What is the recommended treatment for pericarditis pain?

Treatment of Pericarditis Pain

Aspirin (750-1000 mg every 8 hours) or ibuprofen (600 mg every 8 hours) combined with colchicine (weight-adjusted dosing) is the recommended first-line treatment for pericarditis pain, with gastroprotection mandatory. 1, 2

First-Line Therapy: NSAIDs Plus Colchicine

NSAIDs are the cornerstone of pain management:

• Aspirin 750-1000 mg every 8 hours OR ibuprofen 600 mg every 8 hours 1, 2
• Treatment duration is typically 1-2 weeks, guided by symptom resolution and C-reactive protein (CRP) normalization 1, 2
• Gastroprotection is mandatory with proton pump inhibitors or H2 blockers 1
• Choose aspirin over other NSAIDs if the patient already requires antiplatelet therapy 1

Colchicine must be added to NSAIDs as first-line therapy:

• Weight-adjusted dosing: 0.5 mg once daily if <70 kg; 0.5 mg twice daily if ≥70 kg 1, 2
• Continue for 3 months to reduce recurrence risk from 37.5% to 16.7% (absolute risk reduction 20.8%) 2, 3
• Colchicine improves symptom relief and prevents recurrences when combined with NSAIDs 1, 2

Tapering Strategy

NSAIDs should be tapered gradually once symptoms resolve and CRP normalizes:

• Aspirin: decrease by 250-500 mg every 1-2 weeks 1
• Ibuprofen: decrease by 200-400 mg every 1-2 weeks 1
• Do not taper until both symptoms are absent AND CRP is normal 1, 2
• Colchicine tapering is not mandatory but can be considered in the final weeks 1

Second-Line Therapy: Corticosteroids

Corticosteroids should only be used when NSAIDs and colchicine fail or are contraindicated:

• Low to moderate doses: prednisone 0.2-0.5 mg/kg/day (NOT high doses of 1.0 mg/kg/day) 1
• Corticosteroids are NOT first-line because they increase risk of chronic evolution, recurrence, and drug dependence 1, 2
• When used, combine with colchicine and taper very slowly after symptom resolution and CRP normalization 1
• The European Society of Cardiology guidelines emphasize corticosteroids as a second option specifically due to these risks 1

Monitoring and Response Assessment

Use CRP to guide treatment duration and assess response:

• CRP should normalize before considering tapering 1, 2
• If no response to NSAIDs within 7 days, this is a poor prognostic factor requiring hospital admission and etiology search 1
• Monitor for recurrence, which occurs in 15-30% of patients despite optimal first-line therapy 2, 3

Activity Restriction

Physical activity must be restricted until complete resolution:

• Restrict activity beyond ordinary sedentary life until symptoms resolve AND CRP, ECG, and echocardiogram normalize 1, 2
• Athletes require minimum 3 months restriction from competitive sports after initial onset 1, 2
• Non-athletes can return to activity once remission is achieved (shorter than 3 months) 1

Critical Pitfalls to Avoid

Inadequate treatment of the first episode is the most common cause of recurrence:

• Never use corticosteroids as first-line therapy unless NSAIDs are contraindicated 1, 2
• Do not taper NSAIDs too rapidly (within 1 month increases recurrence risk) 4
• Do not omit colchicine—it reduces recurrence by approximately 50% 2, 3
• Avoid high-dose corticosteroids (≥1.0 mg/kg/day prednisone), which promote chronicity 1

Risk stratification determines outpatient vs. inpatient management:

• High fever (>38°C), large pericardial effusion (>20 mm), tamponade, or failure to respond to NSAIDs within 7 days requires hospital admission 1
• Low-risk patients without these features can be managed as outpatients with close follow-up 1, 2