What is the initial treatment for pericarditis?

Initial Treatment for Pericarditis

Start with aspirin (750-1000 mg every 8 hours) or ibuprofen (600 mg every 8 hours) PLUS colchicine (0.5 mg twice daily if ≥70 kg, once daily if <70 kg) for all patients with acute pericarditis, continuing NSAIDs for 1-2 weeks and colchicine for 3 months. 1

First-Line Therapy Algorithm

NSAIDs/Aspirin Selection

• Choose aspirin (750-1000 mg every 8 hours) or ibuprofen (600 mg every 8 hours) based on patient contraindications and comorbidities 1
• Always provide gastroprotection (proton pump inhibitor) with NSAID therapy 1
• Continue treatment every 8 hours until complete symptom resolution and CRP normalization 1
• Taper gradually once symptoms resolve: decrease aspirin by 250-500 mg every 1-2 weeks 1

Mandatory Colchicine Addition

• Add colchicine to NSAIDs as part of first-line therapy—this is NOT optional 1
• Weight-adjusted dosing: 0.5 mg once daily if <70 kg, 0.5 mg twice daily if ≥70 kg 1
• Continue for 3 months to reduce recurrence risk from 37.5% to 16.7% 2
• This combination reduces recurrence rates by 50% compared to NSAIDs alone 3

Monitoring Response

• Use CRP levels to guide treatment duration and assess therapeutic response 1
• Continue therapy until both symptoms resolve AND CRP normalizes 1
• Do not attempt tapering while symptoms persist or CRP remains elevated 1

Second-Line Therapy (When First-Line Fails)

Reserve corticosteroids only for specific situations—they are NOT first-line therapy 1

Indications for Corticosteroids

• Contraindication to NSAIDs/colchicine 1
• Failure of first-line therapy after adequate trial 1
• Infectious causes have been definitively excluded 1
• Pregnancy beyond 20 weeks gestation 4
• Systemic autoimmune diseases with active manifestations 5

Corticosteroid Dosing

• Use LOW doses only: prednisone 0.2-0.5 mg/kg/day 1, 5
• Avoid high-dose corticosteroids—they increase chronicity and recurrence risk 1
• Taper very gradually, especially with multiple recurrences 6

Activity Restriction

• Restrict exercise until symptoms resolve AND CRP, ECG, and echocardiogram normalize 1
• For athletes specifically: minimum 3-month exercise restriction 1
• This prevents complications during the inflammatory phase 1

Critical Pitfalls to Avoid

Most Common Mistake

Inadequate treatment of the first episode is the leading cause of recurrence 1

• Premature discontinuation before CRP normalization 5
• Failure to add colchicine to NSAIDs 5
• Starting with corticosteroids instead of NSAIDs 1

Corticosteroid Trap

• Corticosteroids provide rapid symptom relief but increase recurrence risk 1
• They promote chronicity and make subsequent episodes harder to treat 1
• Recurrence rates increase from 15-30% to 50% after first recurrence, especially with steroid use 1, 2

Treatment Duration Errors

• NSAIDs must continue for full 1-2 weeks minimum 1
• Colchicine must continue for full 3 months (6 months for first recurrence) 2
• Tapering too quickly leads to rebound inflammation 1

Risk Stratification for Complications

Constrictive Pericarditis Risk

• Idiopathic/viral: <1% risk 1
• Autoimmune/neoplastic: 2-5% risk 1, 5
• Bacterial: 20-30% risk 1

Tamponade Risk

• Rare in idiopathic pericarditis (<3%) 2
• Higher with malignancy or purulent pericarditis 1

Outpatient vs. Inpatient Management

Most non-high-risk cases can be managed outpatient with NSAIDs plus colchicine 1, 5

High-risk features requiring hospitalization include:

• Fever >38°C 5
• Large effusion >20mm 5
• Tamponade 5
• Failure to respond to NSAIDs within 7 days 5