What is the initial treatment for pericarditis?

Initial Treatment for Pericarditis

The first-line treatment for pericarditis consists of high-dose NSAIDs (such as aspirin 750-1000 mg every 8 hours or ibuprofen 600 mg every 8 hours) combined with colchicine for 1-2 weeks, with gastroprotection. 1

First-Line Therapy

• Aspirin (750-1000 mg every 8 hours) or ibuprofen (600 mg every 8 hours) should be administered for 1-2 weeks with gastroprotection 1, 2
• NSAIDs should be given at full anti-inflammatory doses until symptoms resolve and C-reactive protein normalizes 1, 3
• Colchicine must be added to NSAIDs as part of first-line therapy at weight-adjusted doses: 0.5 mg once daily if <70 kg or 0.5 mg twice daily if ≥70 kg 1, 3
• Colchicine treatment should be continued for 3 months to reduce recurrence rates (from 37.5% to 16.7%) 1, 3
• The choice between NSAIDs should be based on patient history, concomitant diseases, and contraindications 1

Treatment Duration and Monitoring

• Treatment should continue until complete symptom resolution and normalization of C-reactive protein (CRP) 1, 4
• Tapering should only begin after symptoms resolve and CRP normalizes 1
• When tapering NSAIDs, decrease doses gradually (e.g., aspirin by 250-500 mg every 1-2 weeks) 1, 5
• Exercise restriction is recommended until symptoms resolve and CRP, ECG, and echocardiogram normalize 1
• For athletes, exercise restriction should last at least 3 months 1

Second-Line Treatment

• Corticosteroids should NOT be used as first-line therapy due to their association with increased risk of chronicity and recurrence 1, 3
• 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, 5

Special Considerations

• For non-high-risk cases, outpatient management with NSAIDs and colchicine is appropriate 1, 4
• High-risk features requiring hospitalization include fever >38°C, large effusion >20mm, tamponade, or failure to respond to NSAIDs within 7 days 4, 6
• Aspirin should replace other NSAIDs in pericarditis complicating acute myocardial infarction 7
• Bacterial pericarditis requires urgent drainage and intravenous antibiotics 8
• Tuberculous pericarditis requires specific antituberculous therapy 3, 8

Common Pitfalls to Avoid

• Inadequate treatment of the first episode is a common cause of recurrence 1, 5
• Premature discontinuation of therapy before complete symptom resolution and CRP normalization 1, 4
• Overreliance on corticosteroids, which provide rapid symptom control but increase risk of chronicity and recurrence 1, 5
• Failure to add colchicine to NSAIDs, which significantly reduces recurrence rates 1, 3
• Using high-dose NSAIDs without gastroprotection, increasing risk of gastrointestinal complications 9