What is the treatment for acute pericarditis?

Treatment of Acute Pericarditis

The first-line treatment for acute pericarditis consists of aspirin or NSAIDs combined with colchicine, along with appropriate exercise restriction until symptoms resolve and inflammatory markers normalize. 1, 2

First-Line Therapy

• Aspirin (750-1000 mg every 8 hours) or ibuprofen (600 mg every 8 hours) should be administered for 1-2 weeks with gastroprotection 1, 2
• The choice between NSAIDs should be based on patient history, contraindications, previous efficacy, and concomitant diseases (favor aspirin when antiplatelet therapy is already needed) 1
• Colchicine must be added as an adjunct to aspirin/NSAIDs at weight-adjusted doses:
  • 0.5 mg once daily for patients <70 kg
  • 0.5 mg twice daily for patients ≥70 kg 1, 2
• Colchicine should be continued for 3 months to improve treatment response and prevent recurrences 1, 2
• Treatment duration should be guided by symptom resolution and CRP normalization 1
• Tapering of NSAIDs should be considered by decreasing doses gradually (e.g., aspirin by 250-500 mg every 1-2 weeks) 1

Exercise Restriction

• For non-athletes: Restrict physical activity beyond ordinary sedentary life until symptoms resolve and CRP normalizes 1
• For athletes: Restrict competitive sports for at least 3 months after symptom onset, with return only after normalization of symptoms, CRP, ECG, and echocardiogram 1

Second-Line Therapy

• Low-dose corticosteroids should be considered only when:
  • Contraindications to aspirin/NSAIDs and colchicine exist
  • First-line therapy has failed
  • Infectious causes have been excluded
  • Specific indications such as autoimmune disease are present 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, 3

Monitoring and Follow-up

• Serum CRP should be used to guide treatment length and assess response to therapy 1, 2
• Treatment should be continued until complete symptom resolution and normalization of CRP 1, 2
• For non-high-risk cases, outpatient management is appropriate 1, 4
• High-risk patients (fever >38°C, large pericardial effusion, cardiac tamponade, failure to respond to NSAIDs within 7 days) should be admitted for further evaluation 1, 3

Management of Recurrent Pericarditis

• First-line therapy remains the same: aspirin/NSAIDs plus colchicine 1, 5
• For recurrent cases, colchicine should be continued for at least 6 months 1, 3
• In corticosteroid-dependent recurrent pericarditis not responsive to colchicine, consider:
  • IV immunoglobulin
  • Anakinra
  • Azathioprine 1, 5
• Pericardiectomy may be considered as a last resort after thorough unsuccessful medical therapy 1, 3

Common Pitfalls and Caveats

• Inadequate treatment of the first episode is a common cause of recurrence 1, 2
• Recurrence rates after initial episode range from 15-30% without colchicine, increasing to 50% after first recurrence 1, 3
• 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, 2
• Cardiac tamponade rarely occurs in idiopathic pericarditis but is more common with specific etiologies like malignancy or tuberculosis 1, 3
• Rapid tapering of anti-inflammatory drugs (within 1 month) may increase risk of recurrence 5, 3