What is the treatment for pericarditis?

Treatment of Pericarditis

First-line therapy 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 at least 3 months, with gastroprotection mandatory. 1

Initial Treatment Algorithm

First-Line Therapy (Class I Recommendation)

NSAIDs with gastroprotection: 2, 1

• Aspirin 750-1000 mg every 8 hours for 1-2 weeks 1
• OR Ibuprofen 600 mg every 8 hours for 1-2 weeks 1
• Choice depends on patient contraindications and comorbidities 1
• Continue until symptoms resolve and C-reactive protein (CRP) normalizes 1
• Taper gradually (aspirin by 250-500 mg every 1-2 weeks) 1

Colchicine (mandatory addition to NSAIDs): 2, 1

• Weight-adjusted dosing: 0.5 mg once daily if <70 kg, 0.5 mg twice daily if ≥70 kg 2, 1
• Duration: minimum 3 months 2, 1
• Reduces recurrence risk from 37.5% to 16.7% (absolute risk reduction 20.8%) 3
• For first recurrence, extend colchicine to at least 6 months 3

Critical caveat: Colchicine is contraindicated in severe renal impairment 4. This is a common pitfall—always check renal function before prescribing.

Monitoring and Treatment Duration

Use CRP to guide therapy: 1

• Continue treatment until CRP normalizes 1
• Do not taper medications while CRP remains elevated 1
• Serial CRP measurements determine when tapering is safe 5

Common pitfall: Inadequate treatment duration of the first episode is the most frequent cause of recurrence 1. Without colchicine, recurrence rates are 15-30% after initial episode, increasing to 50% after first recurrence 2, 1.

Second-Line Therapy

Low-dose corticosteroids should only be used when: 2, 1

• Contraindication to NSAIDs/colchicine exists 1
• Failure of first-line therapy after adequate trial 1
• Infectious causes have been definitively excluded 2

Dosing when necessary: 2, 1

• Prednisone 0.2-0.5 mg/kg/day (low to moderate doses) 2, 1
• Avoid high-dose corticosteroids 1
• Taper slowly to prevent rebound 1

Critical warning: Corticosteroids are NOT first-line therapy because they increase risk of chronicity, recurrence, and side effects 2, 1. They provide rapid symptom control but promote worse long-term outcomes 1.

Third-Line Therapy for Refractory Cases

IL-1 blockers (anakinra, rilonacept, goflikicept): 6, 3

• Reserved for patients who cannot discontinue corticosteroids 6
• Consider as second-line in patients with contraindications to corticosteroids or high-risk features (multiple episodes, markedly elevated inflammatory markers, extensive pericardial imaging abnormalities) 6
• May be preferred to corticosteroids in multiple recurrent pericarditis lasting several years 3

Non-Pharmacologic Management

Exercise Restriction (Mandatory)

Restrict physical activity beyond ordinary sedentary life until: 5

• Complete symptom resolution 5
• CRP normalization 5
• ECG normalization 5
• Echocardiogram normalization 5

For athletes specifically: 2, 5

• Minimum 3-month restriction even after all parameters normalize 2, 5
• Structured return-to-play protocol required 5

For myopericarditis (myocardial involvement): 5

• Mandatory 6-month restriction from illness onset 5
• Physical exercise is contraindicated during this period 5

Common pitfall: Never allow return to exercise while inflammatory markers remain elevated or symptoms persist—this may contribute to recurrence or complications 5.

Special Populations and Etiologies

Pericarditis in Renal Failure

Uraemic pericarditis: 4

• Intensify dialysis (Class IIa recommendation) 4
• If non-responsive, consider pericardial aspiration/drainage 4
• NSAIDs and corticosteroids may be considered when intensive dialysis is ineffective 4
• Colchicine is contraindicated in severe renal impairment 4

Purulent Pericarditis

Aggressive management required (death is inevitable if untreated): 4

• Immediate empiric intravenous antimicrobial therapy 4
• Urgent drainage is crucial—purulent effusions are heavily loculated and rapidly re-accumulate 4
• Consider intrapericardial thrombolysis for loculated effusions 4
• Subxiphoid pericardiostomy with pericardial cavity rinsing should be considered 4
• With comprehensive therapy, 85% survival with good long-term outcome 4

Tuberculous Pericarditis

Most common cause worldwide, especially in developing countries: 2

• Accounts for >90% of pericardial disease in HIV-infected individuals in endemic areas 2
• Treat with antituberculosis therapy 3
• Adjunctive steroids may be considered in HIV-negative cases, but avoided in HIV-associated TB pericarditis 4
• Corticosteroids considered for associated constrictive pericarditis 3

Autoimmune Pericarditis

Systemic lupus erythematosus, rheumatoid arthritis, systemic sclerosis: 2, 7

• Same first-line therapy (NSAIDs + colchicine) for uncomplicated cases 8
• Corticosteroids may be necessary for systemic flares 8
• IL-1 blockers emerge as steroid-sparing agents 7

Post-Cardiac Injury Syndromes

Following cardiac surgery, percutaneous interventions, pacemaker insertion, catheter ablation: 2

• Same first-line therapy (NSAIDs + colchicine) 8
• Do NOT use colchicine for asymptomatic post-surgical effusions without inflammation—increases side effects without benefit 1
• Only treat if systemic inflammation is documented (elevated CRP and clinical criteria) 1

Risk Stratification for Complications

Constrictive Pericarditis Risk

Risk varies by etiology: 2, 1

• Low risk (<1%): Viral/idiopathic pericarditis 2, 1
• Intermediate risk (2-5%): Autoimmune/neoplastic pericarditis 2, 1
• High risk (20-30%): Bacterial pericarditis 2, 1

Cardiac Tamponade Risk

Rare in idiopathic pericarditis (<3%), but more common with: 2, 3

• Malignancy 2
• Tuberculosis 2
• Purulent pericarditis 2

Pericardial Effusion Without Inflammation

Critical distinction: If pericardial effusion is present but CRP is normal and no clinical criteria for pericarditis are met, anti-inflammatory drugs are NOT effective 1.

Management approach: 1

• Target therapy at underlying etiology 1
• Monitor with echocardiography every 6 months for moderate effusions 1
• Consider pericardiocentesis if patient becomes symptomatic, effusion progresses to large size with tamponade risk, or suspicion of bacterial/neoplastic etiology requiring diagnosis 1
• Large chronic effusions (>3 months) have 30-35% risk of progression to tamponade 1