Treatment of pericarditis

Pericarditis should be managed in hospital if a treatable cause is identified, or if the patient has one of the following risk factors associated with poor prognosis:

  • high fever—more than 38oC
  • subacute course—symptoms developing over several days without a clear acute onset
  • large pericardial effusion
  • cardiac tamponade
  • failure to respond within 7 days to drug therapy.

Other risk factors to consider include myopericarditis, immunosuppression, trauma and oral anticoagulant therapy.

The treatment of acute pericarditis depends on the cause. Consider specific treatments in patients with connective tissue disorders (immunosuppression), uraemia (dialysis) or purulent pericarditis (antibiotics). Otherwise, the mainstays of therapy are restriction of exercise plus drug therapy with colchicine plus aspirin or another nonsteroidal anti-inflammatory drug (NSAID).

Colchicine combined with an NSAID improves remission rates of acute pericarditis at 1 week and reduces recurrence rates in acute and recurrent pericarditis, compared with anti-inflammatory drug therapy aloneAlabed, 2014Imazio, Bobbio, Cecchi, Demarie, Demichelis, 2005Imazio, Bobbio, Cecchi, Demarie, Pomari, 2005Imazio, 2013. Base anti-inflammatory drug choice on the patient’s history of use (eg previous efficacy or adverse effects; aspirin may be preferred if already being taken as antiplatelet therapy), presence of contraindications or comorbidities, and clinician familiarity with the NSAID. Suitable combinations areAdler, 2015:

colchicine colchicine colchicine colchicine

70 kg or more: 500 micrograms orally, twice daily for 3 months

less than 70 kg: 500 micrograms orally, once daily for 3 months

PLUS ONE OF THE FOLLOWING

1aspirin 750 to 1000 mg orally, 8-hourly for 1 to 2 weeks, then decrease the dose by 250 to 500 mg every 1 or 2 weeks to stop aspirin aspirin aspirin

OR

1ibuprofen immediate-release 600 mg orally, 8-hourly for 1 to 2 weeks, then decrease the dose by 200 to 400 mg every 1 or 2 weeks to stop. ibuprofen ibuprofen ibuprofen

The NSAID is usually given for 1 to 2 weeks, with duration guided by symptom resolution and normalisation of inflammatory markers (eg C-reactive protein). The NSAID dose may be tapered to stop, but it is not essential to taper the dose of colchicine to stop. Reduce the dose of colchicine for patients with kidney impairment.

Although oral corticosteroids often provide relief of acute pericarditis, they are associated with the usual complications of long-term corticosteroid therapy, and recurrence of pericarditis is common after stopping therapy. Corticosteroids should only be considered if NSAIDs are contraindicated or ineffective, or for some immune-mediated causesAdler, 2015Chiabrando, 2020.

Trials of interleukin-1 inhibitors (particularly anakinra) have been promising in resistant or recurrent cases of pericarditis Khayata, 2020. At the time of writing, these drugs are not approved by the Australian Therapeutic Goods Administration (TGA). See the TGA website for current information.

For management of recurrent pericarditis, seek specialist advice.