What is the initial treatment for a patient presenting with pericarditis?

Initial Treatment for Pericarditis

The initial treatment for a patient presenting with pericarditis should be high-dose NSAIDs (aspirin 750-1000 mg every 8 hours or ibuprofen 600 mg every 8 hours) plus colchicine for 1-2 weeks, with appropriate gastroprotection. 1

First-Line Therapy

• NSAIDs/Aspirin: First-line anti-inflammatory therapy for 1-2 weeks 2, 1

  • Aspirin: 750-1000 mg every 8 hours
  • Ibuprofen: 600 mg every 8 hours
  • Indomethacin: 25-50 mg every 8 hours (start at lower dose and titrate upward) 2
  • Continue until symptom resolution and CRP normalization 1

• Colchicine: Should be added to NSAIDs as part of first-line therapy 1, 3

  • Weight-adjusted dosing: 0.5 mg once daily if <70 kg or 0.5 mg twice daily if ≥70 kg 2, 1
  • Treatment duration: 3 months 1
  • Reduces recurrence rates by approximately 50% compared to NSAIDs alone 4, 3

Treatment Duration and Tapering

• Continue treatment until symptoms resolve and CRP normalizes 2, 1
• Taper NSAIDs gradually after symptom resolution 2
  • Aspirin: Decrease by 250-500 mg every 1-2 weeks
  • Ibuprofen: Decrease by 200-400 mg every 1-2 weeks 2
• Tapering should only be attempted when symptoms are absent and CRP is normal 2, 1

Risk Stratification

• Low-risk patients (no risk factors): Outpatient management with NSAIDs and colchicine 2, 1
• High-risk patients (any of the following): Consider hospital admission 2
  • High fever (>38°C/100.4°F)
  • Subacute course (symptoms developing over several days)
  • Large pericardial effusion (>20 mm)
  • Cardiac tamponade
  • Failure to respond to NSAIDs within 7 days 2

Second-Line Treatment

• Corticosteroids: Should be considered only when: 2, 1
  • Contraindications to NSAIDs/colchicine exist
  • First-line therapy fails
  • Infectious causes have been excluded
  • Low to moderate doses (prednisone 0.2-0.5 mg/kg/day) are preferred 2, 1
  • Caution: Corticosteroids provide rapid symptom control but may increase risk of chronicity and recurrence 1, 5

Activity Restrictions

• Restrict physical activity beyond ordinary sedentary life until symptoms resolve and CRP normalizes 2, 1
• For athletes, exercise restriction should last at least 3 months 2, 1

Important Considerations and Pitfalls

• Inadequate treatment of the first episode is a common cause of recurrence 1
• Without colchicine, recurrence rates are 15-30% after initial episode, increasing to 50% after first recurrence 1, 3
• Corticosteroids should be avoided as first-line therapy due to risk of promoting chronicity 2, 1
• If corticosteroids are necessary, very slow tapering is essential (as small as 1.0-2.5 mg decrements at intervals of 2-6 weeks) when below 10-15 mg/day of prednisone 2
• Risk of constrictive pericarditis varies by etiology: low (<1%) for idiopathic/viral, higher for bacterial causes (20-30%) 2, 1
• In North America and Western Europe, most cases (80-90%) are idiopathic or viral in origin 4, 6