What is the initial treatment for acute pericarditis?

Initial Treatment for Acute Pericarditis

The initial treatment for acute pericarditis consists of combination therapy with high-dose NSAIDs (aspirin 750-1000 mg every 8 hours OR ibuprofen 600 mg every 8 hours) plus weight-adjusted colchicine (0.5 mg once daily if <70 kg or 0.5 mg twice daily if ≥70 kg) for 1-2 weeks with gastroprotection, followed by gradual tapering guided by symptom resolution and CRP normalization. 1, 2

First-Line Therapy: NSAIDs Plus Colchicine

NSAID Selection and Dosing

• Aspirin 750-1000 mg every 8 hours is the preferred NSAID, particularly when antiplatelet therapy is already indicated for concomitant coronary disease 1, 2
• Ibuprofen 600 mg every 8 hours is an alternative NSAID with similar efficacy 1, 2
• Always provide gastroprotection (proton pump inhibitor) with NSAID therapy 1
• Continue full-dose NSAID therapy until complete symptom resolution and CRP normalization, typically 1-2 weeks 1, 2

Colchicine as Mandatory Adjunct

• Colchicine must be added to NSAID therapy as first-line treatment, not reserved for refractory cases 1, 2
• Weight-adjusted dosing: 0.5 mg once daily for patients <70 kg; 0.5 mg twice daily for patients ≥70 kg 1, 2
• Continue colchicine for 3 months to prevent recurrences 1, 2
• Colchicine reduces recurrence rates from 37.5% to 16.7% (absolute risk reduction of 20.8%) 3
• The most common side effect is gastrointestinal intolerance, which may require dose adjustment or discontinuation 4, 5

Treatment Duration and Tapering Strategy

NSAID Tapering

• Begin tapering NSAIDs only after symptoms resolve completely and CRP normalizes 1, 2
• Aspirin: decrease by 250-500 mg every 1-2 weeks 1, 2
• Ibuprofen: decrease by 200-400 mg every 1-2 weeks 1, 2
• Use CRP levels to guide treatment length and assess therapeutic response 1, 2

Colchicine Duration

• Continue colchicine for the full 3-month course even after NSAIDs are discontinued 1, 2
• Tapering colchicine is not mandatory but may be considered (0.5 mg every other day for <70 kg or 0.5 mg once daily for ≥70 kg in final weeks) 1

Second-Line Therapy: Corticosteroids

Corticosteroids are NOT recommended as first-line therapy due to increased risk of recurrence, chronic disease evolution, and drug dependence 1, 2

When to Consider Corticosteroids

• Contraindications to both aspirin/NSAIDs AND colchicine 1, 2
• Failure of adequate trial of NSAIDs plus colchicine 1
• Specific autoimmune disease requiring corticosteroid therapy 1, 2
• Always exclude infectious causes before initiating corticosteroids 1, 2

Corticosteroid Dosing if Required

• Use low to moderate doses: prednisone 0.2-0.5 mg/kg/day (NOT high doses of 1.0 mg/kg/day) 1
• Maintain initial dose until symptom resolution and CRP normalization, then taper slowly 1
• Always combine with colchicine when using corticosteroids 1, 5

Risk Stratification and Management Setting

Outpatient Management (Low-Risk Cases)

• No high-risk features present 1, 2
• Treat empirically with NSAIDs plus colchicine without extensive etiologic workup 1
• Monitor CRP to assess treatment response 1, 2

Inpatient Management (High-Risk Cases)

Admit patients with any of the following high-risk features requiring etiologic investigation 1:

• Fever >38°C
• Subacute onset (symptoms developing over days to weeks)
• Large pericardial effusion (>20 mm)
• Cardiac tamponade
• Failure to respond to NSAIDs after 7 days
• Immunosuppression
• Trauma
• Oral anticoagulation therapy

Activity Restriction

Non-Athletes

• Restrict exercise until complete symptom resolution and normalization of CRP, ECG, and echocardiogram 1, 2
• This typically corresponds to the treatment duration of several weeks 1

Athletes

• Minimum 3-month restriction from competitive sports after initial onset, regardless of symptom resolution 1, 2
• Return to competition only after symptoms resolve AND diagnostic tests (CRP, ECG, echocardiogram) normalize 1, 2

Critical Pitfalls to Avoid

Inadequate Initial Treatment

• Inadequate treatment of the first episode is the most common cause of recurrence 1, 2
• Do not use NSAIDs alone without colchicine for first episode 1, 2
• Do not taper NSAIDs before symptoms resolve and CRP normalizes 1, 2
• Do not stop colchicine before completing 3 months 1, 2

Premature Corticosteroid Use

• Using corticosteroids as first-line therapy increases recurrence risk from 15-30% to 50% 1, 3
• Corticosteroids promote chronic disease evolution and drug dependence 1
• Always attempt adequate trial of NSAIDs plus colchicine before considering corticosteroids 1, 5

Rapid Tapering

• Tapering NSAIDs within 1 month increases recurrence risk 5
• Taper only when both symptoms and CRP have normalized 1, 2

Prognosis with Appropriate Treatment

• 70-85% of patients have a benign course with appropriate first-line therapy 3
• Recurrence occurs in 15-30% of patients not treated with colchicine 1, 3
• Colchicine reduces recurrence rate by approximately 50% 1, 4
• Constrictive pericarditis occurs in <1% of idiopathic cases with proper treatment 1
• Cardiac tamponade occurs in <3% of acute pericarditis cases 3