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 once daily if <70 kg, 0.5 mg twice daily if ≥70 kg) for 3 months, with corticosteroids reserved only as second-line therapy. 1, 2, 3

First-Line Pharmacologic Therapy

NSAIDs/Aspirin:

• Aspirin 750-1000 mg every 8 hours OR ibuprofen 600 mg every 8 hours for 1-2 weeks 1, 2, 3
• Choose aspirin if patient already requires antiplatelet therapy for other indications 1, 2
• Continue until complete symptom resolution AND C-reactive protein (CRP) normalization 1, 2, 3
• Taper gradually: aspirin by 250-500 mg every 1-2 weeks; ibuprofen by 200-400 mg every 1-2 weeks 1, 2, 3
• Always provide gastroprotection with proton pump inhibitor 1, 3

Colchicine (mandatory addition to NSAIDs):

• Weight-adjusted dosing: 0.5 mg once daily if <70 kg, 0.5 mg twice daily if ≥70 kg 1, 2, 3
• Duration: 3 months for acute pericarditis 1, 2, 3
• Colchicine reduces recurrence rate from 37.5% to 16.7% (absolute risk reduction 20.8%) 4
• No loading dose required 1

Treatment Monitoring:

• Use CRP levels to guide treatment duration and assess response 1, 2
• Do not taper medications until symptoms resolve AND CRP normalizes 1, 2, 3
• Stop only one class of drugs at a time during tapering 1

Activity Restriction

• Restrict physical activity beyond ordinary sedentary life until symptom resolution and CRP normalization 1, 2
• For athletes: minimum 3-month restriction until symptoms resolve AND CRP, ECG, and echocardiogram normalize 1, 2
• For non-athletes: restriction until remission may be shorter 1

Second-Line Therapy (When First-Line Fails or Contraindicated)

Corticosteroids are NOT first-line therapy due to increased risk of chronic disease evolution, recurrence, and drug dependence 1, 2, 3

Indications for corticosteroids:

• Contraindications to NSAIDs/colchicine 1, 2, 3
• Failure of first-line therapy 1, 2, 3
• Specific conditions: systemic inflammatory diseases, post-pericardiotomy syndrome, pregnancy 1
• Must exclude infectious causes (especially bacterial and tuberculosis) before initiating 1

Corticosteroid dosing:

• Use LOW to moderate doses: prednisone 0.2-0.5 mg/kg/day (NOT 1.0 mg/kg/day) 1, 2, 3
• Add to aspirin/NSAIDs and colchicine as triple therapy, do not replace these drugs 1
• Taper slowly to avoid recurrence 1

Post-Myocardial Infarction Pericarditis (Special Case)

Early pericarditis (1-3 days post-MI):

• Acetaminophen for symptomatic relief 1
• If symptoms persist: high-dose aspirin 500-1000 mg every 6-8 hours until symptoms improve 1
• Consider colchicine 0.5-0.6 mg once (if <70 kg) or twice daily for 3 months 1

Avoid in post-MI pericarditis:

• NSAIDs other than aspirin (increased risk of recurrent MI, impaired myocardial healing, risk of rupture) 1
• Glucocorticoids (potentially harmful) 1

Recurrent Pericarditis

First recurrence:

• Same first-line therapy: NSAIDs + colchicine 1, 2, 3
• Extend colchicine duration to at least 6 months 1, 4
• If inadequate response: add low-dose corticosteroids as triple therapy 1

Multiple recurrences (corticosteroid-dependent):

• Third-line options: IV immunoglobulin, anakinra, or azathioprine 1, 5
• Anti-IL-1 agents (anakinra, rilonacept) reduce recurrences from 78% to 10% 5
• Fourth-line: pericardiectomy only after thorough trial of unsuccessful medical therapy 1

Critical Pitfalls to Avoid

Never start corticosteroids as first-line therapy - they increase recurrence risk from 15-30% to 50% and promote chronic disease 1, 2, 3

Never stop treatment before CRP normalizes - inadequate treatment duration is the most common cause of recurrence 1, 2, 3

Never use high-dose corticosteroids - use only 0.2-0.5 mg/kg/day prednisone, not 1.0 mg/kg/day 1, 2, 3

Never omit colchicine - it halves the recurrence rate and should be added to all first-line regimens 1, 4, 5

Never taper too rapidly - taper only after symptoms resolve and CRP normalizes, stopping one drug class at a time 1, 2

Risk Stratification for Prognosis

Low risk (<1% constriction): idiopathic and presumed viral pericarditis 1

Intermediate risk (2-5% constriction): autoimmune, immune-mediated, neoplastic etiologies 1

High risk (20-30% constriction): bacterial etiologies, especially tuberculosis and purulent pericarditis 1, 6

Predictors of poor prognosis requiring hospitalization:

• Fever >38°C 1
• Subacute course 1
• Large pericardial effusion (>20 mm diastolic echo-free space) 1
• Cardiac tamponade 1
• Failure to respond within 7 days to NSAIDs 1