First-line treatment of acute pericarditis includes off-label use of aspirin or a nonsteroidal anti-inflammatory drug (NSAID) plus colchicine for inflammation, often with a proton pump inhibitor for gastric protection. Aspirin/NSAIDs NSAIDs and aspirin inhibit cyclooxygenase and thereby prevent the production of prostaglandins via the metabolism of arachidonic acid. Relatively higher doses of aspirin/NSAIDs are necessary to mitigate symptoms attributed to pericardial inflammation.46 Aspirin may be used instead of other NSAIDs if the patient is already receiving aspirin for another condition, such as coronary or peripheral artery disease where an antiplatelet effect is required. Acute pericarditis may fail to settle or appear incessant if inadequate doses of NSAIDs are used or if these are stopped abruptly or tapered before symptoms have settled and/or inflammatory markers have normalized. Although other NSAIDs can be used, ibuprofen and aspirin have the advantage that they are inexpensive, readily available and come in tablet dose denominations that greatly facilitate tapering. NSAIDs are contraindicated when creatinine clearance is less than 30 ml/min, or there is an allergy to NSAIDs or a history of associated asthma exacerbation, recent gastrointestinal ulcer or high risk of bleeding due to concomitant use of anticoagulants. NSAIDs are also contraindicated in patients with a history of acute coronary syndromes, heart failure and in pregnancy at 20 weeks or later.1,47 Management of Acute Pericarditis Significant drug interactions with colchicine Cytochrome P450 3A4 (CYP3A4) and P-glycoprotein (P-gp) inhibitors can substantially increase serum colchicine concentrations, increasing toxicity.65 Renal and hepatic impairment further increases this risk. Awareness and risk mitigation strategies should be followed when using these drugs concomitantly. However, concomitant use of strong CYP3A4 and P-gp inhibitors should be avoided, particularly with renal or hepatic impairment. Common interactions are listed in Table 2. Visit https://link.springer.com/article/10.1007/s40264-02201265-1/tables/4 for more information. Table 1. Treatment and tapering of initial therapies for acute and recurrent pericarditis 46,48 Recommended treatment dosing Duration* Tapering recommendations Acute idiopathic pericarditis (initial episode) Recurrent pericarditis Aspirin 750-1000 mg by mouth every 8 hours 1-2 weeks Weeks to months 250-500 mg every 1 to 2 weeks Ibuprofen 600-800 mg by mouth every 8 hours 200-400 mg every 1 to 2 weeks Colchicine† 0.5-0.6 mg PO twice daily (once daily if <70 kg, age >70 years or intolerant to twice daily dosing) 3 months At least 6 months None required 16 *Duration may vary based on symptoms and time to normalization of high-sensitivity C-reactive protein (<1 mg/L). †Renal dose adjustments are required, and presence of CYP3A4/P-glycoprotein drug interactions further influences clearance and may preclude safe use of colchicine. A single loading dose of 1-2 mg may be considered before maintenance dosing, but is not necessary and may negatively impact tolerance and adherence.
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