What is the treatment for pericarditis, specifically using ketorolac (NSAID)?

Ketorolac for Pericarditis

Ketorolac can be used as an NSAID option for acute pericarditis, but aspirin or ibuprofen are preferred first-line choices due to more extensive evidence and favorable dosing profiles; ketorolac is FDA-approved only for short-term use (≤5 days) which is insufficient for typical pericarditis treatment duration of 1-2 weeks. 1

First-Line Treatment Approach

Aspirin or NSAIDs combined with colchicine are the mainstay of therapy for acute pericarditis. 2, 3

Preferred NSAID Options

• Aspirin 750-1000 mg every 8 hours is the preferred choice, particularly in patients with:

  • Coronary artery disease (already requiring antiplatelet therapy) 2, 3
  • Heart failure 4
  • Renal disease 4
  • Treatment duration: 1-2 weeks, guided by symptom resolution and CRP normalization 2, 3
  • Tapering: Decrease by 250-500 mg every 1-2 weeks 2, 3

• Ibuprofen 600 mg every 8 hours is an alternative first-line option 2, 3

  • Inexpensive and accessible 4
  • Avoid in patients with CAD, heart failure, or renal disease 4
  • Same treatment duration and tapering approach as aspirin 2, 3

Ketorolac-Specific Considerations

Ketorolac has relative evidence for pericarditis treatment but faces significant practical limitations: 4

• FDA approval restricts use to ≤5 days maximum (combined IV/IM and oral routes) 1
• This duration is inadequate for typical pericarditis treatment, which requires 1-2 weeks of therapy 2, 3
• Available as IV/IM formulation, useful for patients unable to take oral medications 4
• Must be mindful of maximum dosing limits 4

Mandatory Colchicine Addition

Colchicine must be added to NSAID therapy as first-line treatment to improve response and prevent recurrences (reduces recurrence from 37.5% to 16.7%). 2, 3, 5

• Weight-adjusted dosing: 6, 3
  • 0.5 mg once daily if <70 kg
  • 0.5 mg twice daily if ≥70 kg
• Duration: 3 months 2, 6, 3
• Tapering not mandatory but may be considered 2

Treatment Monitoring and Duration

• Continue NSAIDs until complete symptom resolution AND CRP normalization 2, 3
• Gastroprotection is mandatory with all NSAIDs 2, 3
• Typical treatment duration: 1-2 weeks for uncomplicated cases 2, 3
• Begin tapering only after symptoms resolve and CRP normalizes 3

Activity Restriction

• Restrict physical activity beyond ordinary sedentary life until symptom resolution and CRP normalization 2
• Athletes require minimum 3-month restriction from competitive sports after symptom onset 2, 3
• Non-athletes may resume activity sooner once symptoms resolve 2

Second-Line Treatment (If NSAIDs Fail)

Corticosteroids should be considered only after NSAID/colchicine failure or contraindications, as they risk promoting chronicity and recurrence. 2, 3

• Low to moderate doses: prednisone 0.2-0.5 mg/kg/day (NOT 1.0 mg/kg/day) 2, 3
• Maintain initial dose until symptom resolution and CRP normalization, then taper slowly 2
• Corticosteroids are NOT first-line therapy 3, 5

Critical Pitfalls to Avoid

• Do not use ketorolac as monotherapy beyond 5 days - this violates FDA labeling and is insufficient for pericarditis 1
• Never start NSAIDs without colchicine - inadequate first-episode treatment is the most common cause of recurrence 3
• Avoid premature tapering - only taper when symptoms are absent AND CRP is normal 3
• Do not use corticosteroids first-line - they increase recurrence risk (50% after first recurrence vs. 15-30% without) 3, 5

Clinical Algorithm

1. Diagnose pericarditis (≥2 of: chest pain, ECG changes, pericardial effusion, friction rub) 5
2. Start aspirin 750-1000 mg q8h OR ibuprofen 600 mg q8h (NOT ketorolac due to 5-day limit) 2, 3
3. Add colchicine (weight-adjusted) for 3 months 6, 3
4. Provide gastroprotection 2, 3
5. Monitor CRP to guide treatment duration 3
6. Taper NSAIDs over 1-2 weeks once symptoms resolve and CRP normalizes 2, 3
7. If no response: Consider low-dose corticosteroids 3