Glucocorticoids in Pericarditis Treatment
Glucocorticoids should NOT be used as first-line therapy for acute or recurrent pericarditis and are reserved strictly as second-line treatment when aspirin/NSAIDs plus colchicine are contraindicated, have failed, or when specific indications exist (autoimmune disease, pregnancy, post-pericardiotomy syndrome)—and only after infectious causes, particularly tuberculosis and bacterial infections, have been definitively excluded. 1, 2
Treatment Algorithm for Pericarditis
Acute Pericarditis - First-Line Therapy
- Aspirin 750-1000 mg every 8 hours OR ibuprofen 600 mg every 8 hours as the cornerstone of treatment 1, 2
- PLUS colchicine 0.5 mg twice daily (≥70 kg) or 0.5 mg once daily (<70 kg) for 3 months to reduce recurrence risk by approximately 50% 1, 2
- Continue treatment until complete symptom resolution AND CRP normalization, typically 1-2 weeks for uncomplicated cases 1, 2
- Taper aspirin by 250-500 mg every 1-2 weeks or ibuprofen by 200-400 mg every 1-2 weeks 1
When Glucocorticoids Are Appropriate (Second-Line Only)
Specific indications for glucocorticoid use: 1
- True allergy to aspirin/NSAIDs
- Recent peptic ulcer or gastrointestinal bleeding
- Oral anticoagulation with high bleeding risk
- Systemic autoimmune diseases requiring steroids
- Post-pericardiotomy syndrome
- Pregnancy
- Incomplete response despite adequate doses of aspirin/NSAIDs plus colchicine
Critical Dosing When Glucocorticoids Are Used
If glucocorticoids must be used, LOW doses are mandatory: 1
- Prednisone 0.2-0.5 mg/kg/day (typically 10-25 mg/day) 1
- Avoid higher doses except for special circumstances, and only for a few days with rapid tapering to 25 mg/day 1
- High-dose prednisone (1.0 mg/kg/day) is associated with 3.6-fold increased risk of side effects, recurrences, and hospitalizations compared to low doses 3
Glucocorticoid Tapering Protocol
Tapering must be extremely slow to prevent recurrences: 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 (this is the critical threshold where recurrences are most likely) 1
Each dose reduction should only occur when: 1
- Patient is completely asymptomatic
- CRP has normalized
- Particularly strict adherence to these criteria for doses <25 mg/day
Why Glucocorticoids Are Problematic
Glucocorticoids promote chronicity and increase recurrence rates: 1, 4
- They provide rapid symptom control but favor more recurrences and side effects 1
- Recurrence rates increase to 50% in patients treated with corticosteroids versus 15-30% without them 1
- High doses are particularly harmful, with significantly worse outcomes than low doses 3
Bone Protection Requirements
All patients receiving glucocorticoids require: 1
- Calcium supplementation 1,200-1,500 mg/day (supplement plus dietary intake)
- Vitamin D supplementation 800-1,000 IU/day
- Bisphosphonates for all men ≥50 years and postmenopausal women when glucocorticoid dose ≥5.0-7.5 mg/day prednisone equivalent is anticipated long-term
Recurrent Pericarditis Management
If Recurrence Occurs During Tapering
Do NOT increase glucocorticoid dose. Instead: 1
- Maximize aspirin/NSAID doses (every 8 hours, IV if necessary)
- Ensure colchicine is added if not already prescribed
- Add analgesics for pain control
- Consider triple therapy (low-dose steroids + aspirin/NSAIDs + colchicine) rather than steroid monotherapy 1
Third-Line Options for Steroid-Dependent Cases
For patients requiring unacceptably high long-term steroid doses (≥15-25 mg/day prednisone) or steroid-dependent recurrent pericarditis not responsive to colchicine: 1, 5
- Consider IVIG, anakinra (IL-1β receptor antagonist), or azathioprine
- Requires consultation with immunology/rheumatology specialists
- These options have limited evidence but may allow steroid discontinuation
Common Pitfalls to Avoid
Never use glucocorticoids before excluding infectious causes, especially tuberculosis and bacterial pericarditis, which have 20-30% risk of progression to constrictive pericarditis 1
Never use glucocorticoids as first-line therapy even if symptoms are severe—maximize aspirin/NSAIDs first 1
Never use high-dose glucocorticoids (≥1.0 mg/kg/day) as they triple the risk of adverse outcomes 3
Never taper glucocorticoids rapidly, especially below 15 mg/day where recurrence risk is highest 1
Never increase steroid dose if recurrence occurs during tapering—optimize other anti-inflammatory medications instead 1