What is the treatment for pericarditis?

Treatment of Pericarditis

The first-line treatment for pericarditis consists of high-dose aspirin or NSAIDs combined with colchicine, with treatment duration guided by symptom resolution and CRP normalization. 1

First-Line Treatment

• 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
• Colchicine should be added to NSAIDs/aspirin as part of first-line therapy with weight-adjusted dosing: 0.5 mg once daily if <70 kg or 0.5 mg twice daily if ≥70 kg 2, 1
• Colchicine treatment should be continued for at least 3 months in acute pericarditis and 6 months in recurrent pericarditis 1, 3
• Treatment duration should be guided by symptom resolution and C-reactive protein (CRP) normalization 1
• Tapering should be considered by gradually decreasing doses (e.g., aspirin by 250-500 mg every 1-2 weeks) 2, 1

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 has failed
  • Infectious causes have been excluded 1, 3
• Corticosteroids are NOT recommended as first-line therapy due to the risk of promoting chronicity, recurrences, and side effects 2, 1
• If corticosteroids are necessary, maintain the initial dose until symptoms resolve and CRP normalizes, then taper gradually 3
• For prednisone doses >50 mg, taper by 10 mg/day every 1-2 weeks; for 50-25 mg, taper by 5-10 mg/day every 1-2 weeks; for 25-15 mg, taper by 2.5 mg/day every 2-4 weeks; for <15 mg, taper by 1.25-2.5 mg/day every 2-6 weeks 2

Third-Line Treatment

• For corticosteroid-dependent recurrent pericarditis not responsive to colchicine, consider:
  • Intravenous immunoglobulin (IVIG) 3
  • Anakinra (IL-1 receptor antagonist) 3, 4
  • Azathioprine 2, 3
• These options require careful assessment of costs and risks, and consultation with immunologists/rheumatologists 2

Fourth-Line Treatment

• Pericardiectomy may be considered as a last resort, but only after thorough trial of unsuccessful medical therapy 2, 3
• This procedure requires referral to a center with specific expertise 3

Special Considerations

• Exercise restriction should be maintained until symptoms resolve and CRP, ECG, and echocardiogram normalize 2, 1
• For athletes, exercise restriction should last at least 3 months 2, 1
• Tapering of medications should only be attempted when symptoms are absent and CRP is normal 1, 3
• Outpatient management is appropriate for non-high-risk cases with NSAIDs and colchicine 1

Prognosis and Complications

• Recurrence rates after initial episode range from 15-30% without colchicine, increasing to 50% after first recurrence 2, 5
• Colchicine can reduce recurrence rates by approximately 50% 2, 5
• 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 2, 1
• Cardiac tamponade rarely occurs in idiopathic pericarditis but is more common with specific etiologies like malignancy or purulent pericarditis 2

Common Pitfalls to Avoid

• Inadequate treatment of the first episode is a common cause of recurrence 2, 1
• Using corticosteroids as first-line therapy can increase risk of chronicity and recurrence 2, 1
• Tapering medications too quickly can lead to symptom recurrence 2, 1
• Failure to add colchicine to NSAIDs significantly increases recurrence risk 5
• Continuing treatment without monitoring CRP for normalization 1