Pericarditis: Drug Therapy

Therapeutic Targets

  • Improvement of the symptomatology
  • Avoidance of complications

Therapy recommendations

  • Hospitalization:
    • When a specific cause is highly probable (e.g., tuberculosis, systemic rheumatic diseases, and neoplasms).
    • When markers of poor prognosis are present (e.g., subacute course, large pericardial effusion (pericardial effusion), pericardial tamponade, fever size >38°C, concomitant myocarditis (“accompanying myocarditis”), immunosuppression, trauma, and oral anticoagulation (anticoagulants))
  • Acute pericarditis: basic therapy with acetylsalicylic acid (ASA) or ibuprofen) [plus a proton pump inhibitor/gastric acid blocker], combined with low-dose colchicine.
  • Recurrent (recurrent) pericarditis (recurrence rate after initial event approximately 30%): same approach as for acute pericarditis, but differences in dosage and duration of therapy; colchicine reduces risk of recurrence (recurrence risk) in recurrent pericarditis by half; reduction in postpericardiotomy syndrome risk after cardiac surgery from 30% to 20%.
    • Duration of therapy should be made dependent on CRP concentration; after CRP normalization, gradual reduction of therapy should be considered.
    • In colchicine-therapy-refractory pericarditis in patients with glucocorticoid dependence, intravenous immunoglobulins (IVIG; hyperimmunoglobulins (2 g/kg bw, i. v, over 3-5 months), anakinra (interleukin-1 receptor antagonists), and azathioprine (immunosuppressant, purine analogue that is metabolized in the body to 6-mercaptopurine and methylnitroimidazole) should be considered
    • If symptoms recur during reduction of therapy, glucocorticoid dosing should not be increased to treat these symptoms, but acetylsalicylic acid dosing should be increased to the maximum. Furthermore, colchicine and analgesics (pain relievers) should also be prescribed to control pain.
  • Pericardial effusion: prednisolone (glucocorticoid therapy); during prednisolone therapy, 1,000 mg calcium/day and vitamin D 800 to 1,000 I.U./day should be taken in addition.
  • Postpericardiotomy syndrome as a special form of pericarditis (after occurred cardiac surgery with opening of the pericardium): NSAID (Non-steroidal anti-inflammatory drugs): acetylsalicylic acid in an initial dose of 750-1,000 mg three times daily or alternatively administration of 600-800 mg ibuprofen three times daily; weekly reduction over a therapy duration of 3 to 4 weeks; in therapy refractory courses: Colchicine and glucocorticoids.
  • Depending on the etiology may also need antibiosis (antibiotic therapy), virostasis (antiviral) or mycotic therapy (antifungal).
  • If necessary, interferon α in virus-associated pericarditis.

Further notes

  • In a placebo-controlled phase III trial in symptomatic patients with recurrent pericarditis, rilonacept proved effective. It reduced the risk of pericarditis recurrence by 96% relative to placebo (hazard ratio: 0.04, p<0.0001).Mode of action of rilonacept (known as IL-1 trap): fusion protein that blocks interleukin-1 (IL-1) signaling.Dosage: 160 mg injected subcutaneously once weekly.