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 (0.5 mg twice daily if ≥70 kg, or 0.5 mg once daily if <70 kg) for 3 months, along with exercise restriction until symptoms resolve and inflammatory markers normalize. 1, 2

First-Line Therapy

NSAIDs/Aspirin:

• Aspirin 750-1000 mg every 8 hours or ibuprofen 600 mg every 8 hours are the mainstays of treatment and should be given at full doses until complete symptom resolution 1, 2
• Treatment duration is typically 1-2 weeks, guided by symptoms and C-reactive protein (CRP) normalization 2
• Always provide gastroprotection with proton pump inhibitors 2
• Taper gradually once symptoms resolve: decrease aspirin by 250-500 mg every 1-2 weeks, or ibuprofen by 200-400 mg every 1-2 weeks 1, 2
• If antiplatelet therapy is required or ischemic heart disease is a concern, aspirin should be preferred over other NSAIDs 1

Colchicine (Class I, Level A recommendation):

• Must be added to NSAIDs as part of first-line therapy—this is not optional 1, 2
• Weight-adjusted dosing: 0.5 mg once daily if <70 kg, or 0.5 mg twice daily if ≥70 kg 1, 2
• Continue for 3 months minimum 2, 3
• Colchicine reduces recurrence rates from 37.5% to 16.7% (absolute risk reduction of 20.8%) 3
• No loading dose should be used 1

Exercise Restriction:

• Non-athletes: restrict exercise until symptom resolution and CRP normalization 1
• Athletes: minimum 3 months restriction until symptoms resolve and CRP, ECG, and echocardiogram normalize 1, 2

Second-Line Therapy

Low-dose corticosteroids are NOT recommended as first-line therapy (Class III, Level C) 1, 2

Corticosteroids should only be used when:

• Contraindications exist to aspirin/NSAIDs/colchicine (true allergy, recent peptic ulcer, gastrointestinal bleeding, high bleeding risk with anticoagulation) 1
• Infectious causes (especially bacterial and tuberculosis) have been excluded 1
• Specific indications exist: autoimmune diseases, post-pericardiotomy syndrome, pregnancy 1
• Incomplete response to aspirin/NSAIDs plus colchicine after adequate trial 1

If corticosteroids are necessary:

• Use low to moderate doses: prednisone 0.25-0.5 mg/kg/day 1, 2
• Add corticosteroids to aspirin/NSAIDs and colchicine as triple therapy—do not replace these drugs 1
• Taper extremely slowly (see Table 7 in guidelines): 1

  • 50 mg: decrease by 10 mg/day every 1-2 weeks

  • 50-25 mg: decrease by 5-10 mg/day every 1-2 weeks
  • 25-15 mg: decrease by 2.5 mg/day every 2-4 weeks
  • <15 mg: decrease by 1.25-2.5 mg/day every 2-6 weeks
• Provide calcium (1200-1500 mg/day) and vitamin D (800-1000 IU/day) supplementation 1
• Consider bisphosphonates for men ≥50 years and postmenopausal women on long-term therapy 1

Recurrent Pericarditis

For first recurrence:

• Restart aspirin/NSAIDs plus colchicine for at least 6 months (longer than initial episode) 1, 3
• Exercise restriction applies as with acute pericarditis 1

For corticosteroid-dependent or refractory recurrent pericarditis (third-line):

• Consider IV immunoglobulin (IVIG), anakinra, or azathioprine (Class IIb, Level C) 1
• These should only be used after careful assessment of costs and risks, with multidisciplinary consultation including immunologists/rheumatologists 1
• IL-1 blockers (anakinra, rilonacept) have shown efficacy with 10% vs 78% recurrence rates compared to placebo 4, 5

Fourth-line:

• Pericardiectomy may be considered only after thorough trial of unsuccessful medical therapy, with referral to a center with specific surgical expertise 1

Monitoring and Tapering Strategy

• Use CRP to guide treatment duration and assess response to therapy 1, 2
• Only taper medications when patient is asymptomatic and CRP is normal 1
• Stop one class of drugs at a time during tapering 1
• If symptoms recur during tapering, do NOT increase corticosteroid dose; instead maximize aspirin/NSAID dosing (every 8 hours, IV if necessary), add colchicine, and add analgesics for pain control 1

Critical Pitfalls to Avoid

Corticosteroid use is the single biggest risk factor for recurrence and chronicity 1, 4

• Recurrence rates increase from 15-30% to 50% after first recurrence in patients treated with corticosteroids 1
• Although corticosteroids provide rapid symptom control, they favor recurrences and should be avoided unless absolutely necessary 1, 2

Inadequate treatment of the first episode is a common cause of recurrence 1, 2

• Ensure full 3-month course of colchicine 2, 3
• Do not taper NSAIDs too rapidly 1, 2

Risk stratification for complications:

• Constrictive pericarditis risk: <1% for idiopathic/viral, 2-5% for autoimmune/neoplastic, 20-30% for bacterial (especially TB) 1, 2
• Cardiac tamponade is rare (<3%) in idiopathic pericarditis but more common with specific etiologies (malignancy, TB, purulent pericarditis) 1, 3

Special Populations

Children:

• NSAIDs at high doses are first-line (Class I, Level C) 1
• Aspirin is NOT recommended due to Reye's syndrome risk (Class III, Level C) 1
• Colchicine dosing: <5 years: 0.5 mg/day; >5 years: 1.0-1.5 mg/day in divided doses 1
• Corticosteroids not recommended unless specific indications exist (autoimmune diseases) 1
• Anti-IL-1 drugs may be considered for corticosteroid-dependent cases 1

Pregnancy:

• High-dose aspirin may be used during first and second trimesters 1
• Classic NSAIDs (ibuprofen, indomethacin) may be considered during first and second trimesters but must be withdrawn by gestational week 32 1
• Lowest effective doses of prednisone may be used throughout pregnancy with calcium and vitamin D supplementation 1
• Colchicine is contraindicated during pregnancy and breastfeeding per guidelines, though no adverse events have been reported in familial Mediterranean fever patients 1

Elderly:

• Indomethacin is not indicated 1
• Reduce colchicine dose due to increased risk of side effects 1