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, with exercise restriction until complete symptom resolution and normalization of inflammatory markers. 1, 2
Initial Pharmacologic Management
First-Line Therapy (Class I Recommendation)
NSAIDs at full doses are the mainstay of treatment and should be continued until complete symptom resolution 1
Colchicine must be added as adjunctive therapy, not optional 1, 2
Treatment Duration and Tapering
- Continue therapy for weeks to months based on clinical response 1
- Taper only when patient is completely asymptomatic AND CRP is normalized 1
- Gradual dose reduction prevents recurrence 1:
- Stop one drug class at a time during tapering 1
Monitoring Response to Therapy
- CRP should guide treatment duration and assess therapeutic response 1, 2
- Reassess at 1 week to evaluate response to anti-inflammatory therapy 1
- Failure to respond within 7 days to NSAIDs is a major risk factor for poor prognosis 1
Second-Line Therapy
When to Use Corticosteroids
Corticosteroids are NOT recommended as first-line therapy (Class III recommendation, Level B evidence) 1
Corticosteroids should only be considered in specific situations 1, 2:
- Contraindications to NSAIDs/colchicine (true allergy, recent peptic ulcer, gastrointestinal bleeding, high bleeding risk with anticoagulation) 1
- Incomplete response to NSAIDs plus colchicine after adequate trial 1
- Specific indications: systemic inflammatory diseases, post-pericardiotomy syndrome, pregnancy 1
- Only after infectious causes (especially TB and bacterial) have been excluded 1, 2
Corticosteroid Dosing When Necessary
- Use low to moderate doses: prednisone 0.2-0.5 mg/kg/day (typically 0.25-0.50 mg/kg/day) 1
- Add corticosteroids to aspirin/NSAIDs and colchicine as triple therapy, do not replace first-line agents 1
- Slow, gradual tapering is essential 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 1
Critical Pitfall: Corticosteroids provide rapid symptom control but significantly increase risk of recurrence and chronicity 1, 4
Management of Recurrent Pericarditis
First Recurrence
- Continue NSAIDs at full doses plus colchicine 1
- Extend colchicine duration to at least 6 months (not just 3 months) 1, 3
- Consider longer colchicine therapy (>6 months) based on clinical response 1
Multiple Recurrences or Corticosteroid-Dependent Disease
Third-line options for refractory cases 1:
- IL-1 blockers (anakinra, rilonacept, goflikicept) are highly effective 1, 4, 5
- Intravenous immunoglobulin (IVIG) 1
- Azathioprine 1
- These should only be considered after careful multidisciplinary consultation with immunologists/rheumatologists 1
Fourth-line option:
- Pericardiectomy only as last resort after thorough trial of medical therapy, at experienced surgical centers 1
Non-Pharmacologic Management
Exercise Restriction (Critical Component)
- Restrict physical activity beyond ordinary sedentary life until complete resolution 1, 6
- Continue restriction until symptoms resolve AND CRP, ECG, and echocardiogram all normalize 1, 6
- Avoid strenuous physical exertion while maintaining basic daily activities
- Duration is symptom-guided and continues until all parameters normalize
- Minimum 3-month restriction from symptom onset 1, 6
- Must have complete resolution of symptoms AND normalization of CRP, ECG, and echocardiogram before return to competitive sports 1
For myopericarditis 6:
- Physical exercise contraindicated for at least 6 months from illness onset
- Rest beyond normal sedentary activities is mandatory
Risk Stratification and Triage
Low-Risk Patients (Outpatient Management)
Patients without high-risk features can be managed as outpatients with empiric anti-inflammatories 1, 2
High-Risk Features Requiring Hospitalization
Major risk factors requiring hospital admission and etiologic workup 1:
- High fever >38°C (>100.4°F)
- Subacute course (symptoms over several days without clear acute onset)
- Large pericardial effusion (diastolic echo-free space >20 mm)
- Cardiac tamponade
- Failure to respond within 7 days to NSAIDs
Minor risk factors also warranting admission 1:
- Myopericarditis (concomitant myocardial involvement)
- Immunosuppression
- Trauma
- Oral anticoagulant therapy
Common Pitfalls to Avoid
- Inadequate treatment of first episode is the most common cause of recurrence 1, 2
- Using corticosteroids as first-line therapy dramatically increases recurrence rates (up to 50% after first recurrence) 1, 3, 4
- Rapid tapering of anti-inflammatory drugs (within 1 month) increases recurrence risk 4
- Omitting colchicine from initial therapy—this is no longer optional 1, 2, 3
- Allowing return to exercise before complete normalization of symptoms, CRP, ECG, and echocardiogram 1, 6
- Inadequate colchicine duration (<3 months) increases recurrence risk 2
- Tapering therapy while CRP remains elevated or symptoms persist 1
Prognosis
- With appropriate treatment, 70-85% of patients have a benign course 3
- Recurrence occurs in 15-30% without colchicine, reduced to approximately half with colchicine 1, 3
- Risk of constrictive pericarditis: <1% for idiopathic/viral, 2-5% for autoimmune/neoplastic, 20-30% for bacterial/TB 1, 3
- Cardiac tamponade occurs in <3% of acute pericarditis cases, more common with specific etiologies (malignancy, TB, purulent) 1, 3