What is the recommended dosing regimen for Aspirin (Acetylsalicylic Acid (ASA)) in the treatment of pericarditis?

Aspirin Dosing for Pericarditis

For acute pericarditis, aspirin should be dosed at 750-1000 mg every 8 hours (total daily dose 2.25-3 grams) for 1-2 weeks until complete symptom resolution and CRP normalization, then tapered by 250-500 mg every 1-2 weeks. 1, 2

Initial Dosing Regimen

• Start aspirin at 750-1000 mg every 8 hours (equivalent to 2.25-3 grams daily divided into three doses) 1, 2
• Alternative dosing cited in guidelines ranges from 500-1000 mg every 6-8 hours, with total daily doses of 1.5-4 grams per day, though the 750-1000 mg every 8 hours is the most commonly recommended starting point 3, 4
• Always provide gastroprotection with a proton pump inhibitor when using aspirin at these doses 2
• Aspirin is preferred over NSAIDs when the patient already requires antiplatelet therapy for other cardiac indications 2

Treatment Duration and Monitoring

• Continue full-dose aspirin until both complete symptom resolution and CRP normalization occur, typically 1-2 weeks for uncomplicated cases 1, 2
• Use CRP levels to guide treatment duration - never stop therapy before CRP normalizes, as premature discontinuation causes recurrences 1, 2
• The every-8-hour dosing schedule is critical to ensure full 24-hour symptom control 5

Tapering Protocol

• After achieving symptom resolution and CRP normalization, taper aspirin gradually by 250-500 mg every 1-2 weeks 3, 1, 2
• For more resistant or difficult cases, consider longer tapering intervals 3
• Only attempt tapering when symptoms are completely absent and CRP is normal 3

Mandatory Combination Therapy

• Aspirin must always be combined with colchicine as first-line therapy - never use aspirin as monotherapy 1, 2
• Colchicine dosing is weight-adjusted: 0.5 mg once daily if <70 kg or 0.5 mg twice daily if ≥70 kg 1, 2, 4
• Continue colchicine for 3 months minimum (6 months for recurrent pericarditis) 1, 2, 4
• When discontinuing therapy, taper one drug class at a time before stopping colchicine 4

Critical Pitfalls to Avoid

• Never use corticosteroids as first-line therapy - they increase risk of chronicity, recurrences, and drug dependence 1, 2
• Corticosteroids should only be considered if aspirin/NSAIDs are absolutely contraindicated (true allergy, recent GI bleeding, high bleeding risk on anticoagulation) or after failure of aspirin plus colchicine 3
• Never stop treatment before CRP normalizes - this is the most common cause of recurrence 1, 2
• Inadequate treatment duration (less than 3 months of colchicine) significantly increases recurrence risk 1
• Do not increase doses during tapering if symptoms recur; instead, return to the previous effective dose and maintain it longer before attempting to taper again 3

Activity Restriction

• Restrict physical activity beyond ordinary sedentary life until symptoms resolve and CRP normalizes 2
• For athletes, exercise restriction should last at least 3 months and continue until symptoms resolve and CRP, ECG, and echocardiogram all normalize 3, 1

Special Considerations

• If aspirin fails to control symptoms after 48-72 hours at full doses, consider hospitalization for further evaluation rather than immediately escalating to corticosteroids 6
• Aspirin resistance (failure to respond to adequate doses) is associated with higher rates of recurrence (60.6% vs 10.4%) and constriction (9.1% vs 0.5%) compared to aspirin responders 6