What is the recommended initial treatment for acute pericarditis?

Recommended Initial Treatment for Acute Pericarditis

The recommended initial treatment for acute pericarditis is combination therapy with aspirin (750-1000 mg every 8 hours) or ibuprofen (600 mg every 8 hours) PLUS colchicine (0.5 mg once daily if <70 kg or 0.5 mg twice daily if ≥70 kg) for 3 months, with gastroprotection. 1, 2

First-Line Therapy Algorithm

NSAIDs/Aspirin Component

• Aspirin 750-1000 mg every 8 hours OR Ibuprofen 600 mg every 8 hours for 1-2 weeks 1, 2
• Always provide gastroprotection (proton pump inhibitor) 1, 2
• Choose aspirin if patient already requires antiplatelet therapy for cardiovascular disease 1
• Treatment duration is guided by symptom resolution AND C-reactive protein (CRP) normalization 1, 2
• Taper gradually: decrease aspirin by 250-500 mg every 1-2 weeks or ibuprofen by 200-400 mg every 1-2 weeks 1

Colchicine Component (Mandatory Addition)

• Weight-adjusted dosing: 0.5 mg once daily if <70 kg; 0.5 mg twice daily if ≥70 kg 1, 2
• Duration: 3 months (not tapered with NSAIDs, continues for full 3 months) 1, 2
• Colchicine reduces recurrence rate from 32.3% to 10.7% (number needed to treat = 5) 3
• This combination is Class I, Level A recommendation from the European Society of Cardiology 1

When to Initiate Treatment

Low-Risk Patients (Outpatient Management)

• No fever >38°C, no large effusion (>20mm), no tamponade, responds to NSAIDs within 7 days 1, 2
• Start NSAIDs + colchicine immediately as outpatient 1, 2
• Monitor CRP to guide treatment duration 1, 2

High-Risk Patients (Require Admission)

• Fever >38°C, subacute course, large effusion >20mm, cardiac tamponade, failure to respond to NSAIDs within 7 days 1
• Additional minor risk factors: myopericarditis, immunosuppression, trauma, anticoagulation 1
• Admit for etiology search and monitoring while initiating same first-line therapy 1, 2

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

Corticosteroids should NOT be first-line therapy due to increased risk of chronicity, recurrence, and drug dependence 1, 2

Indications for Corticosteroids

• Contraindication to NSAIDs/colchicine 1, 2
• Failure of first-line therapy after adequate trial 1, 2
• Specific conditions: pregnancy >20 weeks, certain autoimmune diseases 2, 4

Corticosteroid Dosing (If Required)

• Low to moderate dose: prednisone 0.2-0.5 mg/kg/day (NOT high dose 1.0 mg/kg/day) 1
• Maintain initial dose until symptom resolution and CRP normalization, then taper 1
• Always combine with colchicine when using corticosteroids 1
• Corticosteroid use is an independent risk factor for recurrence (OR 4.30) 3

Activity Restriction

• Restrict physical activity beyond ordinary sedentary life until symptom resolution AND normalization of CRP, ECG, and echocardiogram 1, 2
• Athletes: minimum 3-month restriction from competitive sports after initial onset 1, 2
• Non-athletes: restriction until remission (shorter than 3 months acceptable) 1

Monitoring Strategy

• Use CRP to guide treatment length and assess response 1, 2
• Do not taper NSAIDs until symptoms are completely absent AND CRP is normalized 1, 2
• Continue colchicine for full 3 months regardless of symptom resolution 1, 2
• Monitor for recurrence (occurs in 15-30% without colchicine, reduced to 10.7% with colchicine) 2, 3

Critical Pitfalls to Avoid

• Inadequate treatment of first episode is the most common cause of recurrence 2
• Premature tapering before CRP normalization leads to recurrence 1, 2
• Using corticosteroids as first-line therapy increases recurrence risk 1, 3
• Omitting colchicine from initial regimen - this is no longer optional but mandatory first-line therapy 1, 2
• Discontinuing colchicine early (must complete 3 months) 1, 2
• Gastrointestinal side effects from colchicine occur in approximately 8% but rarely require discontinuation 3