What is the initial treatment for pericarditis?

Initial Treatment for Pericarditis

The initial treatment for acute pericarditis should consist of aspirin or NSAIDs as first-line therapy, with colchicine as an adjunctive treatment to improve response and prevent recurrences. 1

First-Line Treatment

NSAIDs/Aspirin

• Aspirin (750-1000 mg every 8 hours) or ibuprofen (600 mg every 8 hours) are recommended as first-line therapy for 1-2 weeks with gastroprotection 1
• The choice between NSAIDs should be based on patient history, concomitant diseases, and contraindications 1
• Treatment duration should be guided by symptoms and C-reactive protein (CRP) normalization 1
• Tapering should be considered by decreasing doses gradually (e.g., aspirin by 250-500 mg every 1-2 weeks) 1

Colchicine

• Colchicine should be added to NSAIDs/aspirin as part of first-line therapy 1
• Weight-adjusted dosing is recommended: 0.5 mg once daily if <70 kg or 0.5 mg twice daily if ≥70 kg 1
• Treatment duration should be 3 months 1
• Colchicine reduces recurrence rates by approximately 50% compared to treatment without colchicine 2, 3

Treatment Algorithm

1. Diagnosis confirmation: At least 2 of the following criteria: typical chest pain, pericardial friction rub, ECG changes, or new/worsening pericardial effusion 2
2. Risk stratification: Assess for high-risk features requiring admission (fever >38°C, large effusion/tamponade, failure of NSAID treatment) 3
3. For non-high-risk cases: Outpatient management with NSAIDs and colchicine 1
4. Monitor response: Use CRP to guide treatment length and assess response 1
5. Treatment adjustment: If no response to NSAIDs and colchicine, consider second-line therapy 1

Second-Line Treatment

• Low-dose corticosteroids should be considered only in cases of:
  • Contraindication to NSAIDs/colchicine
  • Failure of first-line therapy
  • When infectious causes have been excluded
  • Specific indications such as autoimmune disease 1
• If corticosteroids are necessary, use low to moderate doses (prednisone 0.2-0.5 mg/kg/day) rather than high doses 1
• Corticosteroids are NOT recommended as first-line therapy due to risk of promoting chronicity, recurrences, and side effects 1

Special Considerations

• For specific causes like tuberculosis (common in endemic areas), targeted antimicrobial therapy is required 2, 4
• Exercise restriction should be considered until symptoms resolve and CRP, ECG, and echocardiogram normalize 1
• For athletes, exercise restriction should last at least 3 months 1
• Tapering of medications should only be attempted when symptoms are absent and CRP is normal 1

Pitfalls and Caveats

• Inadequate treatment of the first episode is a common cause of recurrence 1
• Corticosteroids provide rapid symptom control but may increase risk of chronicity and recurrence 1
• Recurrence rates after initial episode range from 15-30% without colchicine, increasing to 50% after first recurrence 1, 2
• Risk of constrictive pericarditis varies by etiology: low (<1%) for idiopathic/viral, intermediate (2-5%) for autoimmune/neoplastic, and high (20-30%) for bacterial causes 1
• Cardiac tamponade rarely occurs in idiopathic pericarditis but is more common with specific etiologies like malignancy or purulent pericarditis 1

By following this evidence-based approach, most patients with acute pericarditis will have a favorable outcome, with resolution of symptoms and reduced risk of complications or recurrence.