What is the recommended titration for pericarditis treatment, including nonsteroidal anti-inflammatory drugs (NSAIDs), aspirin, colchicine, and corticosteroids like prednisone?

Pericarditis Treatment Titration

Start with aspirin 750-1000 mg every 8 hours or ibuprofen 600 mg every 8 hours plus weight-adjusted colchicine (0.5 mg once daily if <70 kg, 0.5 mg twice daily if ≥70 kg) for at least 3 months, tapering NSAIDs/aspirin gradually only after symptoms resolve and CRP normalizes. 1

First-Line Therapy: NSAIDs/Aspirin + Colchicine

Initial Dosing

• Aspirin: 500-1000 mg every 6-8 hours (total daily dose 1.5-4 g/day) 2
• Ibuprofen: 600 mg every 8 hours (total daily dose 1200-2400 mg) 2
• Indomethacin: 25-50 mg every 8 hours, starting at the lower end to avoid headache and dizziness 2
• Colchicine: 0.5 mg once daily if body weight <70 kg OR 0.5 mg twice daily if ≥70 kg, without a loading dose 2, 1

Treatment Duration

• NSAIDs/aspirin should be continued for weeks to months, guided by symptom resolution and CRP normalization 2, 1
• Colchicine must be continued for at least 3-6 months for initial episodes 1, 3
• For first recurrence, extend colchicine to at least 6 months 4

Tapering NSAIDs/Aspirin

Critical principle: Only attempt tapering when symptoms are completely absent and CRP is normal 2

• Aspirin: Decrease by 250-500 mg every 1-2 weeks 2
• Ibuprofen: Decrease by 200-400 mg every 1-2 weeks 2
• Indomethacin: Decrease by 25 mg every 1-2 weeks 2
• Longer tapering periods (extending to several months) should be used for difficult, resistant cases 2

Tapering Colchicine

• Colchicine tapering is not necessary in most cases 2
• Alternative approach for patients <70 kg: reduce to 0.5 mg every other day before discontinuation 2
• After obtaining complete response, taper one drug class at a time before gradually discontinuing colchicine over several months in difficult cases 2

Second-Line Therapy: Corticosteroids

When to Use Corticosteroids

Corticosteroids should be added to, not replace NSAIDs/aspirin and colchicine as triple therapy in these specific situations: 2

• Incomplete response to aspirin/NSAIDs and colchicine
• Specific indications: systemic inflammatory diseases, post-pericardiotomy syndrome, pregnancy 2
• True NSAID allergy, recent peptic ulcer/GI bleeding, high bleeding risk with anticoagulation 2
• NSAID intolerance or persistent disease despite appropriate doses 2

Critical caveat: Corticosteroids provide rapid symptom control but promote chronicity, increase recurrence rates, and cause more side effects 2, 1

Corticosteroid Dosing

• Initial dose: Prednisone 0.2-0.5 mg/kg/day (low to moderate doses) 2, 1
• Never use corticosteroids as first-line therapy 1, 3

Corticosteroid Tapering Algorithm

This is the most critical aspect—tapering must be extremely slow: 2

Current Prednisone Dose	Tapering Schedule
>50 mg/day	Decrease by 10 mg every 1-2 weeks [2]
50-25 mg/day	Decrease by 5-10 mg every 1-2 weeks [2]
25-15 mg/day	Decrease by 2.5-5 mg every 2-4 weeks [2]
15-10 mg/day (CRITICAL THRESHOLD)	Decrease by 1.0-2.5 mg every 2-6 weeks [2]
<10 mg/day	Decrease by 1.0-2.5 mg every 2-6 weeks [2]

The 10-15 mg/day threshold is where most recurrences occur—use extremely small decrements at this point 2

Sequential Tapering Strategy

When achieving complete response, follow this order: 2

1. Taper one drug class at a time
2. Complete NSAID/aspirin taper first
3. Then taper corticosteroids (if used) using the slow schedule above
4. Finally discontinue colchicine last, over several months in difficult cases

Each tapering attempt should only occur when symptoms are absent and CRP is normal 2

Common Pitfalls to Avoid

• Inadequate treatment of first episode is the most common cause of recurrence 1
• Never increase corticosteroid dose or reinstate steroids if recurrence occurs—instead, optimize NSAIDs and colchicine 2
• Avoid rapid tapering (within 1 month)—this significantly increases recurrence risk 3
• Do not taper multiple drugs simultaneously—taper one class at a time 2
• Corticosteroids at high doses are associated with higher recurrence rates—use low to moderate doses only 2, 5
• Recurrence rates increase from 15-30% without colchicine to 50% after first recurrence 1

Monitoring During Tapering

• Use CRP levels to guide treatment length and assess response 1, 6
• Symptoms must be completely absent before attempting any dose reduction 2
• Recurrences are possible after discontinuation of each drug 2
• If recurrence occurs during tapering, return to the previous effective dose and maintain longer before attempting slower taper 2