Treatment for First Episode Acute Pericarditis After Viral Illness
Start aspirin 750-1000 mg every 8 hours OR ibuprofen 600 mg every 8 hours for 1-2 weeks with gastroprotection, combined with 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
First-Line Therapy Algorithm
NSAIDs (Choose One)
- Aspirin 750-1000 mg every 8 hours is the preferred first-line NSAID 1, 2
- Ibuprofen 600 mg every 8 hours is an equally effective alternative 1, 2
- Always provide gastroprotection (proton pump inhibitor) with either agent 1
- Continue full doses for 1-2 weeks or until complete symptom resolution and CRP normalization 1, 2
Mandatory Colchicine Addition
- Colchicine must be added to NSAID therapy from the start—this is not optional 1, 2
- Weight-adjusted dosing: 0.5 mg once daily if <70 kg, or 0.5 mg twice daily if ≥70 kg 1, 2
- Continue for exactly 3 months for first episode 1, 2
- Adding colchicine reduces recurrence from 32% to 11% (NNT=5) 3
- Colchicine halves the recurrence rate compared to NSAIDs alone 1
Treatment Duration and Tapering
When to Begin Tapering
- Only start tapering after complete symptom resolution AND CRP normalization—premature tapering causes rebound inflammation 1, 2
- Monitor CRP serially to guide treatment length and assess response 1, 2
NSAID Tapering Schedule
- Aspirin: Decrease by 250-500 mg every 1-2 weeks 2
- Ibuprofen: Decrease by 200-400 mg every 1-2 weeks 2
- Typical tapering duration ranges from several weeks to a few months 2
Colchicine Duration
- Continue colchicine for the full 3 months regardless of symptom resolution 1, 2
- Shorter courses increase recurrence to 15-30% after first episode 1
Exercise Restriction
Non-Athletes
- Restrict all exercise until complete resolution of symptoms AND normalization of CRP, ECG, and echocardiogram 1, 2
Athletes
- Minimum 3 months exercise restriction even after symptom resolution 1, 2
- Must document normal CRP, ECG, and echocardiogram before return to play 1
Second-Line Therapy (When First-Line Fails)
Indications for Corticosteroids
- Use corticosteroids ONLY if:
Corticosteroid Dosing
- Low-dose prednisone 0.2-0.5 mg/kg/day (NOT high-dose 1.0 mg/kg/day) 1, 2
- Maintain initial dose until symptom resolution and CRP normalization, then taper gradually 1
- Critical warning: Corticosteroids increase recurrence risk 4-fold (OR 4.3,95% CI 1.2-15.3) 3
- Recurrence rate with prednisone + colchicine is 40% versus 18% with NSAID + colchicine 2
Common Pitfalls to Avoid
Inadequate Initial Treatment
- Inadequate treatment of the first episode is the most common cause of recurrence 1
- Ensure full 3-month colchicine course—shorter duration dramatically increases recurrence 1, 2
Premature Corticosteroid Use
- Never use corticosteroids as first-line therapy—they provide rapid symptom control but promote chronicity and recurrence 1, 2
- Corticosteroids are Class III (not recommended) for first-line treatment 1
Premature Tapering
- Tapering before complete symptom resolution and CRP normalization leads to rebound inflammation 1, 2
- Continue monitoring CRP throughout treatment and tapering 1, 2
Omitting Colchicine
- Failure to add colchicine to NSAIDs significantly increases recurrence risk 1, 2, 3
- Colchicine is Class I (strongly recommended) as adjunct to NSAID therapy 1
Prognosis and Expected Outcomes
Good Prognosis Indicators
- Most patients with viral/idiopathic pericarditis have excellent long-term prognosis 1
- With appropriate treatment, 70-85% have a benign course 4
- Risk of constrictive pericarditis is <1% for viral/idiopathic causes 1
- Cardiac tamponade rarely occurs (<3%) in idiopathic pericarditis 1, 4