What medications are used to treat pericarditis?

Medications for Pericarditis

Aspirin or NSAIDs combined with colchicine are the first-line treatment for acute pericarditis, with corticosteroids reserved only for cases where NSAIDs fail or are contraindicated. 1

First-Line Therapy: NSAIDs + Colchicine

Both medications should be started together as initial therapy to maximize symptom control and prevent recurrences. 1

NSAID Options and Dosing

Choose one of the following based on patient history and contraindications:

• Aspirin: 750-1000 mg every 8 hours for 1-2 weeks, then taper by 250-500 mg every 1-2 weeks 1
• Ibuprofen: 600 mg every 8 hours for 1-2 weeks, then taper by 200-400 mg every 1-2 weeks 1
• Always provide gastroprotection (proton pump inhibitor) with any NSAID 1

Aspirin is preferred when the patient already requires antiplatelet therapy for other indications. 1

Colchicine Dosing (Weight-Adjusted)

• Patients <70 kg: 0.5 mg once daily 1, 2
• Patients ≥70 kg: 0.5 mg twice daily 1, 2
• Duration: 3 months 1, 2
• Tapering is not mandatory but can be considered (0.5 mg every other day for <70 kg or 0.5 mg once daily for ≥70 kg in final weeks) 1

Colchicine reduces recurrence risk by approximately 50% (17% vs 34% recurrence rate) and should never be omitted from initial therapy. 3

Treatment Duration and Monitoring

• Continue NSAIDs until complete symptom resolution AND CRP normalization, typically 1-2 weeks for uncomplicated cases 1
• Use CRP levels to guide treatment length and assess response 1, 2
• Restrict physical activity beyond ordinary sedentary life until symptoms resolve and CRP normalizes 1

Second-Line Therapy: Corticosteroids

Corticosteroids should only be used when NSAIDs are contraindicated or have failed because they increase the risk of chronic disease evolution and drug dependence. 1

When to Consider Corticosteroids

• Contraindications to NSAIDs 1
• Failure to respond to NSAIDs within 7 days 4
• Specific etiologies (autoimmune diseases, pregnancy) 5

Corticosteroid Dosing

• Low to moderate doses: Prednisone 0.2-0.5 mg/kg/day (NOT high doses of 1.0 mg/kg/day) 1, 4
• Maintain initial dose until symptom resolution and CRP normalization, then taper 1
• Always combine with colchicine when using corticosteroids 1

Critical pitfall: Premature use of corticosteroids or inadequate first-line treatment is a common cause of recurrent pericarditis. 4

Third-Line Therapy: Immunosuppressive Agents

For corticosteroid-refractory or corticosteroid-dependent cases:

• Azathioprine, methotrexate, or mycophenolate mofetil can be effective 6
• These reduce recurrence frequency from 0.22 per month (corticosteroids alone) to 0.01 per month (p<0.0001) 6

Fourth-Line Therapy: IL-1 Receptor Antagonists

For recurrent pericarditis refractory to conventional drugs:

• Anakinra or rilonacept reduce recurrences dramatically (10% vs 78% with placebo, RR=0.14) 3, 7
• Reserved for cases failing NSAIDs, colchicine, and corticosteroids 3, 7

Common Pitfalls to Avoid

• Never start corticosteroids as first-line therapy unless NSAIDs are absolutely contraindicated 1
• Never omit colchicine from initial treatment - this is the most effective way to prevent recurrences 3
• Never stop treatment before CRP normalizes - premature discontinuation causes recurrences 4
• Never use NSAIDs for asymptomatic post-surgical effusions without systemic inflammation 2