What is the recommended treatment regimen for acute pericarditis, including first‑line NSAIDs, colchicine dosing, indications for corticosteroids, and management of underlying etiologies and complications?

Treatment of Acute Pericarditis

Start aspirin 750-1000 mg every 8 hours OR ibuprofen 600 mg every 8 hours combined with weight-adjusted colchicine (0.5 mg once daily if <70 kg, 0.5 mg twice daily if ≥70 kg) as first-line therapy for all patients with acute pericarditis. 1, 2

First-Line Therapy Algorithm

NSAID Selection and Dosing

• Aspirin 750-1000 mg every 8 hours is preferred when the patient already requires antiplatelet therapy for coronary artery disease or other cardiovascular indications 1
• Ibuprofen 600 mg every 8 hours is the primary NSAID choice for most other patients with acute idiopathic or viral pericarditis 2
• Indomethacin 25-50 mg every 8 hours (starting at the lower dose) serves as an alternative NSAID option, though it carries higher risk of headache and dizziness 2
• Always prescribe a proton pump inhibitor for gastroprotection with any NSAID regimen 1

Mandatory Colchicine Co-Administration

• Add colchicine to NSAID therapy from day one—never use NSAIDs alone, as combination therapy reduces 18-month recurrence from 32% to 11% (NNT = 5) 2
• Weight-adjusted dosing: 0.5 mg once daily for patients <70 kg; 0.5 mg twice daily for patients ≥70 kg 1, 2, 3
• Continue colchicine for exactly 3 months for first episodes—shorter courses increase recurrence risk to 15-30% 1, 2
• Extend colchicine to 6 months minimum for first recurrences 2, 4

Treatment Duration and Tapering Strategy

When to Begin Tapering

• Never start tapering until BOTH conditions are met: complete symptom resolution AND CRP normalization 1, 2
• Use serial CRP measurements every 1-2 weeks to guide treatment length and confirm therapeutic response 1, 2
• Premature tapering before CRP normalizes causes rebound inflammation and dramatically increases recurrence risk 2

NSAID Tapering Schedule

Drug	Initial Duration	Taper Step	Taper Interval
Aspirin	1-2 weeks	Reduce by 250-500 mg	Every 1-2 weeks
Ibuprofen	1-2 weeks	Reduce by 200-400 mg	Every 1-2 weeks
Indomethacin	1-2 weeks	Reduce by 25 mg	Every 1-2 weeks

1, 2

• Total tapering duration typically ranges from several weeks to a few months depending on inflammatory marker response 2

Activity Restriction

• Restrict all physical activity beyond ordinary sedentary life until symptoms resolve completely AND CRP, ECG, and echocardiogram normalize 1, 2
• For competitive athletes, mandate 3 months of exercise restriction even after symptom resolution to reduce recurrence risk 2

Second-Line Therapy: When Corticosteroids Are Necessary

Indications for Corticosteroids

• Use corticosteroids ONLY when:
  • NSAIDs are absolutely contraindicated (true NSAID allergy, recent peptic ulcer/GI bleeding, high-risk anticoagulation) 2
  • First-line therapy with NSAIDs plus colchicine has failed after adequate trial 1, 2
  • Infectious causes have been definitively excluded 2

Critical Corticosteroid Warnings

• Never use corticosteroids as first-line therapy—they increase recurrence risk with odds ratio 4.3 (95% CI 1.2-15.3) 2
• Recurrence rate with prednisone plus colchicine is approximately 40% versus 18% with NSAID plus colchicine 2
• Corticosteroids promote chronicity, drug dependence, and side effects 1, 2
• One study found that adding colchicine to prednisone does not reduce recurrence risk, suggesting prednisone may blunt colchicine's protective effects 5

Corticosteroid Dosing When Required

• Use LOW to moderate doses only: prednisone 0.2-0.5 mg/kg/day 1, 2
• Never use high doses (1.0 mg/kg/day)—they worsen outcomes 1
• Always combine corticosteroids with colchicine when using steroids 1
• Taper slowly over months, not weeks, to prevent rebound 2

Special Populations and Situations

Pregnancy

• Corticosteroids are preferred over NSAIDs in pregnant patients, combined with weight-adjusted colchicine 2

Renal Impairment

• Colchicine is contraindicated in severe renal impairment (CrCl <30 mL/min) 2
• For moderate renal impairment (CrCl 30-50 mL/min), use standard colchicine dose with close toxicity monitoring 2
• For CrCl <30 mL/min, if colchicine is essential, reduce to 0.3 mg once daily 2
• For dialysis patients, maximum dose is 0.3 mg twice weekly 2
• Consider low-dose corticosteroids as second-line if NSAIDs/colchicine are contraindicated by renal dysfunction 2

Heart Failure with Reduced Ejection Fraction (HFrEF) or Coronary Artery Disease

• Colchicine monotherapy may be considered in patients with HFrEF and/or CAD where NSAID adverse effects pose significant concern 6
• One retrospective study showed no difference in recurrence between colchicine monotherapy (16.3%), NSAID monotherapy (28.6%), and combination therapy (18.5%), though this requires prospective validation 6

Uraemic Pericarditis

• Intensify dialysis first for uraemic pericarditis 2
• Consider pericardial aspiration or drainage if non-responsive to intensified dialysis 2
• Colchicine is contraindicated in severe renal impairment 2

Tuberculous Pericarditis

• Treat with antituberculous therapy as primary intervention 7
• Adjunctive steroids may be considered in HIV-negative patients with tuberculous pericarditis, particularly for associated constrictive pericarditis 2, 7
• Avoid steroids in HIV-associated TB pericarditis 2

Purulent Pericarditis

• Immediate empiric intravenous antimicrobial therapy is required 2
• Urgent drainage is mandatory—with aggressive management, 85% survival rate with good long-term outcomes is achievable 2

Post-Cardiac Surgery (Post-Pericardiotomy Syndrome)

• Colchicine is indicated ONLY if systemic inflammation is documented (elevated CRP plus at least 2 of 5 criteria: fever, pericarditic chest pain, pericardial/pleural rubs, pericardial effusion, or pleural effusion) 2, 3
• Do NOT use colchicine for asymptomatic post-surgical effusions without inflammation—it increases side effects without benefit 2, 3
• When indicated, use same weight-adjusted colchicine dosing for 3 months combined with NSAIDs 3
• Meta-analysis shows colchicine reduces post-pericardiotomy syndrome risk (OR 0.38) 3

Management of Pericardial Effusion

Effusion WITH Inflammation (Elevated CRP)

• Treat with NSAIDs plus colchicine as outlined above for pericarditis 2
• Continue treatment until symptom resolution and CRP normalization 2
• Monitor with serial echocardiography and CRP measurements 2

Isolated Effusion WITHOUT Inflammation (Normal CRP)

• Anti-inflammatory drugs are NOT effective for isolated pericardial effusion without systemic inflammation 2
• Target therapy at the underlying etiology (approximately 60% of effusions are associated with known disease) 2
• Monitor with echocardiography every 6 months for moderate effusions 2
• Consider pericardiocentesis if:
  • Patient becomes symptomatic 2
  • Effusion progresses to large size with tamponade risk 2
  • Suspicion of bacterial or neoplastic etiology requiring diagnosis 2
  • Large chronic effusion (>3 months) present—carries 30-35% risk of progression to tamponade 2

Third-Line Therapy: IL-1 Blockers

• Interleukin-1 blockers (anakinra, rilonacept, goflikicept) are reserved for patients with multiple recurrences who cannot discontinue glucocorticoids 4, 7
• May be used as second-line therapy after NSAIDs and colchicine in patients with contraindications to glucocorticoids or high-risk features (multiple episodes, markedly elevated inflammatory markers, extensive pericardial imaging abnormalities) 4
• Particularly useful for patients with recurrent disease lasting several years who are steroid-dependent 7

Common Pitfalls to Avoid

• Never start corticosteroids as first-line therapy unless NSAIDs are absolutely contraindicated 1, 2
• Never stop treatment before CRP normalizes—premature discontinuation causes recurrences 1
• Never use NSAIDs for asymptomatic post-surgical effusions without systemic inflammation 1, 3
• Never use colchicine for less than 3 months on first episode—inadequate treatment duration is the most common cause of recurrence 1, 2
• Never taper NSAIDs rapidly within 1 month—rapid tapering increases recurrence risk 4