What is the treatment for pericarditis?

Treatment of Pericarditis

First-line treatment for acute pericarditis consists of high-dose NSAIDs (aspirin 750-1000 mg every 8 hours or ibuprofen 600 mg every 8 hours) combined with colchicine (0.5 mg twice daily if ≥70 kg, or 0.5 mg once daily if <70 kg) for 3 months, with gastroprotection. 1

Initial Management Algorithm

First-Line Therapy (Start Immediately)

NSAIDs or Aspirin:

• Aspirin 500-1000 mg every 6-8 hours (total 1.5-4 g/day) OR ibuprofen 600 mg every 8 hours (total 1200-2400 mg/day) 2, 1
• Continue for 1-2 weeks at full dose until symptoms resolve and CRP normalizes 1, 3
• Taper gradually: decrease aspirin by 250-500 mg every 1-2 weeks, or ibuprofen by 200-400 mg every 1-2 weeks 2
• Always provide gastroprotection (proton pump inhibitor) 1

Colchicine (Mandatory Addition):

• Weight-adjusted dosing: 0.5 mg twice daily if ≥70 kg, or 0.5 mg once daily if <70 kg 2, 1
• Continue for 3 months minimum 1, 3
• This combination reduces recurrence from 37.5% to 16.7% (absolute risk reduction 20.8%) 3

Monitoring Response

• Use CRP levels to guide treatment duration and assess response 1
• Only attempt tapering when symptoms are absent AND CRP is normal 2, 1
• Taper one drug class at a time before discontinuing colchicine 2

Activity Restriction

• Restrict exercise until symptoms resolve and CRP, ECG, and echocardiogram normalize 2, 1
• For athletes specifically: minimum 3 months of exercise restriction 2, 1

Second-Line Therapy (When First-Line Fails)

Corticosteroids are NOT first-line therapy because they promote chronicity, increase recurrence rates, and cause more side effects. 2, 1

Use corticosteroids only if:

• True contraindication to NSAIDs (allergy, recent peptic ulcer, gastrointestinal bleeding, high bleeding risk on anticoagulation) 2
• Failure of NSAIDs plus colchicine after adequate trial 1
• Specific indications: systemic inflammatory diseases, post-pericardiotomy syndrome, pregnancy 2
• Infectious causes (especially bacterial and TB) have been excluded 2

Corticosteroid Dosing (if required):

• Start low-to-moderate dose: prednisone 0.2-0.5 mg/kg/day 2, 1
• Add to NSAIDs and colchicine as triple therapy—do not replace them 2
• Taper extremely slowly using this protocol 2:

  • 50 mg: decrease by 10 mg every 1-2 weeks

  • 50-25 mg: decrease by 5-10 mg every 1-2 weeks
  • 25-15 mg: decrease by 2.5 mg every 2-4 weeks
  • <15 mg: decrease by 1.25-2.5 mg every 2-6 weeks (critical threshold for recurrence) 2
• Provide calcium 1200-1500 mg/day plus vitamin D 800-1000 IU/day 2
• Consider bisphosphonates for men ≥50 years and postmenopausal women on long-term therapy 2

Recurrent Pericarditis Management

For first recurrence:

• Continue NSAIDs/aspirin at full doses 2
• Extend colchicine to at least 6 months (not 3 months) 2, 3
• If inadequate response, add low-dose corticosteroids as triple therapy 2

For multiple recurrences or corticosteroid-dependent disease:

• Consider IL-1 blockers (anakinra, rilonacept, goflikicept) before escalating corticosteroid doses 2, 3, 4
• Alternative immunomodulatory agents: IVIG, azathioprine (require multidisciplinary consultation with immunology/rheumatology) 2, 5
• Pericardiectomy only as last resort after thorough trial of medical therapy at specialized centers 2, 5

Critical Pitfalls to Avoid

Inadequate initial treatment is the most common cause of recurrence. 2, 1

• Never use corticosteroids as first-line therapy—they increase recurrence rates from 15-30% to 50% after first recurrence 2, 1
• Do not taper medications while symptoms persist or CRP remains elevated 2, 1
• Avoid rapid tapering of any medication, especially corticosteroids 2
• Do not increase corticosteroid dose or reinstate them if recurrence occurs during taper—instead optimize NSAIDs and colchicine 2
• Ensure adequate treatment duration: weeks to months, not days 2

Special Etiologies Requiring Different Approaches

Tuberculous pericarditis:

• Antituberculous therapy: isoniazid 300 mg/day, rifampin 600 mg/day, pyrazinamide 15-30 mg/kg/day, ethambutol 15-25 mg/kg/day 6
• Add prednisone 1-2 mg/kg/day for 5-7 days, then taper over 6-8 weeks 6
• Mortality approaches 85% if untreated 6
• High risk (20-30%) of developing constrictive pericarditis 2

Purulent/bacterial pericarditis:

• Urgent pericardial drainage is mandatory 6
• IV antibiotics: vancomycin 1g twice daily, ceftriaxone 1-2g twice daily, ciprofloxacin 400 mg/day 6
• Open surgical drainage preferred over catheter drainage 6
• 40% mortality even with treatment; fatal if untreated 6

Autoimmune/post-pericardiotomy syndrome:

• Same first-line therapy (NSAIDs + colchicine), but corticosteroids may be added earlier 2, 7
• Intermediate risk (2-5%) of constrictive pericarditis 2