What are the treatment guidelines for pericarditis?

Treatment Guidelines for Pericarditis

First-line treatment for pericarditis should include aspirin or NSAIDs combined with colchicine, with exercise restriction until symptoms resolve and laboratory markers normalize. 1

Acute Pericarditis Treatment Algorithm

First-Line Therapy

• Aspirin (750-1000 mg every 8 hours) or ibuprofen (600 mg every 8 hours) for 1-2 weeks with gastroprotection 1
• Colchicine as adjunctive therapy: 0.5 mg once daily if <70 kg or 0.5 mg twice daily if ≥70 kg for 3 months 1, 2
• Treatment duration guided by symptom resolution and CRP normalization 1, 2
• Tapering of NSAIDs: decrease aspirin by 250-500 mg every 1-2 weeks or ibuprofen by 200-400 mg every 1-2 weeks 1
• Exercise restriction until symptoms resolve and CRP, ECG, and echocardiogram normalize 1, 2
  • For non-athletes: until remission 1
  • For athletes: minimum 3 months restriction 1

Second-Line Therapy

• Low-dose corticosteroids (prednisone 0.2-0.5 mg/kg/day) only when:
  • Contraindications to NSAIDs/colchicine exist 1
  • First-line therapy fails 1, 2
  • Infectious causes have been excluded 1
  • Specific indications present (e.g., autoimmune disease) 1, 3
• Maintain initial corticosteroid dose until symptoms resolve and CRP normalizes, then taper gradually 1
• Corticosteroids are NOT recommended as first-line therapy due to risk of promoting chronicity and recurrences 1, 2

Recurrent Pericarditis Management

Definition and Risk

• Recurrent pericarditis: documented first episode, symptom-free interval of 4-6 weeks, and subsequent recurrence 1
• Recurrence rates: 15-30% after initial episode, up to 50% after first recurrence in patients not treated with colchicine 1, 3

Treatment Approach

1. First-line: Same as acute pericarditis but with longer duration

   • Aspirin/NSAIDs at full doses until complete symptom resolution 1
   • Colchicine 0.5 mg twice daily (or 0.5 mg daily if <70 kg) for at least 6 months 1

2. Second-line: Low-dose corticosteroids when first-line fails 1

3. Third-line: For corticosteroid-dependent cases not responsive to colchicine

   • IVIG, anakinra, or azathioprine may be considered 1, 4

4. Fourth-line: Pericardiectomy as last resort after thorough trial of unsuccessful medical therapy 1

Monitoring and Follow-up

• Use serum CRP to guide treatment length and assess response to therapy 1
• Taper medications only when symptoms are absent and CRP is normal 1
• When tapering, stop one drug at a time 1
• If symptoms recur during tapering, increase NSAIDs to maximum dose rather than increasing corticosteroids 1

Important Clinical Considerations and Pitfalls

• Inadequate treatment of the first episode is a common cause of recurrence 1, 3
• Risk of constrictive pericarditis varies by etiology: low (<1%) for idiopathic/viral, intermediate (2-5%) for autoimmune/neoplastic, 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 purulent pericarditis 1
• When selecting NSAIDs, consider patient history, concomitant diseases, and contraindications 1, 5
• For patients requiring antiplatelet therapy, aspirin is preferred over other NSAIDs 1, 5
• Colchicine significantly reduces recurrence rates and should not be omitted from treatment regimens 1, 2, 4
• Rapid tapering of medications (especially within 1 month) increases risk of recurrence 4, 6