Glucocorticoid Tapering in Adult Myopericarditis
For myopericarditis, glucocorticoids should be avoided whenever possible and reserved only for cases with contraindications to NSAIDs/colchicine or failure of first-line therapy; when used, start with low-dose prednisone 0.25-0.5 mg/kg/day and taper extremely slowly using the ESC protocol, with particularly cautious decrements of only 1.25-2.5 mg every 2-6 weeks once below 15 mg/day. 1
Critical Context: Glucocorticoids Are NOT First-Line for Myopericarditis
- First-line therapy for myopericarditis is high-dose NSAIDs (ibuprofen 600 mg every 8 hours) plus colchicine (0.5 mg twice daily if ≥70 kg, 0.5 mg once daily if <70 kg) for at least 6 months. 2, 3
- Colchicine is safe and efficacious in myopericarditis, reducing recurrences from 43.8% to 19.2% without increasing adverse events. 3
- Glucocorticoids favor chronicity, increase recurrence rates (up to 50% after first recurrence), and cause more side effects compared to NSAIDs/colchicine. 4, 5
- Women and corticosteroid use are independent risk factors for recurrences in myopericarditis (HR 2.27 for corticosteroids). 3
When Glucocorticoids Must Be Used
Indications (second-line only): 1
- Contraindications to NSAIDs/colchicine
- Incomplete response to NSAIDs plus colchicine after adequate trial
- Autoimmune etiology requiring immunosuppression
Critical warning: NSAIDs should be used cautiously in myopericarditis at lower anti-inflammatory doses primarily for symptom control, as animal models suggest they may enhance myocarditic processes. 6
ESC-Recommended Tapering Protocol for Pericarditis/Myopericarditis
Starting Dose
- Use low-dose prednisone 0.25-0.5 mg/kg/day (typically 15-35 mg/day for most adults). 1
- Avoid doses >50 mg except for special cases, and only for a few days with rapid tapering to 25 mg/day. 1
- Higher doses (1.0 mg/kg/day) are associated with 3.6-fold increased risk of side effects, recurrences, and hospitalizations. 5
Tapering Schedule (Dose-Dependent)
For doses >50 mg: 1
- Decrease by 10 mg/day every 1-2 weeks
For doses 50-25 mg: 1
- Decrease by 5-10 mg/day every 1-2 weeks
For doses 25-15 mg: 1
- Decrease by 2.5 mg/day every 2-4 weeks
For doses <15 mg (CRITICAL THRESHOLD): 1, 4
- Decrease by only 1.25-2.5 mg every 2-6 weeks
- This is the most critical phase where recurrences are most likely
- The 10-15 mg/day threshold is where the inflammatory process becomes "rebound-prone" 4
Essential Prerequisites for Each Dose Reduction
Every decrease should only occur when: 1
- Patient is completely asymptomatic
- C-reactive protein (CRP) is normal
- This applies particularly for doses <25 mg/day
Bone Protection During Glucocorticoid Therapy
Mandatory supplementation: 1
- Calcium 1,200-1,500 mg/day (supplement plus dietary intake)
- Vitamin D 800-1,000 IU/day
Bisphosphonates recommended for: 1
- All men ≥50 years on long-term glucocorticoids
- All postmenopausal women on long-term glucocorticoids
- When prednisone dose ≥5.0-7.5 mg/day is anticipated long-term
Common Pitfalls to Avoid
- Tapering too rapidly below 15 mg/day: This is the most common cause of recurrence. 1, 4
- Increasing dose or restarting glucocorticoids at recurrence: Every effort should be made NOT to increase the dose; instead, optimize NSAIDs/colchicine. 1
- Using high initial doses (>0.5 mg/kg/day): Associated with worse outcomes. 5
- Tapering while CRP is still elevated: Wait for complete normalization. 1
- Tapering multiple drugs simultaneously: Taper one class at a time, with colchicine discontinued last (over several months in difficult cases). 1
Alternative Approaches for Refractory Cases
If requiring unacceptably high long-term doses (prednisone 15-25 mg/day) or corticosteroid-dependent: 1, 4, 7
- Consider anakinra (IL-1 receptor antagonist) as third-line therapy
- IVIG or azathioprine are alternatives
- Requires consultation with immunology/rheumatology specialists 1