What is the treatment for pericarditis?

Treatment of Pericarditis

First-line treatment for acute pericarditis consists of high-dose NSAIDs (aspirin 750-1000 mg every 8 hours OR ibuprofen 600 mg every 8 hours) combined with colchicine (weight-adjusted: 0.5 mg once daily if <70 kg, 0.5 mg twice daily if ≥70 kg) for 3 months, with corticosteroids reserved strictly as second-line therapy only when NSAIDs fail or are contraindicated. 1, 2, 3

Initial Assessment and Risk Stratification

Before initiating treatment, assess for predictors of poor prognosis that warrant hospital admission and etiologic workup: 1

Major risk factors requiring admission: 1

• High fever >38°C (>100.4°F)
• Subacute onset (symptoms developing over days without clear acute onset)
• Large pericardial effusion (diastolic echo-free space >20 mm)
• Cardiac tamponade
• Failure to respond to NSAIDs within 7 days

Minor risk factors to consider: 1

• Myopericarditis
• Immunosuppression
• Trauma
• Oral anticoagulant therapy

Patients without these risk factors can be managed as outpatients with empiric anti-inflammatory therapy. 1, 2

First-Line Pharmacologic Therapy

NSAIDs (Choose One)

Aspirin: 750-1000 mg every 8 hours for 1-2 weeks 1, 2, 3

• Preferred when patient already requires antiplatelet therapy for other indications 1, 3
• Taper by 250-500 mg every 1-2 weeks after symptom resolution and CRP normalization 1, 2, 3

Ibuprofen: 600 mg every 8 hours for 1-2 weeks 1, 2, 3

• Alternative to aspirin based on patient history and contraindications 1
• Taper by 200-400 mg every 1-2 weeks after symptom resolution and CRP normalization 1, 2, 3

Critical: Always provide gastroprotection (proton pump inhibitor) with any NSAID. 3

Colchicine (Mandatory Addition to NSAIDs)

Dosing: 1, 2, 3

• <70 kg: 0.5 mg once daily
• ≥70 kg: 0.5 mg twice daily
• Duration: 3 months minimum for first episode 1, 2, 3
• Start simultaneously with NSAIDs, not sequentially 3

Evidence: Colchicine reduces recurrence rates from 37.5% to 16.7% (absolute risk reduction 20.8%) and improves symptom control. 4 Without colchicine, recurrence rates after initial episode range from 15-30%, increasing to 50% after first recurrence. 1, 2

Treatment Duration and Monitoring

Continue NSAIDs until BOTH of the following are achieved: 1, 2, 3

• Complete symptom resolution
• CRP normalization

Use CRP levels to guide treatment duration and assess therapeutic response—this is not optional. 1, 2, 3 Treatment typically lasts 1-2 weeks for uncomplicated cases, but must be individualized based on CRP trends. 1, 2

Common pitfall: Premature discontinuation before CRP normalizes is a leading cause of recurrence. 2

Activity Restriction

Non-athletes: Restrict physical activity beyond ordinary sedentary life until symptom resolution AND CRP normalization. 1, 2

Athletes: 1, 2

• Minimum 3-month restriction from competitive sports after initial onset
• Return only after symptoms resolve AND CRP, ECG, and echocardiogram normalize
• This prolonged restriction is mandatory for athletes specifically

Second-Line Therapy: Corticosteroids

Corticosteroids are NOT recommended as first-line therapy due to increased risk of chronic disease evolution, recurrence promotion, and drug dependence. 1, 3 They should only be used when: 1, 2, 3

Specific indications: 1

• Contraindications to NSAIDs (true allergy, recent peptic ulcer/GI bleeding, high bleeding risk with anticoagulation)
• Failure of adequate doses of NSAIDs plus colchicine
• Specific conditions: systemic inflammatory diseases, post-pericardiotomy syndrome, pregnancy
• After infectious causes (especially bacterial and tuberculosis) are excluded

Dosing when necessary: 1, 2, 3

• Prednisone 0.2-0.5 mg/kg/day (NOT 1.0 mg/kg/day)
• Use LOW to MODERATE doses only
• Always combine with colchicine to reduce risk of progressive disease 1
• Add to NSAIDs as triple therapy rather than replacing them 1
• Taper slowly over 1-2 weeks 1

Critical warning: Corticosteroids provide rapid symptom control but significantly increase recurrence risk and promote chronicity. 1, 5, 4

Management of Treatment Failure

If symptoms recur during tapering: 1

• Do NOT increase corticosteroid dose
• Increase NSAIDs to maximum dose, well-distributed every 8 hours
• Consider IV NSAIDs if necessary
• Ensure colchicine is at full dose
• Add analgesics for pain control

Recurrent Pericarditis

For recurrences (symptom-free interval of 4-6 weeks, then recurrence): 1

First recurrence: 1, 5, 4

• Restart NSAIDs plus colchicine
• Extend colchicine duration to at least 6 months 1, 5, 4
• Consider longer colchicine duration (>6 months) based on clinical response 1

Multiple recurrences (corticosteroid-dependent): 1, 5

• Third-line options: IV immunoglobulin, anakinra (IL-1 blocker), or azathioprine 1, 5
• IL-1 blockers may be preferred over corticosteroids in patients with multiple recurrences 5, 4
• Pericardiectomy as last resort after thorough trial of medical therapy at specialized center 1

Special Etiologies Requiring Different Approaches

Tuberculosis pericarditis (endemic areas): 4

• Antitubercular therapy is primary treatment
• Consider corticosteroids specifically for associated constrictive pericarditis

Histoplasmosis-related pericarditis: 1

• NSAIDs for mild cases
• Prednisone 0.5-1.0 mg/kg daily (max 80 mg) for hemodynamic compromise
• Itraconazole 200 mg three times daily for 3 days, then once or twice daily for 6-12 weeks if corticosteroids used
• Pericardial drainage if hemodynamic compromise present

Key Pitfalls to Avoid

1. Never start corticosteroids as first-line therapy unless NSAIDs are absolutely contraindicated 1, 3

2. Never stop treatment before CRP normalizes—this is the most common cause of recurrence 2, 3

3. Never use NSAIDs alone without colchicine for initial treatment—colchicine halves the recurrence rate 1, 2

4. Never use high-dose corticosteroids (>0.5 mg/kg/day)—low to moderate doses are sufficient and safer 1, 2, 3

5. Never taper medications too rapidly (within 1 month)—this increases recurrence risk 5

6. Never allow premature return to exercise—especially for athletes who require minimum 3-month restriction 1, 2

Prognosis

With appropriate guideline-directed therapy, 70-85% of patients have a benign course. 4 Risk of constrictive pericarditis varies by etiology: <1% for idiopathic/viral, 2-5% for autoimmune/neoplastic, and 20-30% for bacterial causes. 1, 2 Cardiac tamponade occurs in <3% of acute pericarditis cases but is more common with specific etiologies like malignancy or purulent pericarditis. 2, 4