What is the treatment for pericarditis?

Treatment for Pericarditis

First-Line Therapy: NSAIDs Plus Colchicine

The cornerstone of pericarditis treatment is combination therapy with high-dose NSAIDs (aspirin 750-1000 mg every 8 hours OR ibuprofen 600 mg every 8 hours) PLUS colchicine for 3 months, with gastroprotection. 1

NSAID Selection and Dosing

• Aspirin 750-1000 mg every 8 hours (total daily dose 1.5-4 g/day) is preferred by many experts, particularly during pregnancy 2
• Ibuprofen 600 mg every 8 hours (total daily dose 1200-2400 mg) is an equally effective alternative 2, 1
• Indomethacin 25-50 mg every 8 hours can be used but is NOT recommended in elderly patients 2
• Always provide gastroprotection (proton pump inhibitors or H2 blockers) 2
• Continue NSAIDs for 1-2 weeks at full dose until symptoms resolve AND C-reactive protein (CRP) normalizes 1, 3

Colchicine Dosing (Critical Component)

• Weight-adjusted dosing is mandatory: 0.5 mg once daily if <70 kg OR 0.5 mg twice daily if ≥70 kg 2, 1
• Duration: 3 months minimum for first episode 1, 3
• NO loading dose should be used 2
• Colchicine reduces recurrence risk from 37.5% to 16.7% (absolute risk reduction 20.8%) 3

Tapering Strategy

• Begin tapering NSAIDs ONLY after complete symptom resolution AND CRP normalization 1
• Taper aspirin by 250-500 mg every 1-2 weeks 2, 1
• Taper ibuprofen by 200-400 mg every 1-2 weeks 2
• Continue colchicine at full dose throughout NSAID taper and for full 3-month course 1

Second-Line Therapy: Low-Dose Corticosteroids

Corticosteroids are NOT first-line therapy and should only be added when NSAIDs/colchicine fail, are contraindicated, or when specific indications exist. 2, 1

When to Use Corticosteroids

• Incomplete response to NSAIDs plus colchicine after adequate trial 2
• True NSAID allergy, recent peptic ulcer/GI bleeding, or high bleeding risk with anticoagulation 2
• Specific indications: systemic autoimmune diseases, post-pericardiotomy syndrome, pregnancy (after first trimester) 2
• Must exclude bacterial and tuberculous infection before starting 2

Corticosteroid Dosing

• Prednisone 0.2-0.5 mg/kg/day (low to moderate dose) 2, 1
• Add corticosteroids as triple therapy (with NSAIDs and colchicine), do NOT replace these drugs 2
• Maintain initial dose until symptom resolution and CRP normalization, then taper extremely slowly 1
• Critical pitfall: Corticosteroids provide rapid symptom control but significantly increase risk of chronicity and recurrence 2, 1, 4

Recurrent Pericarditis (≥1 Recurrence)

First Recurrence

• Continue NSAIDs at full dose 2
• Extend colchicine to at least 6 months (not just 3 months) 2, 3
• If inadequate response, add low-dose corticosteroids as triple therapy 2

Multiple Recurrences or Corticosteroid-Dependent Disease

• Third-line options when corticosteroid-dependent or refractory to NSAIDs/colchicine:
  • Anakinra (IL-1 receptor antagonist) - preferred option 4, 5, 6, 7
  • Rilonacept or goflikicept (alternative IL-1 blockers) 7
  • Intravenous immunoglobulin (IVIG) 4
  • Azathioprine 4
• IL-1 blockers are increasingly preferred over long-term corticosteroids due to better safety profile 3, 7
• Pericardiectomy is last resort after exhaustive medical therapy failure, requires expert surgical center 4

Activity Restriction

• Restrict exercise until symptoms resolve AND CRP, ECG, and echocardiogram normalize 2, 1, 4
• Athletes require minimum 3 months restriction regardless of symptom resolution 2, 1, 4

Special Populations

Pregnancy

• High-dose aspirin is preferred NSAID during first and second trimesters 2
• Ibuprofen and indomethacin may be used in first/second trimester but must be stopped by week 32 (risk of ductus arteriosus constriction) 2
• Low-dose prednisone can be used throughout pregnancy if needed 2
• Colchicine is contraindicated during pregnancy and breastfeeding per guidelines, though some FMF data suggest safety 2

Elderly Patients

• Avoid indomethacin due to CNS side effects 2
• Use lower colchicine dose (0.5 mg once daily if <70 kg) 2
• Monitor closely for medication interactions and adherence 2

Children

• NSAIDs at high doses are first-line (NOT aspirin due to Reye's syndrome risk) 2
• Colchicine dosing: <5 years: 0.5 mg/day; >5 years: 1.0-1.5 mg/day in divided doses 2
• Anti-IL-1 drugs may be considered if corticosteroid-dependent 2
• Avoid corticosteroids unless specific autoimmune indication due to growth effects 2

Critical Pitfalls to Avoid

• Inadequate treatment duration is the most common cause of recurrence - ensure full 3-month colchicine course 1, 4
• Never use corticosteroids as first-line therapy - they increase recurrence rates from 15-30% to 50% 2, 1
• Do not taper medications while symptoms persist or CRP remains elevated 1, 4
• Rapid tapering (within 1 month) increases recurrence risk - taper slowly over weeks 7
• Recurrence rate without colchicine: 15-30% after first episode, up to 50% after first recurrence 2, 1

Monitoring Response

• CRP is the key biomarker for guiding treatment duration and tapering 1, 3
• Monitor symptoms, CRP, ECG, and echocardiogram serially 2, 1
• Most patients with idiopathic/viral pericarditis have excellent prognosis with proper treatment 2, 3
• Constrictive pericarditis risk: <1% for idiopathic/viral, 2-5% for autoimmune, 20-30% for bacterial/TB 2, 1