First-Line Therapy for Acute Idiopathic or Viral Pericarditis
The recommended first-line therapy is aspirin 750-1000 mg every 8 hours OR ibuprofen 600 mg every 8 hours for 1-2 weeks with gastroprotection, PLUS weight-adjusted colchicine (0.5 mg once daily if <70 kg or 0.5 mg twice daily if ≥70 kg) for 3 months. 1, 2
NSAID Selection and Dosing
Choose between aspirin and ibuprofen based on:
- Aspirin 750-1000 mg every 8 hours is preferred when the patient already requires antiplatelet therapy for coronary disease 1
- Ibuprofen 600 mg every 8 hours is the primary NSAID choice for most other patients 2
- Base selection on contraindications, prior efficacy/side effects, and concomitant diseases 1
Always provide gastroprotection (proton pump inhibitor) with any NSAID regimen 1
Mandatory Colchicine Addition
Colchicine must be added to NSAID therapy—it is NOT optional: 1
- Reduces recurrence from 32% to 11% at 18 months (NNT = 5) 2
- Weight-adjusted dosing: 0.5 mg once daily if <70 kg; 0.5 mg twice daily if ≥70 kg 1, 2
- Duration: Full 3 months required—shorter courses increase recurrence to 15-30% after first episode and 50% after first recurrence 1, 2, 3
Treatment Duration and Monitoring
Use C-reactive protein (CRP) to guide treatment length: 1
- Continue NSAIDs until symptoms resolve AND CRP normalizes (typically 1-2 weeks) 1, 2
- Do not begin tapering until both symptoms are absent AND CRP is normal—premature tapering causes rebound inflammation 2
- Colchicine continues for full 3 months regardless of symptom resolution 1, 2
NSAID Tapering Protocol
After symptoms resolve and CRP normalizes, taper NSAIDs gradually: 1, 2
| Drug | Tapering Schedule |
|---|---|
| Aspirin | Decrease by 250-500 mg every 1-2 weeks [1] |
| Ibuprofen | Decrease by 200-400 mg every 1-2 weeks [1,2] |
Colchicine tapering is not mandatory but may use 0.5 mg every other day (<70 kg) or 0.5 mg once daily (≥70 kg) in final weeks 1
When NSAIDs Are Contraindicated
If NSAIDs cannot be used (true allergy, recent GI bleeding, high-risk anticoagulation): 2
- Use low-dose prednisone 0.2-0.5 mg/kg/day PLUS colchicine 1, 2
- Exclude infectious causes before starting corticosteroids 1, 2
- Maintain initial dose until symptom resolution and CRP normalization, then taper 1
Critical Pitfall: Corticosteroids Are NOT First-Line
Corticosteroids dramatically increase recurrence risk: 2
- Odds ratio 4.3 (95% CI 1.2-15.3) for recurrence 2
- Recurrence rate ~40% with prednisone+colchicine vs. ~18% with NSAID+colchicine 2
- Risk of promoting chronic evolution and drug dependence 1
- Class III recommendation (not recommended) as first-line therapy 1
Activity Restriction
Restrict exercise until complete resolution: 1
- For non-athletes: Until symptoms resolve AND CRP, ECG, and echocardiogram normalize 1
- For competitive athletes: Minimum 3 months from onset even after normalization of tests 1
Common Causes of Treatment Failure
Inadequate initial treatment is the most common cause of recurrence: 1
- Using NSAIDs for <1-2 weeks 1
- Stopping colchicine before 3 months 2, 3
- Tapering before CRP normalizes 2
- Using corticosteroids as first-line therapy 1, 2
Risk Stratification for Prognosis
Most patients with idiopathic/viral pericarditis have excellent prognosis: 1