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, 0.5 mg once daily if <70 kg) for 3 months, along with exercise restriction until complete resolution of symptoms and normalization of inflammatory markers. 1

First-Line Therapy

Anti-Inflammatory Medications

• Aspirin or NSAIDs are the mainstay of treatment and must be given at full doses every 8 hours to ensure continuous symptom control 2
• Aspirin dosing: 750-1000 mg every 8 hours (total daily dose 1.5-4 g/day) 1
• Ibuprofen dosing: 600 mg every 8 hours (total daily dose 1200-2400 mg) 2, 1
• Continue treatment for 1-2 weeks at full dose, then taper only after symptoms resolve and CRP normalizes 1, 3
• Gastroprotection is mandatory with NSAID/aspirin therapy 1
• Tapering should be gradual: decrease aspirin by 250-500 mg every 1-2 weeks or ibuprofen by 200-400 mg every 1-2 weeks 2, 1

Colchicine as Essential Adjunct

• Colchicine must be added to NSAIDs/aspirin as part of first-line therapy, not as optional therapy 2, 1
• Weight-adjusted dosing is critical: 0.5 mg once daily if <70 kg or 0.5 mg twice daily if ≥70 kg 2, 1
• Duration: minimum 3 months for first episode 2, 1
• Colchicine reduces recurrence rates from 37.5% to 16.7% (absolute risk reduction of 20.8%) 3
• Without colchicine, recurrence rates are 15-30% after first episode and increase to 50% after first recurrence 2, 3

Exercise Restriction

• Restrict all physical activity beyond ordinary sedentary life until complete resolution of symptoms AND normalization of CRP, ECG, and echocardiogram 1, 4
• For non-athletes: continue restriction until all parameters normalize 4
• For athletes: minimum 3-month restriction even after normalization of all parameters 2, 1, 4
• If myopericarditis is present: mandatory 6-month exercise restriction from illness onset 4

Second-Line Therapy

When to Use Corticosteroids

Corticosteroids are NOT recommended as first-line therapy because they promote chronicity, increase recurrence rates, and have significant side effects 2, 1

Corticosteroids should only be used when: 2, 1

• True contraindications to NSAIDs exist (documented allergy, recent peptic ulcer, active GI bleeding, high bleeding risk on anticoagulation)
• Contraindications to colchicine exist
• Incomplete response to adequate doses of NSAIDs plus colchicine
• Specific indications: systemic inflammatory diseases, post-pericardiotomy syndrome, pregnancy

Corticosteroid Dosing When Necessary

• Use low to moderate doses: prednisone 0.2-0.5 mg/kg/day 2
• Add corticosteroids as triple therapy WITH aspirin/NSAIDs and colchicine, do not replace these drugs 2
• Must exclude infectious causes (especially bacterial and tuberculosis) before initiating 2
• Taper very slowly to avoid rebound 2

Treatment Monitoring and Duration

Using CRP to Guide Therapy

• CRP should guide treatment duration and assess response to therapy 2, 1
• Do not begin tapering any medication until CRP normalizes 2, 1
• Stop only one class of drugs at a time during tapering 2
• If symptoms recur during tapering: do NOT increase corticosteroid dose; instead maximize NSAID dosing to every 8 hours, add IV NSAIDs if needed, ensure colchicine is on board, and add analgesics for pain control 2

Recurrent Pericarditis Management

First Recurrence

• Use same first-line approach: NSAIDs plus colchicine 2
• Extend colchicine duration to at least 6 months (not just 3 months) 2, 3
• Consider longer colchicine duration based on clinical response 2

Multiple Recurrences or Corticosteroid-Dependent Disease

Third-line options for refractory cases: 2

• IV immunoglobulin (IVIG)
• Anakinra (IL-1 blocker)
• Azathioprine

These are reserved for patients not responsive to colchicine or who are corticosteroid-dependent 2, 5

Critical Pitfalls to Avoid

Common Causes of Treatment Failure

• Inadequate treatment of the first episode is the most common cause of recurrence 2, 1
• Using corticosteroids as first-line therapy dramatically increases recurrence risk 2, 1
• Tapering medications too rapidly (within 1 month) increases recurrence 5
• Inadequate colchicine duration (<3 months) increases recurrence 1
• Allowing return to exercise before complete normalization of all parameters 1, 4

Dosing Errors

• Not dosing NSAIDs every 8 hours leads to inadequate symptom control 2
• Using colchicine without weight adjustment leads to either underdosing or intolerance 2, 1
• Starting corticosteroids at high doses rather than low-to-moderate doses 2

Prognosis Considerations

• Most patients with idiopathic/viral pericarditis have excellent long-term prognosis 2, 3
• Risk of constrictive pericarditis: <1% for idiopathic/viral, 2-5% for autoimmune/neoplastic, 20-30% for bacterial (especially TB) 2, 1
• Cardiac tamponade is rare (<3%) in idiopathic pericarditis but more common with specific etiologies (malignancy, TB, purulent) 2, 3
• With appropriate treatment (NSAIDs plus colchicine), 70-85% of patients have a benign course 3