Acute%20pericarditis Treatment

Treatment

Treatment goals are to relieve pain, resolve inflammation and prevent recurrence
Specific therapy tailored to the identified etiology or underlying disorder is indicated
Choice of therapeutic agent is based on patient’s medical history (prior efficacy or side effects, contraindications), concomitant diseases (preferring Aspirin when it is already used as antiplatelet therapy) and physician’s knowledge and skills
Physical activity restriction is recommended for all patients until resolution of symptoms and normalization of CRP, ECG and echocardiogram [at least 3 months for athletes, shorter period (until remission) for non-athletes]

Aspirin and Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

First-line agents for acute pericarditis
Aspirin is the preferred agent for patients with pericarditis following myocardial infarction or any history of coronary disease
Commonly used NSAIDs include Ibuprofen and Indomethacin
Given for 1-2 weeks then tapered once symptoms resolve and serum inflammatory markers improve (consider serum CRP levels in guiding duration of treatment and evaluating efficacy of therapy)
- 2-4 weeks for recurrent pericarditis
Gastroprotection should be considered due to the high doses required
Suspect a cause other than postviral or idiopathic if symptoms (eg fever or chest discomfort) persist >1 week or a larger or new pericardial effusion develops during treatment
Use is off-label

Colchicine

Used as an adjunct to Aspirin and NSAID therapy
Reduces persistence of symptoms at 72 hours, increases remission rate at 7 days and helps reduce recurrence rate in half
Duration of therapy is up to 3 months
- Up to 6 months for recurrent pericarditis
Well tolerated when given long-term at a low dose
- Uncommon side effects include hepatic toxicity and myelosuppression
Reduce dose in patients with moderate renal dysfunction; avoid concurrent therapy with P-glycoprotein inhibitors or strong CYP3A4 inhibitors in patients with renal or hepatic impairment
Generally effective for post-cardiac injury syndromes and systemic inflammatory pericarditis but not in cases of malignancy-related or bacterial pericarditis

Glucocorticoids

Given to patients who are intolerant of, refractory to, or have contraindications to Aspirin or NSAIDs and Colchicine
- Also considered when a specific indication, eg autoimmune disease, is present or an infectious etiology has been excluded
Not used as primary therapy in patients with acute pericarditis due to high rate of relapse
Given at a low dose for 2 weeks then tapered slowly; 2-4 weeks for recurrent pericarditis
- In the setting of incomplete response to Aspirin or NSAIDs and Colchicine in patients with recurrent pericarditis, triple therapy with low- to moderate-dose steroids added to Aspirin or NSAIDs and Colchicine is given (not to be used as a substitute for these drugs) then tapered with a single drug class at a time before Colchicine is slowly discontinued, ie Colchicine is the last drug to be stopped
- Slow tapering and a prolonged course of steroid therapy may be required though with potential for steroid-associated side effects and risk of additional recurrences; consider measures for osteoporosis prevention

Other Agents

For patients who failed treatment with 2nd-line agents (eg Aspirin or NSAIDs with Colchicine plus steroid) or those with refractory recurrent pericarditis, other promising therapeutic agents to consider include Azathioprine, intravenous immunoglobulins (IVIG), interleukin-1 (IL-1) antagonist (Anakinra), immunosuppressive drugs [Methotrexate, anti-tumor necrosis factor (TNF) agent, Cyclosporine, Cyclophosphamide, Hydroxychloroquine]
- In patients with documented corticosteroid-dependent, infection-negative recurrent pericarditis unresponsive to Colchicine, consider giving Azathioprine, IVIG and Anakinra
  - Advantages of treatment with Anakinra (eg rapid onset of treatment effects and quick steroid withdrawal) were seen in the randomized controlled Anakinra-Treatment of Recurrent Idiopathic Pericarditis (AIRTRIP) trial
- Methotrexate and Mycophenolate mofetil may be considered in patients with idiopathic recurrent pericarditis unresponsive or with contraindications to corticosteroids

Pericardiectomy

May be performed in patients with refractory recurrent pericarditis or constrictive pericarditis only when a trial of medical therapy had been unsuccessful
- May also be done in patients with a prior history of cardiac surgery, cardiac tamponade resulting from repeated pericardial effusion recurrences or steroid toxicity limiting additional medical therapy
Results can vary from complete remission to continuing symptoms; complete pericardial resection gives the best outcome

Pericardial Window