What is the initial treatment for pericarditis?

Initial Treatment for Pericarditis

The initial treatment for pericarditis should consist of high-dose NSAIDs (aspirin 750-1000 mg every 8 hours or ibuprofen 600 mg every 8 hours) combined with colchicine as first-line therapy. 1

First-Line Treatment Algorithm

NSAIDs

• Aspirin (750-1000 mg every 8 hours) or ibuprofen (600 mg every 8 hours) should be administered for 1-2 weeks with gastroprotection 1
• The choice between NSAIDs should be based on patient history, concomitant diseases, and contraindications 1
• Continue treatment until complete symptom resolution and normalization of C-reactive protein (CRP) 1
• Taper medication gradually (e.g., aspirin by 250-500 mg every 1-2 weeks) after symptoms resolve and CRP normalizes 1

Colchicine

• Must be added to NSAIDs/aspirin as part of first-line therapy to reduce recurrence risk 1, 2
• Use weight-adjusted dosing: 0.5 mg once daily if <70 kg or 0.5 mg twice daily if ≥70 kg 1, 3
• Continue colchicine for 3 months to significantly reduce recurrence rates (16.7% vs 37.5% without colchicine) 1, 2

Risk Stratification and Management Setting

• Assess for high-risk features: fever >38°C, large effusion >20mm, tamponade, or failure to respond to NSAIDs within 7 days 3
• For non-high-risk cases, outpatient management with NSAIDs plus colchicine is recommended 1, 3
• Monitor treatment response using CRP to guide treatment duration 1

Second-Line Treatment

• Low-dose corticosteroids (prednisone 0.2-0.5 mg/kg/day) should be considered only when: 1
  • NSAIDs/colchicine are contraindicated
  • First-line therapy fails
  • Infectious causes have been excluded
• Corticosteroids are NOT recommended as first-line therapy due to their association with increased risk of chronicity and recurrence 1, 2
• Despite traditional concerns, recent evidence suggests that low-dose steroids with very gradual tapering may be effective without increasing recurrence rates in selected cases 4

Activity Restrictions and Follow-up

• Exercise restriction should be maintained until symptoms resolve and CRP, ECG, and echocardiogram normalize 1
• For athletes, exercise restriction should last at least 3 months 1
• Tapering of medications should only begin when symptoms are absent and CRP is normal 1, 3

Common Pitfalls and Caveats

• Inadequate treatment of the first episode is a common cause of recurrence - ensure full dosing and duration 1
• Premature discontinuation of therapy before complete resolution of symptoms and normalization of inflammatory markers increases recurrence risk 3
• Failure to add colchicine to NSAIDs significantly increases recurrence rates 3, 5
• Recurrence rates after initial episode range from 15-30% without colchicine, increasing to 50% after first recurrence 1
• Risk of constrictive pericarditis varies by etiology: low (<1%) for idiopathic/viral, intermediate (2-5%) for autoimmune, and high (20-30%) for bacterial causes 1
• Transthoracic echocardiography should be performed in all patients to characterize effusion size and evaluate for complications 6

Special Considerations

• For specific etiologies like tuberculosis (common in endemic areas), targeted therapy with antitubercular medications is required 2
• In patients with multiple recurrences, interleukin-1 blockers have demonstrated efficacy and may be preferred to corticosteroids 2, 5
• For patients with autoimmune conditions like lupus, treatment should address the underlying disease activity 3