From the Guidelines
Recurrent pericarditis in a 45-year-old female should be treated with aspirin or NSAIDs as the mainstay of therapy, with colchicine recommended as an adjunct to improve response and prevent recurrences.
Diagnosis and Treatment
- The diagnosis of recurrent pericarditis is established with a documented first episode of acute pericarditis, a symptom-free interval of 4–6 weeks or longer, and evidence of subsequent recurrence of pericarditis 1.
- Aspirin or NSAIDs, such as ibuprofen or indomethacin, are recommended at full doses until complete symptom resolution, with colchicine (0.5 mg twice daily or 0.5 mg daily for patients < 70 kg) used as an adjunct for at least 6 months 1.
- Colchicine therapy is recommended for recurrent pericarditis to improve remission rates and prevent recurrences, with a treatment duration of at least 6 months 1.
- Corticosteroids may be used in cases of incomplete response to aspirin/NSAIDs and colchicine, but should be added at low to moderate doses and avoided if infections cannot be excluded 1.
- CRP dosage should be considered to guide treatment duration and assess response to therapy 1.
- Tapering of therapies should be done gradually, with a single class of drugs stopped at a time, and only if symptoms are absent and CRP is normal 1.
From the Research
Diagnosis of Recurrent Pericarditis
- The diagnosis of recurrent pericarditis is based on clinical criteria, including chest pain, a pericardial rub, electrocardiographic changes, and pericardial effusion 2, 3, 4.
- The etiology of pericarditis may be infectious (e.g., viral and bacterial) or noninfectious (e.g., systemic inflammatory diseases, cancer, and post-cardiac injury syndromes) 2, 3.
Treatment of Recurrent Pericarditis
- The most common treatment for idiopathic and viral pericarditis is nonsteroidal anti-inflammatory drug (NSAID) therapy, with adjunctive colchicine to ameliorate the initial episode and reduce recurrence rates 5, 2, 3, 4.
- Colchicine is the mainstay of treatment in acute and recurrent pericarditis, with a 3-month course recommended to relieve symptoms and reduce the risk of recurrence 5, 3.
- Corticosteroids are a second-line therapy for those who do not respond, are intolerant, or have contraindications to NSAIDs and colchicine, but their use should be avoided due to the associated risk of recurrence 2, 6, 4.
- Anti-interleukin-1 (IL-1) agents, such as anakinra and rilonacept, are a valuable option in case of recurrent pericarditis refractory to conventional drugs 5, 3.
- In true refractory cases, combination therapy with two or three drugs, such as NSAIDs, colchicine, and corticosteroid, may be considered before applying other more complex and less safe treatments 6.
Management of Refractory Recurrent Pericarditis
- More invasive diagnostic and therapeutic choices, such as pericardial window and pericardiectomy, should be carefully considered for possible side-effects and the risk of promoting further recurrences 6.
- Patience and appropriate medical therapy are the keys to successful management, with immunosuppressive drugs and steroid-sparing agents potentially used, but with weak evidence-based data supporting their use 6.