From the Guidelines
Treatment of pericarditis due to autoimmune disease should focus on addressing both the pericardial inflammation and the underlying autoimmune condition, with first-line therapy typically including nonsteroidal anti-inflammatory drugs (NSAIDs) and colchicine, and corticosteroids reserved for refractory cases. The management of pericarditis due to autoimmune disease involves a step-wise approach, starting with NSAIDs such as ibuprofen (600-800mg three times daily) or indomethacin (25-50mg three times daily) for 1-2 weeks, followed by gradual tapering 1.
- Colchicine (0.5-0.6mg twice daily for patients >70kg or 0.5-0.6mg once daily for patients <70kg) should be added to NSAIDs for 3-6 months to improve response and prevent recurrence, as recommended by the European Society of Cardiology (ESC) guidelines 1.
- For autoimmune-related pericarditis that is refractory to NSAIDs and colchicine, corticosteroids like prednisone (0.25-0.5mg/kg/day) may be necessary, with slow tapering over months, according to the ESC guidelines 1.
- Disease-modifying antirheumatic drugs (DMARDs) such as methotrexate, azathioprine, or mycophenolate mofetil are often added as steroid-sparing agents, and for severe or recurrent cases, biological agents like anakinra (IL-1 receptor antagonist, 100mg daily subcutaneously) or tocilizumab (IL-6 inhibitor) may be considered 1. The treatment of the underlying autoimmune disease (such as lupus, rheumatoid arthritis, or scleroderma) with appropriate immunosuppressive therapy is crucial for long-term management, and regular cardiac monitoring with echocardiography is essential to assess for complications like constrictive pericarditis or cardiac tamponade 1.
From the Research
Treatment Options for Pericarditis due to Autoimmune Disease
- The therapeutic armamentarium for pericarditis includes high-dose nonsteroidal anti-inflammatory drugs (NSAIDs) that are tapered rapidly once symptoms are controlled 2.
- Colchicine is necessary to both relieve symptoms and reduce the rate of recurrences and is continued for at least 3-6 months 2, 3.
- Low- to moderate-dose glucocorticoids are reserved for patients with a first recurrence for which NSAIDs and colchicine failed and/or who have an autoimmune disorder, with a slow tapering 2.
- Interleukin-1 blockers-anakinra, rilonacept, and goflikicept-are used as a third-line option in patients who cannot come off glucocorticoids or as second-line therapy after NSAIDs and colchicine in patients with contraindications to glucocorticoids or in those with high-risk features 2, 3.
Autoimmune Disease Considerations
- Patients with autoimmune etiology are at higher risk of recurrence 2.
- Corticosteroids are a second choice for difficult cases requiring multi-drug therapies and specific medical conditions, such as systemic autoimmune diseases 4, 5.
- Immunosuppressive agents, including azathioprine, methotrexate, and mycophenolate mofetyl, seem efficacious and well tolerated in patients with idiopathic recurrent pericarditis unresponsive to corticosteroids 5.
Pharmacotherapy Management
- The combination of colchicine and nonsteroidal antiinflammatory drugs (NSAIDs) plus aspirin (ASA) is considered first-line therapy for acute idiopathic pericarditis 6.
- Emerging therapies and management strategies, such as high-sensitivity C-reactive protein-guided therapy and novel immunotherapies, are also being reviewed 6.
- A correct pharmacological management of pericarditis is key to prevent recurrences, with colchicine being the mainstay of treatment in acute and recurrent pericarditis 3.