What is the initial management for a patient with pericarditis and no known history of autoimmune diseases or recent surgeries?

Initial Management of Acute Pericarditis

Start combination therapy with high-dose NSAIDs (aspirin 750-1000 mg every 8 hours OR ibuprofen 600 mg every 8 hours) PLUS colchicine (weight-adjusted: 0.5 mg once daily if <70 kg, 0.5 mg twice daily if ≥70 kg) as first-line treatment for all patients with acute pericarditis. 1

First-Line Therapy

NSAIDs with Gastroprotection

• Aspirin 750-1000 mg every 8 hours OR ibuprofen 600 mg every 8 hours for 1-2 weeks 1
• Always provide gastroprotection (proton pump inhibitor) with NSAID therapy 1
• Choose between NSAIDs based on patient comorbidities and contraindications 1
• Continue treatment until complete symptom resolution AND CRP normalization 1

Colchicine as Mandatory Add-On

• Colchicine MUST be added to NSAIDs as part of first-line therapy, not reserved for refractory cases 1
• Weight-adjusted dosing: 0.5 mg once daily if <70 kg, 0.5 mg twice daily if ≥70 kg 1
• Duration: 3 months minimum for first episode 1, 2
• Colchicine reduces recurrence from 37.5% to 16.7% (absolute risk reduction 20.8%) 2

Treatment Duration and Tapering

• Continue NSAIDs until symptoms resolve AND CRP normalizes, typically 1-2 weeks 1
• Taper NSAIDs gradually: decrease aspirin by 250-500 mg every 1-2 weeks 1
• Do NOT taper until both symptoms are absent AND CRP is normal 1
• Continue colchicine for full 3 months regardless of symptom resolution 1

Monitoring Response

• Use CRP as the primary biomarker to guide treatment duration and assess response 1
• Follow-up at 1 week to assess treatment response 3
• Monitor for high-risk features: fever >38°C, large effusion >20mm, tamponade, or failure to respond within 7 days 1

Exercise Restriction

• Restrict exercise until symptoms resolve AND CRP, ECG, and echocardiogram normalize 1
• For athletes: minimum 3-month exercise restriction 1

Second-Line Therapy (When First-Line Fails)

Indications for Corticosteroids

• Corticosteroids are NOT first-line therapy 1
• Consider low-dose corticosteroids ONLY when: 1
  • Contraindication to NSAIDs/colchicine exists
  • First-line therapy fails after adequate trial
  • Infectious causes have been definitively excluded

Corticosteroid Dosing

• Use LOW to moderate doses: prednisone 0.2-0.5 mg/kg/day 1
• Avoid high-dose corticosteroids 1
• Taper slowly to prevent rebound 1

Outpatient vs. Inpatient Management

Outpatient Management Appropriate When:

• No high-risk features present 1
• Patient can tolerate oral medications 3
• Reliable follow-up available 3

Admit for Inpatient Management If:

• Fever >38°C (>100.4°F) 3, 4
• Large pericardial effusion (>20mm) 1
• Cardiac tamponade 3, 4
• Subacute course suggesting non-viral etiology 4
• Failure to respond to NSAIDs within 7 days 1, 4

Critical Pitfalls to Avoid

• Inadequate treatment of the first episode is the most common cause of recurrence 1
• Premature tapering before CRP normalization increases recurrence risk 1
• Using corticosteroids as first-line therapy promotes chronicity and increases recurrence rates 1
• Omitting colchicine from initial therapy—recurrence rates are 15-30% without colchicine vs. significantly lower with it 1, 2
• Inadequate colchicine duration (less than 3 months) increases recurrence risk 1

Expected Outcomes

• 70-85% of patients have a benign course with appropriate treatment 2
• Constrictive pericarditis occurs in <1% of idiopathic/viral cases 1
• Cardiac tamponade occurs in <3% of acute pericarditis cases 2
• Recurrence occurs in 15-30% without colchicine, increasing to 50% after first recurrence 1