What is the recommended treatment for pericarditis?

Treatment of Pericarditis

The first-line treatment for pericarditis consists of high-dose aspirin or NSAIDs combined with colchicine, with treatment duration guided by symptom resolution and CRP normalization. 1

First-Line Treatment

• 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) or indomethacin (25-50 mg every 8 hours) should be used at full doses until complete symptom resolution 2
• Add colchicine (0.5 mg twice daily for patients ≥70 kg or 0.5 mg once daily for patients <70 kg) to aspirin/NSAIDs for at least 3 months for acute pericarditis and 6 months for recurrent pericarditis 2, 1
• Treatment duration should be guided by symptoms and C-reactive protein (CRP) normalization 2
• Gastroprotection should be considered when using high-dose NSAIDs or aspirin 1

Treatment Algorithm

1. Initial therapy: High-dose NSAIDs/aspirin + colchicine + exercise restriction 2
2. Monitoring: Use CRP levels to guide treatment duration and assess response 2
3. Tapering: After CRP normalization, gradually taper medications by decreasing doses (e.g., aspirin by 250-500 mg every 1-2 weeks) 2

Second-Line Treatment

• Low-dose corticosteroids (prednisone 0.2-0.5 mg/kg/day) should be used only when:
  • Contraindications to aspirin/NSAIDs/colchicine exist 2
  • First-line therapy fails 2
  • Infectious causes have been excluded 2
• Corticosteroids are not recommended as first-line therapy due to increased risk of chronicity and recurrence 2

Third-Line Treatment

• For corticosteroid-dependent recurrent pericarditis not responsive to colchicine, consider:
  • Intravenous immunoglobulin (IVIG) 2, 3
  • Anakinra (IL-1 receptor antagonist) 2, 3, 4
  • Azathioprine 2, 3

Fourth-Line Treatment

• Pericardiectomy may be considered as a last resort after thorough trial of unsuccessful medical therapy 2, 3

Special Considerations

Exercise Restrictions

• Non-athletes: Restrict exercise until symptom resolution and CRP normalization 2
• Athletes: Restrict exercise for at least 3 months until symptom resolution and normalization of CRP, ECG, and echocardiogram 2

Myopericarditis Management

• Similar to pericarditis management but some authors recommend reduced NSAID dosages 2
• Rest and avoidance of physical activity beyond normal sedentary activities is recommended 2
• Return to physical exercise contraindicated for at least 6 months from illness onset 2

Prognosis and Complications

• Recurrence rates: 15-30% after initial episode without colchicine, increasing to 50% after first recurrence 2, 4
• Risk of constrictive pericarditis varies by etiology:
  • Low (<1%) for idiopathic/viral pericarditis 2, 1
  • Intermediate (2-5%) for autoimmune/neoplastic causes 2
  • High (20-30%) for bacterial etiologies 2
• Cardiac tamponade is rare in idiopathic pericarditis but more common with specific etiologies like malignancy or purulent pericarditis 2

Common Pitfalls

• Inadequate treatment of the first episode is a common cause of recurrence 2
• Corticosteroids provide rapid symptom control but increase risk of chronicity and recurrence 1
• Tapering medications too quickly can lead to symptom recurrence 2
• When symptoms recur during therapy tapering, don't increase corticosteroid dose; instead maximize aspirin/NSAID dosing and ensure colchicine is being used 2