What is the initial treatment for recurrent pericarditis syndrome?

Initial Treatment for Recurrent Pericarditis Syndrome

The initial treatment for recurrent pericarditis should consist of aspirin or NSAIDs as the mainstay of therapy, with colchicine added as an adjunctive agent to improve response rates and prevent further recurrences. 1, 2

First-Line Therapy

• Aspirin (500-1000 mg every 6-8 hours, range 1.5-4 g/day) or ibuprofen (600 mg every 8 hours, range 1200-2400 mg) should be used as first-line anti-inflammatory therapy for weeks to months 1, 2
• Indomethacin (25-50 mg every 8 hours) is another option, starting at the lower end of the dosing range to avoid headache and dizziness 1
• Gastroprotection should be provided with all NSAID regimens to prevent gastrointestinal complications 2
• Colchicine must be added to NSAIDs/aspirin as part of the initial treatment regimen using weight-adjusted doses: 0.5 mg once daily if <70 kg or 0.5 mg twice daily if ≥70 kg, for at least 6 months 1
• Colchicine has been shown to reduce recurrence rates by approximately 50% compared to conventional treatment alone 1, 3

Treatment Duration and Monitoring

• Treatment duration should be guided by symptoms and C-reactive protein (CRP) normalization 1, 2
• CRP should be monitored regularly to assess treatment response and guide therapy length 1
• Tapering should only be attempted when the patient is asymptomatic and CRP has normalized 1, 4
• When tapering NSAIDs, decrease doses gradually (aspirin by 250-500 mg every 1-2 weeks; ibuprofen by 200-400 mg every 1-2 weeks; indomethacin by 25 mg every 1-2 weeks) 1

Second-Line Therapy

• In cases of incomplete response to aspirin/NSAIDs and colchicine, low to moderate dose corticosteroids may be used 1
• Corticosteroids should be added as triple therapy with aspirin/NSAIDs and colchicine, not replace these drugs 1
• Use low to moderate doses (prednisone 0.2-0.5 mg/kg/day) only after excluding infections, particularly bacterial and TB 1, 5
• Corticosteroids should be restricted to patients with specific indications (systemic inflammatory diseases, post-pericardiotomy syndromes, pregnancy) or NSAID contraindications 1, 4
• If corticosteroids are necessary, taper very slowly, especially at the critical threshold of 10-15 mg/day of prednisone, with decrements as small as 1.0-2.5 mg at intervals of 2-6 weeks 1

Special Considerations

• Exercise restriction should be maintained until symptoms resolve and CRP, ECG, and echocardiogram normalize 1, 2
• For athletes, exercise restriction should last at least 3 months 2
• After obtaining complete response, tapering should be done with a single class of drug at a time, with colchicine gradually discontinued last (over several months in difficult cases) 1
• Influenza vaccine is not recommended as a preventive measure for pericarditis, as it may trigger or worsen episodes through immune stimulation 1

Management of Refractory Cases

• For patients who require unacceptably high long-term doses of corticosteroids or who do not respond to anti-inflammatory therapies, consider immunomodulatory agents 1
• Options include azathioprine, IVIG (immunomodulatory and anti-viral), or anakinra (IL-1β receptor antagonist) 1, 4
• Long-term prognosis is generally good even in difficult-to-treat patients with recurrent pericarditis 6

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, so they should not be used as first-line therapy 1, 2
• The recurrence rate after an initial episode ranges from 15-30% without colchicine, increasing to 50% after first recurrence 1
• Constrictive pericarditis is rare (<1%) in idiopathic and presumed viral pericarditis but more common with specific etiologies 1
• Always rule out underlying causes (especially bacterial, tuberculous, or neoplastic) before assuming idiopathic recurrent pericarditis 5