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 for 3 months, with corticosteroids reserved only for specific indications or treatment failures. 1, 2

First-Line Therapy

NSAIDs/Aspirin

• Aspirin 500-1000 mg every 6-8 hours (range 1.5-4 g/day) OR ibuprofen 600 mg every 8 hours (range 1200-2400 mg/day) 1, 2
• Continue at full doses until complete symptom resolution and C-reactive protein (CRP) normalization, typically 1-2 weeks 1, 2
• Always provide gastroprotection 2
• Taper gradually: decrease aspirin by 250-500 mg every 1-2 weeks, or ibuprofen by 200-400 mg every 1-2 weeks 1
• Only taper when patient is asymptomatic and CRP is normal 1

Colchicine (Mandatory Addition)

• Weight-adjusted dosing: 0.5 mg once daily if <70 kg, or 0.5 mg twice daily if ≥70 kg 1, 2
• Duration: 3 months for first episode 1, 2
• No loading dose recommended 1
• Colchicine reduces recurrence rates from 37.5% to 16.7% (absolute risk reduction 20.8%) 3
• For recurrent pericarditis, extend colchicine to at least 6 months 1

Activity Restriction

• Restrict exercise until complete symptom resolution and normalization of CRP, ECG, and echocardiogram 1, 2
• For athletes: minimum 3 months restriction 1, 2

Second-Line Therapy (When First-Line Fails or Contraindicated)

Corticosteroids

• Use ONLY when: 1, 2

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

• Dosing: Prednisone 0.2-0.5 mg/kg/day (low to moderate doses) 1

• Add corticosteroids as triple therapy WITH aspirin/NSAIDs and colchicine, not as replacement 1

• Corticosteroids are NOT recommended as first-line therapy due to increased risk of recurrence and chronicity 1, 2

Corticosteroid Tapering Protocol 1

• >50 mg: decrease by 10 mg/day every 1-2 weeks
• 50-25 mg: decrease by 5-10 mg/day every 1-2 weeks
• 25-15 mg: decrease by 2.5 mg/day every 2-4 weeks
• <15 mg: decrease by 1.25-2.5 mg/day every 2-6 weeks
• Only taper when asymptomatic with normal CRP 1

Third-Line Therapy (Refractory Cases)

For corticosteroid-dependent recurrent pericarditis not responsive to colchicine: 1

• Anakinra (IL-1 receptor antagonist): reduces recurrences from 78% to 10% (RR 0.14) 4
• Intravenous immunoglobulin (IVIG) 1
• Azathioprine 1, 5
• These require consultation with immunology/rheumatology specialists 1

Fourth-Line: Pericardiectomy

• Reserved only after thorough trial of unsuccessful medical therapy 1
• Refer to centers with specific surgical expertise 1

Special Consideration: Post-MI Pericarditis

Early Post-MI Pericarditis (1-3 days after MI)

• Acetaminophen for symptomatic relief 1
• If symptoms persist: high-dose aspirin 500-1000 mg every 6-8 hours 1
• Consider colchicine 0.5-0.6 mg once or twice daily for 3 months 1
• Use once daily dosing if <70 kg 1

Late Post-MI Pericarditis (Dressler's Syndrome)

• Same treatment as early pericarditis but often requires additional therapy 1
• Avoid NSAIDs other than aspirin due to risk of impaired myocardial healing and rupture 1
• Avoid glucocorticoids due to increased risk of recurrent MI and myocardial rupture 1

Critical Pitfalls to Avoid

• Inadequate treatment of first episode is the most common cause of recurrence 1, 2
• Never use corticosteroids as first-line therapy - they provide rapid symptom control but increase recurrence rates from 15-30% to 50% 1, 2
• Never taper medications before symptoms resolve and CRP normalizes 1
• Never omit colchicine - it halves the recurrence rate 1
• Always exclude infectious causes before starting corticosteroids, particularly bacterial and tuberculous pericarditis 1, 6
• Recurrence rates: 15-30% after initial episode without colchicine, increasing to 50% after first recurrence, especially if treated with corticosteroids 1, 2

Monitoring Strategy

• Use CRP to guide treatment duration and assess response 1, 2
• Monitor for high-risk features: fever >38°C, large effusion >20mm, tamponade, failure to respond within 7 days 2
• Repeat echocardiogram to assess for complications 1
• Stop one drug class at a time during tapering 1