What is the drug of choice for treating pericarditis?

Drug Treatment for Pericarditis

The first-line treatment for pericarditis consists of aspirin or NSAIDs (particularly ibuprofen) combined with colchicine, with NSAIDs serving as the mainstay of therapy. 1, 2

First-Line Treatment Algorithm

NSAIDs/Aspirin

• Aspirin (750-1000 mg every 8 hours) or ibuprofen (600 mg every 8 hours) should be used as initial therapy for 1-2 weeks 1, 2
• Choice between aspirin and NSAIDs should be based on:
  • Patient history and contraindications 1
  • Presence of concomitant diseases (favoring aspirin when antiplatelet therapy is already needed) 1
  • Previous efficacy or side effects 1
• Gastroprotection should be provided with NSAID therapy 1, 2
• Treatment duration should be guided by symptom resolution and CRP normalization 1, 2
• Tapering should be considered by gradually decreasing doses:
  • Aspirin: decrease by 250-500 mg every 1-2 weeks 1
  • Ibuprofen: decrease by 200-400 mg every 1-2 weeks 1

Colchicine (Add-on to NSAIDs/Aspirin)

• Colchicine should be added to NSAIDs/aspirin as part of first-line therapy 1, 2
• Weight-adjusted dosing:
  • <70 kg: 0.5 mg once daily 1, 2
  • ≥70 kg: 0.5 mg twice daily 1, 2
• Treatment duration: 3 months 1, 2
• Tapering is not mandatory but may be considered to prevent symptom persistence and recurrence 1

Second-Line Treatment

• Corticosteroids should only be considered when:
  • NSAIDs and colchicine have failed 1, 2
  • Contraindications to NSAIDs/colchicine exist 1, 2
  • Infectious causes have been excluded 1
  • Specific indications such as autoimmune disease are present 1
• If corticosteroids are necessary, use low to moderate doses (prednisone 0.2-0.5 mg/kg/day) rather than high doses 1, 2
• Corticosteroids should be maintained until symptom resolution and CRP normalization, then tapered gradually 1

Special Considerations

• For patients on anticoagulants, corticosteroids may be considered as first-line therapy due to bleeding risk with NSAIDs 3
• Exercise restriction is recommended until symptoms resolve and CRP normalizes 1, 2
• For athletes, exercise restriction should last at least 3 months 1, 2
• Serum CRP should be monitored to guide treatment duration and assess response 1, 2

Management of Recurrent Pericarditis

• Colchicine has proven efficacy for preventing and treating recurrences 4, 5
• For multiple recurrences, colchicine added to conventional anti-inflammatory treatment significantly reduces subsequent recurrences (NNT = 5) 4
• Immunosuppressive agents (azathioprine, methotrexate, mycophenolate mofetil) may be considered for corticosteroid-dependent or resistant cases 6, 7
• IL-1 blockers (anakinra, rilonacept) can be used as third-line options in patients who cannot discontinue glucocorticoids 7

Pitfalls and Caveats

• Inadequate treatment of the first episode is a common cause of recurrence 2
• Corticosteroids provide rapid symptom control but may increase risk of chronicity and recurrence 1, 2
• Previous corticosteroid use is an independent risk factor for further recurrences (OR 2.89) 5
• Recurrence rates after initial episode range from 15-30% without colchicine, increasing to 50% after first recurrence 2
• Common adverse effects of colchicine include gastrointestinal intolerance and hepatotoxicity, but serious adverse events are rare 4