What is the initial management for pericarditis?

Initial Management of 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, unless contraindications exist. 1

First-Line Therapy Algorithm

Standard Treatment Regimen

• NSAIDs form the cornerstone: Choose aspirin 750-1000 mg every 8 hours OR ibuprofen 600 mg every 8 hours, administered with gastroprotection for 1-2 weeks 1
• Always add colchicine: Weight-adjusted dosing at 0.5 mg once daily (<70 kg) or 0.5 mg twice daily (≥70 kg) for 3 months to reduce recurrence from 37.5% to 16.7% 1, 2
• Selection between aspirin versus ibuprofen depends on patient comorbidities, contraindications, and concurrent medications 1

Treatment Duration and Monitoring

• Continue NSAIDs until complete symptom resolution AND C-reactive protein (CRP) normalization, typically 1-2 weeks 1
• Monitor CRP levels to guide treatment duration and assess therapeutic response 1
• Taper NSAIDs gradually once asymptomatic and CRP normalized: decrease aspirin by 250-500 mg every 1-2 weeks 1
• Continue colchicine for full 3-month course even after NSAID discontinuation 1

Risk Stratification for Outpatient vs. Inpatient Management

• Outpatient management appropriate for patients without high-risk features 1
• Hospitalization required if any of the following present: fever >38°C, large effusion >20mm, tamponade, or failure to respond to NSAIDs within 7 days 3, 2

Second-Line Therapy

When to Use Corticosteroids

Corticosteroids should NOT be first-line therapy due to increased risk of chronicity and recurrence 1, 3

Use low-dose corticosteroids (prednisone 0.2-0.5 mg/kg/day) ONLY when: 1

• Contraindication to NSAIDs/colchicine exists
• First-line therapy fails after adequate trial
• Infectious causes definitively excluded
• Patient on anticoagulation (bleeding risk with NSAIDs) 4

Corticosteroid Tapering Protocol

When corticosteroids are necessary, use structured tapering: 4

• >50 mg/day: Decrease by 10 mg every 1-2 weeks
• 50-25 mg/day: Decrease by 5-10 mg every 1-2 weeks
• 25-15 mg/day: Decrease by 2.5 mg every 2-4 weeks
• <15 mg/day: Decrease by 1.25-2.5 mg every 2-6 weeks
• Taper only when patient asymptomatic and CRP normalized 4

Special Considerations

Exercise Restriction

• Restrict all exercise until symptoms resolve AND CRP, ECG, and echocardiogram normalize 1
• Athletes require minimum 3-month restriction from competitive sports 1

Anticoagulation Management

• For patients on anticoagulants (e.g., apixaban), use corticosteroids as primary anti-inflammatory agent instead of NSAIDs due to bleeding risk 4
• Still add colchicine as adjunctive therapy 4
• Consider temporary anticoagulation interruption for procedures: 24 hours before low-risk procedures, 3 days before high-risk procedures 4

Etiology-Specific Modifications

• Post-cardiac procedure pericarditis: Same NSAID + colchicine regimen 2
• Lupus/autoimmune pericarditis: Same initial approach, but may require earlier corticosteroid use if associated with active systemic disease 3
• Tuberculous pericarditis: Requires antituberculous therapy (isoniazid, rifampin, pyrazinamide, ethambutol) PLUS prednisone 1-2 mg/kg/day for 5-7 days, tapered over 6-8 weeks 5
• Purulent pericarditis: Urgent pericardial drainage plus IV antibiotics (vancomycin, ceftriaxone, ciprofloxacin); mortality 40% even with treatment 5

Critical Pitfalls to Avoid

Common Causes of Treatment Failure

• Inadequate treatment of first episode is the most common cause of recurrence 1
• Premature discontinuation before CRP normalization leads to relapse 3
• Starting corticosteroids too early increases recurrence risk from 15-30% to 50% after first recurrence 1
• Failing to add colchicine to NSAIDs—this single intervention reduces recurrence by absolute 20.8% 2

Monitoring for Complications

• Constrictive pericarditis risk varies by etiology: <1% for idiopathic/viral, 2-5% for autoimmune, 20-30% for bacterial 1, 3
• Tamponade rarely occurs in idiopathic cases (<3%) but more common with malignancy or purulent pericarditis 1, 2
• Assess response after 1 week; if no improvement, consider second-line therapy rather than continuing ineffective regimen 4

Bone Protection with Corticosteroids

• All patients on corticosteroids require calcium (1,200-1,500 mg/day) and vitamin D (800-1,000 IU/day) supplementation 4
• Consider bisphosphonates for men ≥50 years and postmenopausal women on prolonged corticosteroid therapy 4

Refractory Cases

• For patients failing NSAIDs, colchicine, and corticosteroids, consider immunomodulatory agents (azathioprine, IVIG) or IL-1 receptor antagonists (anakinra) 4, 2
• Pericardiectomy reserved as last resort after medical therapy failure 4