The Bottom Line: Aspirin or non-steroidal anti-inflammatory drugs are standard first-line therapy for acute pericarditis.
Acute pericarditis (for complete information, see DynaMed Plus):
- ibuprofen 600 mg every 8 hours for 1-2 weeks, then taper by 200-440 mg every 1-2 weeks until resolution of symptoms and improvement of acute inflammatory markers
- aspirin 750-1,000 mg orally every 8 hours for 1-2 weeks, then taper by 250-500 mg every 1-2 weeks until resolution of symptoms and improvement of acute inflammatory markers (preferred if other indication for antiplatelet therapy)
- give colchicine as first-line therapy for acute pericarditis as adjunct to aspirin/NSAID (ESC Class I, Level A)
- typical colchicine dosing for acute pericarditis
- 0.5-0.6 mg once daily for 3 months for patients < 70 kg
- 0.5-0.6 mg twice daily for 3 months for patients ≥ 70 kg
- available tablets in United States (Colcrys) are 0.6 mg instead of 0.5 mg
Recurrent pericarditis (for complete information, see DynaMed Plus):
- give aspirin or NSAIDs at full doses (if tolerated) until complete resolution of symptoms (ESC Class I, Level A)
- if ischemic heart disease is a concern or antiplatelet therapy is required, aspirin should be considered at medium doses (1-2.4 g/day) (ESC Class IIa, Level C)
- NSAIDs contraindicated in patients with pericarditis complicating acute myocardial infarction (aspirin preferred with addition of colchicine if unresponsive to high-dose aspirin)
- aspirin 500-1,000 mg every 6-8 hours (range 1.5-4 g/day) for weeks-months, then taper by 250-500 mg every 1-2 weeks
- ibuprofen 600 mg every 8 hours (range 1,200-2,400 mg/day) for weeks-months, then taper by 200-400 mg every 1-2 weeks
- give colchicine 0.5 mg twice daily (or 0.5 mg daily for patients < 70 kg or intolerant to higher doses) for 6 months as adjunct to aspirin/NSAIDs
- continuation of colchicine for > 6 months should be considered in select patients to improve response to medication and remission rates and prevent recurrences
References: Bach RG. ACP Journal Club. Colchicine reduced further recurrence after a first recurrence of pericarditis. Ann Intern Med. 2012 Feb 21;156(4):JC2-04. doi:10.7362/0003-4819-156-4-201202210-02004.
DynaMed Plus [Internet]. Ipswich (MA): EBSCO Information Services. 1995 – . Record No. 115401, Acute and recurrent pericarditis/Treatment/Medications/Nonsteroidal anti-inflammatory drugs (NSAIDS); [updated 2017 Sep 26, cited 2017 Oct 12]; [about 19 screens]. University login required.
Imazio M, Brucato A, Cemin R, Ferrua S, et al. A randomized trial of colchicine for acute pericarditis. N Engl J Med. 2013 Oct 17;369(16):1522-8. doi:10.1056/NEJMoa1208536.
Summary: Because recurrence may imply a lack of sustained benefit from non-steroidal anti-inflammatory drugs, clinicians often prescribe corticosteroids, a common practice supported by limited observational data. Corticosteroid use in pericarditis, however, is associated with an increased risk for recurrence and side effects (Bach, 2012).
The CORP trial is the first multicenter, blinded, randomized, placebo-controlled trial to test the efficacy and safety of colchicine for recurrent pericarditis. Recurrence at 18 months and persistence of symptoms at 72 hours were reduced by > 50% compared with placebo. Notably, colchicine was well tolerated at the doses used, with no severe side effects, and drug withdrawal rates were similar to placebo.
In a separate randomized control trial, Imazio et al (2013) found that colchicine reduced the rate of symptom persistence at 72 hours (19.2% vs. 40.0%, P = 0.001), the number of recurrences per patient (0.21 vs. 0.52, P = 0.001), and the hospitalization rate (5.0% vs. 14.2%, P = 0.02). Colchicine also improved the remission rate at 1 week (85.0% vs. 58.3%, P<0.001).
Given the increased risk for recurrence and side effects with corticosteroids (2), colchicine should be strongly endorsed as first-line treatment for recurrent pericarditis (Bach, 2012).