19 A Toolkit for Health Care Professionals Recurrent Pericarditis Glucocorticoids may reduce the efficacy of colchicine, and they have been associated with increased rates of recurrent pericarditis. used first-line when there is an underlying systemic autoimmune rheumatic disease or a contraindication to NSAIDs. Where not contraindicated, colchicine should be co-prescribed with prednisone.1,54 Prednisone prescribed at a dose of 0.2-0.5 mg/kg/day for up to 4 weeks is required before slow tapering is begun, assuming symptoms have resolved, and inflammatory markers have normalized. Doses higher than this can increase the risks of adverse effects without any gain in efficacy. The risk of recurrence is highest when doses are tapered to below 12.5-15 mg, and therefore, tapering below this should be slow.58 Where not contraindicated, colchicine should be co-prescribed with prednisone and should be stopped only after steroids have been tapered off or at 3 months, whichever is longer. Patients receiving a prolonged course of oral corticosteroids should be warned about the risks of adrenal suppression and given advice on sick day rules, should they develop any intercurrent illness that prevents them taking and/or adequately absorbing their prednisone. Before initiating oral corticosteroids, consider checking a baseline hemoglobin A1c (HbA1c), vitamin D and parathyroid hormone (PTH) to ensure patients are vitamin D replete and to guide calcium/vitamin D supplementation to mitigate any impact on bone density. Use the opportunity to promote other lifestyle changes that may reduce risks, such as moderating alcohol intake and smoking cessation. In high-risk patients, consider the need for bone densitometry and formal bone protection. If a patient is exposed to prolonged courses of oral corticosteroids, once a dose of 4-5 mg is reached, it may be necessary to check adrenal reserve with a 9 a.m. cortisol (taken before 10 a.m. and before dosing with prednisone on that day). Where this is insufficient, consider the need for a Synacthen test (ACTH stimulation test) to guide further tapering.59,60,61 Table 4: Guidance on corticosteroid therapy46 Treatment dose: prednisone 0.2-0.5 mg/kg/day* Prednisone dose Tapering based on initial treatment dose More than 50 mg 10 mg/day every 1-2 weeks 25-50 mg 5-10 mg/day every 1-2 weeks 15-25 mg 2.5 mg/day every 2-4 weeks Less than 15 mg 1.5-2.5 mg/day every 2-6 weeks *prednisone 5 mg = prednisolone 5 mg = methylprednisolone 4 mg = dexamethasone 0.75 mg = hydrocortisone 20 mg General approach to tapering Although clinical practice guidelines have defined durations of therapy for acute pericarditis, tapering should only occur if patients are asymptomatic with normalized high-sensitivity C-reactive protein (hs-CRP). Prolonged treatment courses are warranted in persistently symptomatic patients or if hs-CRP remains elevated. Persistent elevation in hs-CRP concentrations (>3 mg/L) after 1 week is an independent risk factor for recurrent pericarditis.62 Hs-CRP should be monitored at baseline and one week after starting therapy to ensure resolution and to help guide therapy. Once symptoms have resolved and hs-CRP has normalized (<1mg/L), tapering of aspirin/ NSAIDs and/or corticosteroids can begin.
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