Colchicine Dosing for Acute Pericarditis
For acute pericarditis, colchicine should be dosed at 0.5 mg once daily for patients weighing less than 70 kg or 0.5 mg twice daily for patients weighing 70 kg or more, continued for 3 months as adjunctive therapy to NSAIDs or aspirin. 1, 2
Weight-Adjusted Dosing Regimen
The dosing is straightforward and based solely on body weight:
This weight-adjusted approach differs from older studies that used higher doses (1.0-2.0 mg loading dose followed by 0.5-1.0 mg daily), but current guidelines favor lower doses to minimize gastrointestinal side effects while maintaining efficacy. 1, 4, 5
Treatment Duration
Colchicine should be continued for 3 months for the first episode of acute pericarditis. 1, 3, 2 This duration is based on high-quality evidence showing significant reduction in recurrence rates when colchicine is used for this period. 1, 4
For recurrent pericarditis (first recurrence), the duration extends to at least 6 months. 6, 5
Integration with Other Therapies
Colchicine must be added on top of aspirin (750-1000 mg every 8 hours) or ibuprofen (600 mg every 8 hours), not used as monotherapy. 1, 2 The combination of NSAIDs plus colchicine is now considered first-line therapy with Class I, Level A recommendation from the European Society of Cardiology. 1
Gastroprotection should be provided when using NSAIDs. 1, 2
Tapering Considerations
Tapering of colchicine is not mandatory but may be considered in the final weeks of treatment. 1 If tapering is chosen:
In contrast, NSAIDs should be tapered gradually (aspirin by 250-500 mg every 1-2 weeks, ibuprofen by 200-400 mg every 1-2 weeks) after symptoms resolve and C-reactive protein normalizes. 1, 2
Evidence for Efficacy
The recommendation for colchicine is supported by robust evidence:
- Reduces recurrence rate from 32-37% to 11-17% in patients with acute pericarditis, with a number needed to treat of 4-5. 4, 7
- Improves symptom relief at 72 hours (88% vs 63% with conventional therapy alone). 4
- Meta-analysis of randomized controlled trials confirms significant benefit (hazard ratio 0.40 for recurrence prevention). 7
Monitoring and Treatment Duration Guidance
Treatment length should be guided by symptom resolution and normalization of C-reactive protein (CRP). 1, 2 The 3-month duration for colchicine is fixed, but NSAID duration (typically 1-2 weeks) depends on inflammatory marker response. 1, 2
Do not attempt tapering of any medication until symptoms are completely absent and CRP is normalized. 2, 8
Common Pitfalls to Avoid
Inadequate treatment of the first episode is the most common cause of recurrence. 2 Specific pitfalls include:
- Premature discontinuation: Stopping colchicine before 3 months increases recurrence risk from 10-17% to 32-37%. 4, 7
- Using corticosteroids as first-line therapy: This increases recurrence risk (odds ratio 4.30) and promotes chronicity. 4, 5 Corticosteroids should only be used when NSAIDs and colchicine are contraindicated or have failed. 1, 2
- Inadequate NSAID dosing or duration: NSAIDs must be used at full anti-inflammatory doses, not analgesic doses. 1, 2
Adverse Effects and Discontinuation
Gastrointestinal side effects, primarily diarrhea, occur in approximately 8-10% of patients and may require discontinuation. 4, 7 However, the lower weight-adjusted dosing reduces this risk compared to historical higher-dose regimens. 1
The risk of stopping treatment due to adverse events is higher with colchicine (relative risk 1.87) but the absolute increase is small, and no serious adverse effects have been reported in clinical trials. 7
Special Populations
For post-operative pericarditis (post-cardiac injury syndrome), the same weight-adjusted dosing applies, but colchicine should only be initiated when systemic inflammation is confirmed (elevated CRP plus at least 2 of 5 criteria: fever, chest pain, pericardial/pleural rubs, pericardial or pleural effusion). 3 Colchicine is not recommended for asymptomatic postoperative effusions without inflammation. 3