Recurrent Pericarditis Therapeutic options for recurrent pericarditis vary by region. The recommendations in this toolkit are based on the 2025 ESC guidelines. Clinicians should follow current evidence and locally available therapies. Overview and epidemiology Recurrent pericarditis is defined, according to the 2025 ESC guidelines, as new symptoms or disease activity following clinical remission. This typically occurs after a documented first episode of acute pericarditis, a symptom-free interval, complete discontinuation of anti-inflammatory therapy and subsequent recurrence of pericarditis, usually within 18 months of the index episode.14 Recurrence occurs in about 20–30% of patients within 18 months after a first episode of acute pericarditis and up to 50% after a first recurrence.68,69 Corticosteroid use (especially long-term use or doses above 1 mg/kg/day), lack of response to anti-inflammatories and persistent elevations in hsCRP are independent risk factors for recurrence.70 Therapeutic options for recurrent pericarditis differ between regions. In the United States, rilonacept is currently the only IL-1 pathway inhibitor approved by the FDA for this indication, whereas no IL-1 pathway inhibitors have received EMA approval in Europe. The recommendations outlined below reflect the 2025 ESC Guidelines, which is the only published guideline on pericarditis management. Clinicians should adhere to best practices based on current evidence and the therapeutics available in their region. Recurrent pericarditis is an autoinflammatory disease which results in activation of the inflammatory cascade mediated by interleukin-1 and other cytokines, which can last for years, characterized by multiple recurrences. The median duration of disease in patients with two or more recurrences is three years, with ~35% of patients still suffering at five years and ~25% at eight years.5 These findings were affirmed by a multicenter, longitudinal study with longest follow-up showing a median disease of 3.8 years.71 Pharmacologic management Initial therapy: Initial therapy for the first recurrence of pericarditis is similar to that of the first episode of acute pericarditis but with longer durations of therapy. (See Table 1: Treatment and tapering of initial therapies for acute and recurrent pericarditis on page 14.) For recurrent pericarditis, aspirin/ NSAID therapy lasts weeks to months, while colchicine therapy should be continued for at least six months. Combination therapy with aspirin/NSAIDs plus colchicine for recurrent pericarditis has been shown to significantly reduce further recurrence compared to standard therapy, with an absolute risk reduction of 26.6% at 18 months.72 Subsequent therapy: Over the past decade, IL-1 pathway inhibition has emerged as a therapeutic strategy for patients with multiple recurrences of pericarditis. Earlier expert opinions and the 2025 ACC Concise Clinical Guidance (CCG) position IL-1 pathway inhibitors (e.g., rilonacept — the only FDAapproved treatment for recurrent pericarditis — or anakinra) as second-line monotherapy in patients failing NSAIDs and colchicine ahead of or instead of corticosteroids.73 The 2025 ESC Guidelines provide more nuanced recommendations. It recommends anti-IL-1 therapy for patients with recurrent pericarditis who have failed firstline therapies and corticosteroids and who show elevated C-reactive protein (CRP) levels to reduce recurrences and allow corticosteroid withdrawal (Class I). IL-1 blockade may also be considered in cases of failure, contraindications and intolerance to first-line therapies and corticosteroids regardless of CRP levels to reduce recurrences and allow corticosteroid withdrawal.14 20
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