How pericarditis is treated:
anti-inflammatory drugs, colchicine and other therapies

Article written and reviewed by Dr Luca Moretti

In acute idiopathic or presumed viral pericarditis, first-line treatment generally consists of aspirin or an NSAID at an anti-inflammatory dose combined with colchicine. The anti-inflammatory drug is used mainly to control pain and inflammation; colchicine significantly reduces the risk of the disease returning. However, the choice of medication, dose and duration must be established by a physician because they depend on age, weight, kidney function, coexisting diseases and other medications being taken.
Treatment is not identical for every form of pericarditis. When there is a specific cause, such as a bacterial infection, autoimmune disease, cancer or a metabolic condition, the problem that caused the inflammation of the pericardium must also be treated.

The pericarditis should therefore not be self-treated with an anti-inflammatory drug found at home. Before starting treatment, the diagnosis should be confirmed, the presence of high-risk features assessed, and it should be ensured that the pain is not due to another condition, such as an acute coronary syndrome.

Aspirin and NSAIDs: the basis of anti-inflammatory treatment

The 2025 ESC guidelines recommend as first-line treatment high-dose aspirin or an NSAID, together with a proton pump inhibitor for gastric protection when these medications are used. Among NSAIDs, ibuprofen is frequently used; the choice may change in the presence of ischemic heart disease, kidney failure, bleeding risk, gastrointestinal disease or other clinical conditions.
Treatment is started at a fully anti-inflammatory dose and then gradually tapered once symptoms have resolved and inflammatory activity is under control. The 2025 ESC guidelines list, as reference regimens for adults, aspirin 750-1000 mg three times daily or ibuprofen 600-800 mg three times daily for the initial period, but these doses must not be interpreted as instructions for self-medication.

The reason is simple: anti-inflammatory doses of aspirin and NSAIDs can cause gastrointestinal bleeding, kidney injury, fluid retention, increased blood pressure and interactions with other medications. In some patients they are contraindicated or require particular caution.
Response is assessed mainly by resolution of symptoms and regression of inflammation. If adequate treatment does not produce improvement after about one week, the diagnosis, adherence to treatment, cause of pericarditis and presence of complications should be reassessed.

Colchicine: why it is used even after the pain has improved

Colchicine is recommended as an addition to first-line treatment because it reduces the risk of recurrence. Unlike the anti-inflammatory drug, its role is not assessed only by its immediate effect on pain. For this reason it is continued for longer: modern recommendations indicate at least about 3 months after a first episode and at least 6 months in incessant or recurrent forms, with adjustment for the individual patient.
The dose is generally adjusted according to body weight and must be reduced or adapted in severe kidney failure or with certain drug interactions. The most frequent adverse effects are gastrointestinal, especially diarrhea and nausea.

Colchicine is not an ordinary painkiller and the dose should not be increased independently if pain returns. If symptoms recur while treatment is being tapered, it is more important to determine whether there is true reactivation of inflammation.
Randomized studies have shown that adding colchicine to conventional therapy reduces recurrences both after a first episode and in patients who have already had recurrences. This is why it is now a central element of the treatment strategy, unless contraindicated or not tolerated.

When corticosteroids and anti-IL-1 drugs are used

Corticosteroids are not normally the first choice in uncomplicated idiopathic pericarditis. They may be used when aspirin or NSAIDs are contraindicated or not tolerated, when the response to first-line therapies is inadequate, or when there is a specific indication, for example an autoimmune disease. When needed, low or moderate doses are preferred, together with colchicine, and tapering must be slow.
Inappropriate use of corticosteroids can promote treatment dependence and recurrences. The issue is therefore not that corticosteroids are "forbidden", but that they must be used in the right patient, with a precise strategy and after excluding infectious causes in which immunosuppression would be problematic.

In more difficult recurrent or incessant forms, drugs that block interleukin-1, a cytokine central to autoinflammatory inflammation, are available. The 2025 ESC guidelines recommend anakinra or rilonacept in patients with recurrent pericarditis who have failed first-line therapies and corticosteroids and have inflammatory activity; in some scenarios they may also be considered on the basis of inflammation documented by cardiac magnetic resonance imaging.
These are specialist therapies and are not used in an ordinary uncomplicated first episode. They require patient selection, appropriate screening and clinical monitoring.

Why sometimes the cause must be treated, not only the inflammation

In idiopathic or presumed viral forms, no specific agent to treat is usually identified and therapy is mainly anti-inflammatory. Antibiotics therefore have no routine role. If, however, bacterial pericarditis or purulent pericarditis is diagnosed, treatment changes radically and requires targeted antimicrobial therapy and often drainage of the pericardium.
Tuberculous pericarditis also follows a specific treatment pathway. Forms associated with autoimmune diseases require control of the systemic disease, whereas in neoplastic forms the strategy depends on the cancer, the amount of effusion and the risk of tamponade.

A pericardial effusion is not drained automatically simply because it is present. Drainage is indicated under certain clinical conditions, especially cardiac tamponade, a symptomatic moderate or large effusion despite medical therapy, or when the fluid needs to be analyzed to clarify a possible bacterial or neoplastic cause.
In unstable cardiac tamponade, drainage is instead an urgent treatment and cannot be replaced by anti-inflammatory drugs alone.

What to do during treatment and what to avoid

During the active phase, limitation of physical activity is indicated. Exertion increases heart rate and may promote mechanical stress on inflamed pericardial surfaces. Return to activity should be gradual and guided by clinical remission, with a more cautious approach if there is also myocardial involvement.
It is not advisable to change doses independently, stop colchicine when the pain disappears, take leftover corticosteroids from a previous treatment, or add other NSAIDs. Using several anti-inflammatory drugs at the same time also increases the risk of adverse effects without necessarily providing additional benefit.

If high fever, worsening pain, increasing shortness of breath, fainting, marked weakness or very low blood pressure develops during treatment, reassessment is required. Failure to respond to therapy should not be managed simply by increasing medication doses: it may indicate an incomplete diagnosis, a specific cause or a complication.
Treatment and recovery times are discussed in more detail in the guide how long pericarditis lasts.

Frequently asked questions about pericarditis treatment

What is the most common treatment?
In acute idiopathic or presumed viral forms, aspirin or an NSAID at an anti-inflammatory dose is generally used together with colchicine.
Why is colchicine used?
To reduce the risk of recurrences. It is continued for longer than the medication used to control pain and inflammation.
Are corticosteroids a first-line treatment?
Usually not. They are reserved for selected situations and must be tapered slowly when used.

Are there therapies for resistant recurrent forms?
Yes. In selected patients, anti-IL-1 drugs such as anakinra or rilonacept may be used as part of specialist management.
Are antibiotics needed for all cases of pericarditis?
No. They are indicated in bacterial forms, not in most idiopathic or presumed viral pericarditis.