What is the role of colchicine in Coronary Artery Disease (CAD) and pericarditis?

From the Guidelines

Colchicine is a recommended treatment for both Coronary Artery Disease (CAD) and pericarditis, as it has been shown to reduce the risk of recurrent cardiovascular events and prevent recurrence of pericarditis. For CAD, colchicine at a dose of 0.5-0.6mg daily is recommended as secondary prevention in patients with recent myocardial infarction or chronic coronary disease, as it reduces the risk of recurrent cardiovascular events by targeting inflammation in atherosclerotic plaques 1. The LODOCO2 trial, a recent landmark study, demonstrated that low-dose colchicine (0.5 mg daily) significantly reduced the primary endpoint of cardiovascular death, spontaneous MI, ischemic stroke, or ischemia-driven revascularization by 31% compared to placebo 1.

Key Findings in CAD

• The primary endpoint occurred in 6.8% on colchicine vs. 9.6% on placebo (HR 0.69; 95% CI, 0.57–0.83; P < .001) 1
• The main secondary endpoint was reduced by 28% (4.2% on colchicine vs. 5.7% on placebo; HR 0.72; 95% CI, 0.57–0.92; P = .007) 1
• A recent meta-analysis including over 12,000 patients with atherothrombotic CAD estimated that colchicine significantly lowered the risks of MI, stroke, and unstable angina-driven revascularization compared to placebo 1

Role in Pericarditis

For acute pericarditis, colchicine should be given at 0.5mg twice daily (or 0.5mg once daily for patients <70kg) for 3 months, alongside NSAIDs, to reduce symptoms and prevent recurrence 1. In recurrent pericarditis, treatment duration extends to 6-12 months with a gradual taper. Colchicine works by inhibiting neutrophil function, reducing inflammatory cytokines, and disrupting the NLRP3 inflammasome pathway. Common side effects include gastrointestinal symptoms like diarrhea and nausea. Dose adjustment is necessary in patients with renal or hepatic impairment, and colchicine should be used cautiously with certain medications like strong CYP3A4 inhibitors due to potential drug interactions.

Clinical Considerations

• Competitive athletes with acute pericarditis should be managed according to the standard of care, which includes nonsteroidal anti-inflammatory medications for 2 to 4 weeks and 3 months of colchicine 1
• Steroids generally should be avoided to reduce the risk of recurrent pericarditis 1
• Hospitalization is warranted to determine the etiology and observe for tamponade as well as the effect of treatment 1

From the Research

Role of Colchicine in CAD

• Colchicine has shown potential therapeutic benefits in cardiovascular conditions owing to its broad anti-inflammatory properties 2.
• A meta-analysis of 5 randomized controlled trials with 11,790 patients with CAD found that colchicine administration was associated with a significantly lower incidence of major adverse cardiovascular events (relative risk 0.65,95% confidence interval 0.52 to 0.82) 2.
• Colchicine treatment also decreased the risk of myocardial infarction, coronary revascularization, and stroke in CAD patients, but had no impact on cardiovascular mortality 2, 3, 4.
• The COLCOT and LoDoCo2 trials demonstrated that long-term use of colchicine was associated with a reduced rate of CV events in both acute and chronic presentations of CAD, with an overall good safety profile 5.

Role of Colchicine in Pericarditis

• Colchicine has been suggested to be beneficial in preventing recurrent pericarditis 6.
• A systematic review of 4 randomized controlled trials found that colchicine reduces episodes of pericarditis in people with recurrent pericarditis over 18 months follow-up (hazard ratio 0.37,95% confidence interval 0.24 to 0.58) 6.
• Colchicine also reduces recurrence in people with acute pericarditis (hazard ratio 0.40,95% confidence interval 0.27 to 0.61) 6.
• Adverse effects of colchicine were mainly gastrointestinal, but the quality of evidence was low owing to imprecision, and there was no statistically significant difference between the treatment groups 6.

Landmark Trials

• COLCOT trial: demonstrated that long-term use of colchicine was associated with a reduced rate of CV events in acute coronary syndrome 5.
• LoDoCo2 trial: demonstrated that long-term use of colchicine was associated with a reduced rate of CV events in chronic coronary artery disease 5.
• Other trials: including the meta-analysis by 2, 3, and 4, which found that colchicine reduces the risk of major adverse cardiovascular events, myocardial infarction, and stroke in CAD patients.