSAIDs/colchicine are contraindicated or ineffective (Class III, Level B for first-line use) 1
• Recommended tapering protocol:
  • 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 1

Third-Line Treatment

Immunosuppressive Agents

• For recurrent cases unresponsive to corticosteroids or corticosteroid-dependent cases
• Options include:
  • Azathioprine
  • Methotrexate
  • Mycophenolate mofetil 2
• Recent evidence shows IL-1 blockers (anakinra, rilonacept, goflikicept) are effective for patients who cannot discontinue glucocorticoids or as second-line therapy when glucocorticoids are contraindicated 3

Treatment Based on Etiology

• Idiopathic/Viral Pericarditis:

  • NSAIDs/Aspirin plus 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

• Neoplastic/Autoimmune Pericarditis:

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

Special Considerations

Pregnancy

• First and second trimesters: Low-moderate dose aspirin preferred
• 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• All NSAIDs except low-dose aspirin must be withdrawn by gestational week 32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 adjusted by age 1

Myopericarditis

• Rest, avoidance of physical activity, and restriction of exercise for at least 6 months 1

Treatment Monitoring

• Track CRP levels to guide treatment duration
• Assess symptom resolution and ECG changes
• 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
• Repeat echocardiogram if symptoms worsen or new symptoms develop 1

Common Pitfalls to Avoid

1. Premature discontinuation of therapy before complete resolution of inflammation (monitor CRP)
2. Rapid tapering of anti-inflammatory drugs (especially within 1 month) increases recurrence risk 3
3. Using corticosteroids as first-line therapy (associated with higher recurrence rates)
4. Inadequate dosing of NSAIDs (full anti-inflammatory doses are required)
5. Omitting colchicine from the treatment regimen (doubles recurrence risk) 4
6. Inadequate duration of colchicine therapy (should be continued for at least 3 months for first episode, 6 months for recurrences) 4

The evidence strongly supports a stepwise approach to treating pericarditis, with NSAIDs plus colchicine forming the cornerstone of therapy. Recent research confirms that proper implementation of this regimen significantly reduces recurrence rates and improves outcomes 4.