Treatment of Pericarditis
First-Line Therapy: NSAIDs Plus Colchicine
The cornerstone of pericarditis treatment is combination therapy with high-dose NSAIDs (aspirin 750-1000 mg every 8 hours OR ibuprofen 600 mg every 8 hours) plus weight-adjusted colchicine for at least 3 months. 1
NSAID Therapy
- Aspirin 750-1000 mg every 8 hours OR ibuprofen 600 mg every 8 hours should be administered for 1-2 weeks 1
- Always provide gastroprotection (proton pump inhibitor) with NSAID therapy 1
- Continue the full dose every 8 hours until symptoms resolve AND C-reactive protein (CRP) normalizes 1
- Taper gradually only after symptom resolution and CRP normalization (e.g., decrease aspirin by 250-500 mg every 1-2 weeks) 1
- The choice between aspirin and ibuprofen should be based on patient contraindications and comorbidities 1
Colchicine Therapy
- Mandatory addition to NSAIDs as part of first-line therapy to reduce recurrence risk from 30% to approximately 15% 1, 2
- Weight-adjusted dosing: 0.5 mg once daily if <70 kg OR 0.5 mg twice daily if ≥70 kg 1
- Duration: minimum 3 months for first episode 1
- For first recurrence, extend colchicine to at least 6 months 2
- Contraindicated in severe renal impairment 1
Monitoring Treatment Response
- Use CRP levels to guide treatment duration and assess response 1
- Do not attempt tapering until symptoms are completely absent AND CRP is normalized 1
- Inadequate treatment duration (less than 3 months of colchicine) significantly increases recurrence risk 1
Second-Line Therapy: Low-Dose Corticosteroids
Corticosteroids should NOT be used as first-line therapy due to increased risk of chronicity and recurrence 1, 3
Indications for Corticosteroids
- Contraindication to both NSAIDs and colchicine 1
- Failure of first-line therapy (NSAIDs plus colchicine) 1
- Only after infectious causes have been excluded 1
- Specific etiologies: systemic autoimmune diseases, pregnancy, or uremic pericarditis 4
Corticosteroid Dosing
- Prednisone 0.2-0.5 mg/kg/day (low to moderate doses preferred over high doses) 1, 3
- Maintain initial dose until symptom resolution and CRP normalization 5
- Taper very slowly to avoid rebound (much slower than NSAID taper) 5
- For tuberculous pericarditis, higher doses may be needed (1-2 mg/kg/day) due to rifampicin-induced metabolism 4
Critical Pitfall
- Corticosteroids provide rapid symptom relief but increase risk of recurrence and chronicity 1, 5
- Early or inappropriate corticosteroid use is a common cause of recurrent pericarditis 1
Third-Line Therapy: Immunomodulatory Agents
For corticosteroid-dependent recurrent pericarditis not responsive to colchicine:
- Anakinra (IL-1 receptor antagonist) 5, 6
- Rilonacept (IL-1 blocker) 6
- Intravenous immunoglobulin (IVIG) 5
- Azathioprine 5
These agents may be considered as second-line therapy (before corticosteroids) in patients with contraindications to corticosteroids or high-risk features (multiple episodes, markedly elevated inflammatory markers) 6
Activity Restriction
- Exercise restriction is mandatory until symptoms resolve AND CRP, ECG, and echocardiogram normalize 1, 3
- For athletes: minimum 3-month restriction from competitive sports 1, 3
- Premature return to activity increases recurrence risk 1
Etiology-Specific Considerations
Tuberculous Pericarditis
- Antituberculous therapy is the primary treatment 4
- Adjunctive corticosteroids may reduce mortality and need for pericardiectomy (prednisone 1-2 mg/kg/day for 5-7 days, then taper over 6-8 weeks) 4
- Avoid corticosteroids in HIV-associated tuberculous pericarditis 1
- If constriction develops despite treatment, pericardiectomy is indicated 4
Uremic Pericarditis
- Intensify dialysis as first-line treatment 1
- Consider pericardial drainage if non-responsive to intensified dialysis 1
- Colchicine is contraindicated in severe renal impairment 1
Purulent Pericarditis
- Immediate empiric intravenous antibiotics 1
- Urgent surgical drainage (pericardiocentesis or surgical drainage preferred over medical management alone) 4, 1
- 85% survival rate with aggressive management 1
Autoimmune/Connective Tissue Disease
- Corticosteroids are appropriate first-line therapy for this specific etiology 4
- Treat underlying autoimmune condition concurrently 3
Pericardiocentesis Indications
- Life-saving in cardiac tamponade (Class I indication) 4
- Large effusions >20 mm in diastole on echocardiography 4
- Smaller effusions for diagnostic purposes (suspected bacterial, tuberculous, or neoplastic etiology) 4
- Symptomatic moderate-to-large effusions not responsive to medical therapy 1
Contraindications
- Aortic dissection (absolute contraindication) 4
- Uncorrected coagulopathy, anticoagulation, thrombocytopenia <50,000/mm³ (relative contraindications) 4
Risk Stratification and Prognosis
High-Risk Features Requiring Hospitalization
- Temperature >38°C (>100.4°F) 7
- Subacute course 7
- Large pericardial effusion or tamponade 7
- Failure of NSAID treatment 7
Recurrence Risk
- 15-30% after first episode without colchicine 1, 3
- Increases to 50% after first recurrence 1
- Inadequate treatment of first episode is the most common cause of recurrence 1
Constrictive Pericarditis Risk (by etiology)
- Low (<1%): idiopathic/viral pericarditis 1, 3
- Intermediate (2-5%): autoimmune/neoplastic 1, 3
- High (20-30%): bacterial/tuberculous 1, 3
Common Pitfalls to Avoid
- Inadequate treatment duration: Colchicine must be continued for minimum 3 months, not stopped when symptoms resolve 1
- Premature tapering: Only taper NSAIDs after both symptom resolution AND CRP normalization 1
- Early corticosteroid use: Increases recurrence risk; reserve for true second-line situations 1, 3
- Ignoring CRP monitoring: CRP normalization is essential before tapering therapy 1
- Inadequate exercise restriction: Athletes require minimum 3-month restriction regardless of symptom resolution 1