What is the initial treatment for pericarditis?

Initial Treatment for Pericarditis

The first-line treatment for pericarditis consists of high-dose NSAIDs (aspirin 750-1000 mg every 8 hours or ibuprofen 600 mg every 8 hours) combined with 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 high 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 must be added to NSAIDs as part of first-line therapy to reduce recurrence risk (recurrence rates are 15-30% without colchicine, increasing to 50% after first recurrence) 1, 2
• Tapering of NSAIDs should be gradual (e.g., aspirin by 250-500 mg every 1-2 weeks) and only attempted when symptoms are absent and CRP has normalized 1

Treatment Algorithm

1. Initial assessment and treatment:

   • For non-high-risk cases, initiate outpatient management with NSAIDs and colchicine 1
   • Monitor response using CRP levels to guide treatment duration 1, 2

2. Treatment adjustment:

   • If no response to first-line therapy, consider second-line options 1
   • Treatment should continue until symptoms resolve and CRP normalizes 1, 2

Second-Line Treatment

• Low-dose corticosteroids (prednisone 0.2-0.5 mg/kg/day) should be considered only when:
  • NSAIDs/colchicine are contraindicated
  • First-line therapy fails
  • Infectious causes have been excluded 1, 3
• Corticosteroids are NOT recommended as first-line therapy due to risk of promoting chronicity, recurrences, and side effects 1
• Recent evidence suggests that low-dose steroids with very gradual tapering may be effective and safe for treating acute and recurrent idiopathic pericarditis 4

Special Considerations

• For patients taking anticoagulants (e.g., apixaban), corticosteroids are recommended as primary anti-inflammatory agents due to high bleeding risk when combining anticoagulants with NSAIDs 5
• Exercise restriction should be maintained until symptoms resolve and CRP, ECG, and echocardiogram normalize (at least 3 months for athletes) 1
• For refractory cases not responding to corticosteroids and colchicine, consider immunomodulatory agents such as azathioprine, IVIG, or IL-1 receptor antagonists (anakinra) 5, 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 if used as first-line therapy 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
• Patients with multiple recurrent pericarditis can have a disease duration of several years 2
• Patients receiving glucocorticoids should receive calcium (1,200-1,500 mg/day) and vitamin D (800-1,000 IU/day) supplementation to prevent bone loss 5