Therapy for specific forms of myocarditis
Updated: 26 Feb 2026
Lymphocytic myocarditis (virus negative)
1st line therapy
Non-severe: prednisone 1 mg/kg/day p.o. then tapered
Severe: i.v. methylprednisolone 7–14 mg/kg/day for 3 days, then 1 mg/kg/day p.o.
2nd line therapy
Oral corticosteroids + azathioprine or mycophenolate mofetil, cyclosporine, methotrexate
3rd line therapy
IVIGe or plasmapheresis
Eosinophilic myocarditis
1st line therapy
Same as lymphocytic myocarditis + Treat EM-associated condition if identified
2nd line therapy
Same as lymphocytic myocarditis + Treat EM-associated condition if identified
3rd line therapy
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Giant-cell myocarditis
1st line therapy
Non-severe: prednisone 1 mg/kg/day p.o. then tapered Severe: i.v. methylprednisolone 7–14 mg/kg/day for 3 days, then 1 mg/kg/day p.o. + immunosuppressive (azathioprine or mycophenolate mofetil , cyclosporine )
2nd line therapy
Antithymocyte Globulin (ATG) cyclophosphamide , rituximab
3rd line therapy
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Cardiac sarcoidosis
1st line therapy
Non-severe: prednisone 1 mg/kg/day p.o., tapering from 40–60 mg daily
Severe: i.v. methylprednisolone 7–14 mg/kg/day for 3 days, then 1 mg/kg/day p.o.
2nd line therapy
Methotrexate (1st choice), or azathioprine mycophenolate mofetil , cyclophosphamide
3rd line therapy
Infliximabj or adalimumabk , rituximabi
Lyme carditis
1st line therapy
(a) Oral antibiotics (mild cases):
– Doxycycline 100 mg b.i.d. (14–21 days)
– Amoxicillin 500 mg t.i.d. (14–21 days)
– Cefuroxime axetil 500 mg b.i.d. (14–21 days)
(b) i.v. antibiotics (severe cases):
– Ceftriaxone 2 g/day (14–21 days)
2nd line therapy
i.v. antibiotics: Cefotaxime (2 g q8h × 14–21 days) or Penicillin G (18–24 MU/day i.v. q4h × 14–21 day)
3rd line therapy
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Chagas disease
1st line therapy
Benznidazole 5–7 mg/kg/day in 2 doses for 60 days Nifurtimox 8–10 mg/kg/day in 3 doses for 60–90 days
2nd line therapy
-
3rd line therapy
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ICI-induced myocarditis
1st line therapy
Withdraw ICI, reassess
Non-severe: methylprednisolone 500–1000 mg/day × 3 days, then taper with oral prednisone
Severe: i.v. methylprednisolone 7–14 mg/kg/day × 3 days, then 1 mg/kg/day
2nd line therapy
If no response in 24–48 h: mycophenolate mofetil, ATGg abatacept, alemtuzumab
3rd line therapy
Infliximab or adalimumab , rituximab
Drugs
-Azathioprine (immunosuppressant purine analog):
1–2 mg/kg per day p.o. (typically 100–150 mg daily, in 1–2 divided doses, main target: lymphocytes.
-Mycophenolate mofetil (immunosuppressant that inhibits inosine monophosphate dehydrogenase, main target: lymphocytes):
500–1000 mg p.o. b.i.d. (total 1–2 g/day).
-Cyclosporine (calcineurin inhibitor that prevents IL-2 transcription in activated T-cells):
∼3–5 mg/kg/day p.o. (divided b.i.d.) adjusted to target trough levels ∼150–250 ng/mL.
-Methotrexate (antimetabolite that inhibits dihydrofolate reductase and other folate-dependent steps, reducing proliferation of active lymphocytes):
15–20 mg/week p.o. or s.c. (low-dose weekly, with folic acid supplementation).
- IVIG (immunomodulatory therapy providing pooled IgG antibodies) = standard dose off-label 2 g/kg total dose, typically administered over 1 to 2 days; alternative dosing: 0.4 g/kg/day for 5 consecutive days (less commonly used in myocarditis but sometimes used in autoimmune settings).
- Plasmapheresis (therapeutic plasma exchange that filters out and removes circulating autoantibodies, immune complexes, and inflammatory mediators)
3–5 sessions in 5–10 days.
- Antithymocyte Globulin (ATG; polyclonal anti-T-lymphocyte antibody that causes profound T-cell depletion):
∼1 mg/kg i.v., often given daily for 3–5 days.
- Cyclophosphamide (cytotoxic alkylating agent that crosslinks DNA in rapidly dividing cells, main target: lymphocytes): 600 mg/m² i.v. bolus on days 1, 15, and 30 (pulse therapy).
- Rituximab (monoclonal antibody against CD20 on B cells): 375 mg/m² i.v. weekly × 4 doses (1 month).
- Infliximab (monoclonal antibody against TNF-α): 5 mg/kg i.v. at weeks 0, 2, 6, then every ∼8 weeks (maintenance).
- Adalimumab (anti-TNF-α fully human monoclonal antibody) 40 mg SC every week (or every 2 weeks, per clinical response).
- Abatacept (CTLA-4 Ig fusion protein that binds CD80/86 on antigen-presenting cells, blocking the CD28 co-stimulatory signal required for full T-cell activation): 500 mg i.v. every 2 weeks × 5 doses (approximately 10 weeks).
- Alemtuzumab (monoclonal antibody against CD52 on lymphocytes): 30 mg i.v. once (alternative: 15 mg i.v. daily for 2 days).
Reference
Jeanette Schulz-Menger, Valentino Collini, Jan Gröschel, Yehuda Adler, Antonio Brucato, Vanessa Christian, Vanessa M Ferreira, Estelle Gandjbakhch, Bettina Heidecker, Mathieu Kerneis, Allan L Klein, Karin Klingel, George Lazaros, Roberto Lorusso, Elena G Nesukay, Kazem Rahimi, Arsen D Ristić, Marcin Rucinski, Leyla Elif Sade, Hannah Schaubroeck, Anne Grete Semb, Gianfranco Sinagra, Jens Jakob Thune, Massimo Imazio, the ESC Scientific Document Group , 2025 ESC Guidelines for the management of myocarditis and pericarditis: Developed by the task force for the management of myocarditis and pericarditis of the European Society of Cardiology (ESC) Endorsed by the Association for European Paediatric and Congenital Cardiology (AEPC) and the European Association for Cardio-Thoracic Surgery (EACTS), European Heart Journal, Volume 46, Issue 40, 21 October 2025, Pages 3952-4041, https://doi.org/10.1093/eurheartj/ehaf192