What is the initial treatment for pericarditis?

Initial Treatment for Pericarditis

The initial treatment for pericarditis should be a combination of high-dose NSAIDs (aspirin 750-1000 mg every 8 hours or ibuprofen 600 mg every 8 hours) plus colchicine (0.5 mg once daily if <70 kg or 0.5 mg twice daily if ≥70 kg) for 3 months. 1

First-Line Therapy

• NSAIDs should be administered at anti-inflammatory doses with gastroprotection for 1-2 weeks, with treatment duration guided by symptom resolution and C-reactive protein (CRP) normalization 1
• Choice between aspirin and ibuprofen should be based on patient history, concomitant diseases, and contraindications 1
• Colchicine should be added to NSAIDs as part of first-line therapy to reduce the risk of recurrence (from 37.5% to 16.7%) 1, 2
• Treatment duration for colchicine should be 3 months for the first episode of pericarditis 1
• Tapering of NSAIDs should be considered only after symptoms resolve and CRP normalizes, by decreasing doses gradually (e.g., aspirin by 250-500 mg every 1-2 weeks) 1

Treatment Algorithm

1. Initial assessment:

   • For non-high-risk cases, outpatient management with NSAIDs and colchicine is recommended 1
   • Monitor response using CRP to guide treatment length 1

2. Treatment adjustment:

   • If no response to NSAIDs and colchicine, consider second-line therapy 1
   • Continue treatment until symptoms resolve and CRP normalizes 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 1
• If corticosteroids are necessary, use low to moderate doses (prednisone 0.2-0.5 mg/kg/day) rather than high doses 1, 3
• Corticosteroids are NOT recommended as first-line therapy due to risk of promoting chronicity, recurrences, and side effects 1

Special Considerations

• In patients taking anticoagulants (e.g., apixaban), low to moderate dose corticosteroids should be used as primary anti-inflammatory agent due to bleeding risk with NSAIDs, with colchicine as adjunctive therapy 3
• 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
• For patients with multiple recurrences, interleukin-1 (IL-1) blockers have demonstrated efficacy and may be preferred to corticosteroids 2, 4

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, 4
• 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
• When using corticosteroids, calcium (1,200-1,500 mg/day) and vitamin D (800-1,000 IU/day) supplementation should be provided to prevent bone loss 3
• Tapering of medications should only be attempted when symptoms are absent and CRP is normal 1