How should acute pericarditis be managed in an otherwise healthy adult?

Treatment of Acute Pericarditis in Otherwise Healthy Adults

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 a minimum of 3 months, along with exercise restriction until complete symptom resolution and CRP normalization. 1

Initial Assessment and Risk Stratification

Before initiating treatment, assess for high-risk features that warrant hospital admission and etiologic workup: 1

• Major risk factors: Fever >38°C, subacute onset over several days, large pericardial effusion (>20 mm diastolic echo-free space), cardiac tamponade, or failure to respond to NSAIDs within 7 days 1
• Minor risk factors: Myopericarditis, immunosuppression, trauma, or oral anticoagulant therapy 1

Low-risk patients without these features can be managed as outpatients. 1

First-Line Pharmacologic Therapy

NSAIDs or Aspirin (Mandatory)

Choose one of the following regimens: 1, 2

• Aspirin: 750-1000 mg every 8 hours for 1-2 weeks 1, 2
• Ibuprofen: 600 mg every 8 hours for 1-2 weeks 1, 2

Always provide gastroprotection (proton pump inhibitor) with NSAID therapy. 1, 2 The choice between aspirin and ibuprofen should be based on contraindications, prior efficacy/side effects, and concomitant conditions (favor aspirin if already indicated for antiplatelet therapy). 1

Colchicine (Mandatory Add-On)

Colchicine must be added to NSAID therapy—it is not optional. 1, 2 This combination reduces recurrence from 32-37.5% to 11-16.7% (NNT=5). 2, 3

Weight-adjusted dosing: 1, 2, 4

• <70 kg: 0.5 mg once daily
• ≥70 kg: 0.5 mg twice daily

Duration: Minimum 3 months for first episode of acute pericarditis. 1, 2, 4

Critical contraindication: Severe renal impairment (CrCl <30 mL/min)—colchicine is contraindicated or requires dose reduction to 0.3 mg once daily with extreme caution. 2, 4

Treatment Duration and Tapering Strategy

When to Begin Tapering

Do not initiate tapering until BOTH conditions are met: 1, 2, 4

1. Complete resolution of chest pain and all pericarditis symptoms
2. Normalization of C-reactive protein (CRP)

Premature tapering before CRP normalization causes rebound inflammation and markedly increases recurrence risk. 2, 4

Tapering Protocol

Taper NSAIDs/aspirin first, then colchicine: 1, 2, 4

• Aspirin: Decrease by 250-500 mg every 1-2 weeks 1
• Ibuprofen: Decrease by 200-400 mg every 1-2 weeks 1
• Colchicine (final weeks):
  • <70 kg: 0.5 mg every other day 4
  • ≥70 kg: 0.5 mg once daily 4

Monitor CRP serially to guide tapering and confirm therapeutic response. 1, 2

Exercise Restriction

Non-athletes: Restrict physical activity beyond ordinary sedentary life until symptoms resolve AND CRP, ECG, and echocardiogram normalize. 1, 2

Athletes: Minimum 3-month restriction from competitive sports after symptom onset, even after clinical resolution. 1, 2

Second-Line Therapy (When First-Line Fails or Is Contraindicated)

Low-dose corticosteroids should be considered ONLY when: 1

• Contraindications to NSAIDs/colchicine exist
• Incomplete response to aspirin/NSAIDs plus colchicine after adequate trial
• Infectious causes have been excluded

Dosing: Prednisone 0.2-0.5 mg/kg/day (typically 0.25-0.50 mg/kg/day starting dose) 1, 2

Why Corticosteroids Are NOT First-Line

Corticosteroids markedly increase recurrence risk (odds ratio 4.3,95% CI 1.2-15.3) and promote drug dependence. 2, 4 Recurrence rate with prednisone plus colchicine is approximately 40% versus 18% with NSAID plus colchicine. 2

If corticosteroids are necessary, use the lowest effective dose and taper slowly according to symptoms and CRP. 1 Tapering should follow a structured protocol: 1

• 50 mg: Decrease by 10 mg/day every 1-2 weeks

• 50-25 mg: Decrease by 5-10 mg/day every 1-2 weeks
• 25-15 mg: Decrease by 2.5 mg/day every 2-4 weeks
• <15 mg: Decrease by 1.25-2.5 mg/day every 2-6 weeks

Every dose decrease should occur only when the patient is asymptomatic and CRP is normal. 1

Management of Recurrence

Recurrence occurs in 15-30% of patients after a first episode without colchicine, rising to 50% after a first recurrence. 2, 3, 5

If recurrence develops during or after treatment: 1, 2, 4

• Resume or maximize NSAID dosing to full dose every 8 hours
• Ensure strict adherence to colchicine
• Do NOT increase corticosteroids—this worsens long-term outcomes
• Extend colchicine duration to minimum 6 months for recurrent pericarditis 1, 4

Common Pitfalls to Avoid

1. Inadequate treatment duration: Courses shorter than 3 months for acute pericarditis or 6 months for recurrent pericarditis increase recurrence rates. 2, 4

2. Using corticosteroids as first-line therapy: This is associated with a 4-fold increase in recurrence risk. 2, 4

3. Omitting colchicine: Colchicine is mandatory, not optional—it reduces recurrence by approximately 56%. 2

4. Premature tapering: Beginning taper before complete symptom resolution and CRP normalization leads to rebound inflammation. 2, 4

5. Colchicine monotherapy: Colchicine must always be combined with NSAIDs/aspirin; monotherapy is ineffective. 4

6. Failure to adjust colchicine in renal impairment: Can lead to life-threatening toxicity (neuromyopathy, rhabdomyolysis, bone marrow suppression). 2, 4

Monitoring Parameters

Serial monitoring should include: 1, 2

• CRP levels to guide treatment duration and readiness for tapering
• Clinical symptoms (chest pain resolution)
• ECG and echocardiogram before exercise resumption
• Response assessment at 1 week (failure to respond is a high-risk feature) 1

Third-Line Options for Refractory Cases

For corticosteroid-dependent recurrent pericarditis not responsive to colchicine: 1, 6, 5

• IL-1 blockers (anakinra, rilonacept) are effective (10% vs 78% recurrence with placebo, RR=0.14) 5
• Consider IVIG or azathioprine after multidisciplinary consultation 1
• Pericardiectomy only as last resort after unsuccessful medical therapy 1