From the Guidelines
Pericarditis should be treated with aspirin or NSAIDs as first-line therapy, along with colchicine, to reduce the risk of recurrence and improve outcomes, as recommended by the 2015 ESC guidelines 1. The treatment of pericarditis typically begins with nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (600-800mg three times daily) or indomethacin (25-50mg three times daily) for 1-2 weeks, followed by a gradual taper over 2-4 weeks.
- Colchicine should be added to NSAIDs (0.5mg twice daily for patients >70kg or 0.5mg once daily for patients <70kg) for 3 months in acute cases and 6 months for recurrent cases to reduce the risk of recurrence, as supported by the guidelines 1.
- For severe or refractory cases, corticosteroids like prednisone (0.25-0.5mg/kg/day) may be used, but should be tapered slowly to prevent rebound, as cautioned by the guidelines 1. Some key points to consider in the management of pericarditis include:
- Hospital admission is recommended for high-risk patients with acute pericarditis, as stated in the guidelines 1.
- CRP should be considered to guide the treatment duration and assess the response to therapy, as recommended by the guidelines 1.
- Rest and activity restriction, particularly avoiding strenuous physical activity for at least 3 months after diagnosis, is important for recovery, as suggested by the guidelines 1.
- Patients should be monitored for complications such as cardiac tamponade or constrictive pericarditis, which can have a significant impact on morbidity, mortality, and quality of life.
From the Research
Treatment Options for Pericarditis
- Aspirin and non-steroidal anti-inflammatory drugs (NSAIDs) are the mainstay of therapy for acute and recurrent pericarditis, with the possible adjunct of colchicine, especially for recurrences 2.
- Corticosteroids are a second choice for difficult cases requiring multi-drug therapies and specific medical conditions, such as systemic autoimmune diseases, postpericardiotomy syndrome, and pregnancy 2.
- Colchicine has been shown to be effective in reducing episodes of pericarditis in people with recurrent pericarditis over 18 months follow-up, with a number needed to treat (NNT) of 4 3.
- Colchicine also reduces recurrence in people with acute pericarditis, with moderate quality evidence showing a hazard ratio (HR) of 0.40 at 18 months follow-up 3.
Efficacy of Colchicine
- Colchicine, as adjunctive therapy to NSAIDs, is effective in reducing the number of pericarditis recurrences in patients with recurrent pericarditis or acute pericarditis 3.
- A systematic review and meta-analysis of controlled clinical trials found that colchicine was effective in the reduction of recurrent pericarditis, compared with standard treatment, with a relative risk (RR) of 0.50 4.
- Anti-interleukin-1 agents, such as anakinra and rilonacept, are also effective in reducing recurrences, compared with placebo, with an RR of 0.14 4.
Pharmacological Management
- A correct pharmacological management of pericarditis is key to prevent recurrences, with colchicine being the mainstay of treatment in acute and recurrent pericarditis 4.
- Anti-IL1 agents are a valuable option in case of recurrent pericarditis refractory to conventional drugs 4.
- The treatment of pericarditis should be individualized, providing the attack dose every 8 hours to ensure full daily control of symptoms and till remission and C-reactive protein normalization, and then tapering should be considered 2.