Can colchicine be used in a patient with pericarditis, systemic lupus erythematosus (SLE), and impaired renal function requiring dialysis, and are there alternative treatments available?

From the Guidelines

Colchicine should be avoided in patients with pericarditis, systemic lupus erythematosus (SLE), and dialysis-dependent renal impairment due to the risk of accumulation and toxicity. The primary concern with using colchicine in patients with renal impairment is its potential to accumulate to toxic levels, leading to severe complications such as bone marrow suppression, neuromyopathy, and gastrointestinal effects 1.

Alternative Treatments

For such patients, the preferred first-line treatment would be:

• NSAIDs (if not contraindicated by their renal status)
• Combined with corticosteroids, typically prednisone at 0.25-0.5 mg/kg/day with a gradual taper over 2-4 weeks. Alternative treatments include:
• Hydroxychloroquine (200-400 mg daily), which can address both SLE and pericarditis
• Immunosuppressants like azathioprine (50-150 mg daily) or mycophenolate mofetil (1-2 g daily) for refractory cases.

Management Considerations

The patient's complex condition requires a multidisciplinary approach involving rheumatology, nephrology, and cardiology to balance treatment of pericarditis while managing SLE and considering the limitations imposed by dialysis-dependent renal disease 1. It is essential to closely monitor the patient's response to treatment and adjust the therapeutic strategy as needed to minimize the risk of adverse effects and optimize outcomes.

Key Points to Consider

• The use of colchicine in patients with renal impairment requires careful consideration of the potential risks and benefits.
• Alternative treatments should be considered first, taking into account the patient's underlying conditions and renal function.
• A multidisciplinary approach is crucial in managing patients with complex conditions like pericarditis, SLE, and dialysis-dependent renal impairment.

From the FDA Drug Label

For the prophylaxis of gout flares in patients undergoing dialysis, the starting doses should be 0.3 mg given twice a week with close monitoring For patients undergoing dialysis, the total recommended dose for the treatment of gout flares should be reduced to a single dose of 0.6 mg (one tablet). In patients with severe renal failure (Cl cr less than 30 mL/min) and end-stage renal disease requiring dialysis, Colchicine Tablets, USP may be started at the dose of 0.3 mg/day.

Colchicine use in patients with pericarditis, lupus, and requiring dialysis: Colchicine can be used in patients with pericarditis and lupus, but caution is advised due to the patient's renal impairment requiring dialysis.

• The recommended dose for prophylaxis of gout flares in patients undergoing dialysis is 0.3 mg twice a week.
• The recommended dose for treatment of gout flares in patients undergoing dialysis is a single dose of 0.6 mg, which should not be repeated more than once every two weeks. Alternative treatments may be considered for patients with gout flares requiring repeated courses, especially if they have severe renal impairment or are undergoing dialysis. However, the FDA label does not provide specific alternative treatment options for this patient population 2, 2, 2.

From the Research

Colchicine Use in Pericarditis

• Colchicine has been established as a first-line treatment option for acute and recurrent pericarditis, on top of conventional treatment, due to its effectiveness in reducing recurrences and symptom relief 3, 4.
• The use of colchicine in patients with systemic lupus erythematosus (SLE) and pericarditis has shown promising results, with colchicine being safe and effective in treating SLE pericarditis and used as a steroids-sparing agent 5.

Considerations for Patients with Impaired Renal Function

• There is limited information available on the use of colchicine in patients with impaired renal function requiring dialysis.
• However, a case report suggests that colchicine can be used effectively in a renal transplant patient with COVID-19-related pericarditis, without complications 6.

Alternative Treatments

• Non-steroidal anti-inflammatory drugs (NSAIDs) such as aspirin, ibuprofen, and indomethacin are commonly used to treat pericarditis, and can be used as an alternative to colchicine 4.
• Corticosteroids may also be used to treat pericarditis, especially in patients with SLE or other autoimmune disorders, but their use should be carefully considered due to potential side effects 5.

Safety and Efficacy

• Colchicine has a good safety profile, with gastrointestinal intolerance being the most common side effect, which can lead to treatment withdrawal in some cases 3, 4.
• The efficacy of colchicine in reducing pericarditis recurrences and symptom relief has been demonstrated in several studies, with moderate to high-quality evidence 3, 4.