Skip to textbook content
Doctor’s PassportTextbook
TopicsAll topics

Loading topic navigation…

Textbook navigation
TopicsAll topics

Loading topic navigation…
Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Recurrent and chronic pericarditis

Cardiology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

RapidFull
!
Escalate

Hypotension, raised JVP, rapidly enlarging effusion, severe breathlessness, syncope, new ventricular dysfunction or malignant arrhythmia requires urgent admission and echo; chronic history does not make tamponade safe.

Synopsis

Confirm inflammatory relapse, find secondary causes and use slow, steroid-sparing escalation to prevent repeated flares and constriction.

  • Recurrent pericarditis is a new episode after a documented first attack and a symptom-free interval, conventionally at least 4-6 weeks.
  • Incessant disease continues beyond 4-6 weeks without remission; chronic disease lasts beyond 3 months.
  • Do not label every recurrent chest pain inflammatory: document CRP rise, ECG/effusion change or CT/CMR inflammation when criteria are incomplete.
  • Recheck TB, bacterial, malignant, autoimmune, post-injury and drug causes when the course is atypical, systemic or treatment-resistant.
  • Aspirin/NSAID plus weight-adjusted colchicine for at least 6 months is usual first-line recurrent-disease therapy.
  • Avoid an early high-dose steroid reflex; if steroids are necessary, use low-to-moderate dose after excluding infection and taper only after complete remission.
  • Steroid-dependent, colchicine-resistant inflammatory disease may qualify for specialist IL-1 blockade; infection screening and a taper plan are mandatory.
  • Persistent effusion without inflammatory evidence is not treated automatically with repeated anti-inflammatory courses; reassess haemodynamics and cause.

Key red flags

Tamponade

Rising JVP, tachycardia, pulsus paradoxus, hypotension or echo chamber collapse is an emergency irrespective of chronicity.

Constrictive evolution

Ascites, oedema, Kussmaul sign, pericardial knock or ventricular interdependence needs specialist constriction assessment.

Investigation priorities

01
CRP/ESR, FBC, U&E/eGFR and LFTFirst step

Document inflammation and treatment safety; look for systemic clues.

Management branches

RelapseFirst confirmed recurrence

New criteria or objective inflammation after remission.

  1. Recheck high-risk features and aetiology, adherence, prior dose/duration and whether a rapid taper or steroid exposure preceded relapse.
  2. Restart aspirin/ibuprofen at full anti-inflammatory dose with gastroprotection and add/continue weight-adjusted colchicine for at least 6 months.
  3. Restrict strenuous activity and review symptoms/CRP within 1-2 weeks; admit for high-risk features or myocardial involvement.
  4. After full clinical and CRP remission, taper NSAID/aspirin first; keep colchicine until last and avoid changing two drugs simultaneously.
SteroidNSAID contraindication or defined systemic indication

First-line agents unsafe/ineffective and infection excluded.

  1. Confirm objective inflammation and exclude TB, bacterial disease and untreated malignancy before immunosuppression.
  2. Use low-to-moderate prednisolone 0.2-0.5 mg/kg/day with colchicine rather than a high-dose burst; treat osteoporosis/infection risks as appropriate.

Key medicines

Ibuprofen600 mg orally three times daily initially, then taper by about 200 mg per dose each week only after symptom and CRP remission; maximum 2400 mg/day.Renal injury, ulcer/bleeding, fluid retention, hypertension and late pregnancy; reassess anticoagulant and cardiovascular context.
Colchicine0.5 mg orally once daily at 70 kg or less, or 0.5 mg twice daily if over 70 kg, for at least 6 months in recurrent disease.In mild or moderate renal or hepatic impairment use 0.5 mg once daily; severe impairment is contraindicated. Do not combine with strong CYP3A4/P-gp inhibitors when renal or hepatic function is impaired, and reduce or interrupt treatment even with normal function according to the interacting medicine. Monitor GI intolerance, cytopenia and myopathy.
Open full textbook →Answer 2 questionsCardiology check
Sources and review status5 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • 2025 ESC Guidelines for myocarditis and pericarditisCurrent recurrent/chronic definitions, imaging and escalation framework.
  • ESC: Tips and tricks for acute and recurrent pericarditisDose, duration, steroid and IL-1 pathways.
  • ESC: Secondary pericarditisCause-directed investigation and treatment.
  • Ibuprofen 600 mg SmPCUK dose ceiling and safety.
  • Colchicine 250 micrograms/mL oral solution SmPCLicensed UK recurrent-pericarditis dose and duration, with renal/hepatic cautions and interaction toxicity.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom
Hold the dose until symptoms resolve and CRP normalises, then taper particularly slowly around 10-15 mg/day where relapses cluster.
  • If relapse occurs during taper, return to the last effective dose and seek specialist steroid-sparing advice rather than repeatedly escalating peaks.