What is the role of empiric colchicine (anti-inflammatory medication) in preventing post-procedural pericarditis after ablation procedures?

From the Guidelines

Empiric colchicine is recommended for preventing post-procedural pericarditis after ablation procedures, particularly following atrial fibrillation ablation. The typical regimen is colchicine 0.5 mg twice daily for 1-3 months post-procedure, with a reduced dose of 0.5 mg once daily for patients weighing less than 70 kg or those with renal impairment, as suggested by the 2015 ESC guidelines for the diagnosis and management of pericardial diseases 1. This prophylactic approach has been shown to significantly reduce the incidence of post-ablation pericarditis, which occurs in approximately 1-2% of patients following cardiac ablation procedures.

Key Considerations

• Colchicine works by inhibiting neutrophil chemotaxis and activity, thereby reducing the inflammatory response that contributes to pericarditis, and it also interferes with the assembly of the NLRP3 inflammasome, decreasing the production of pro-inflammatory cytokines.
• Common side effects include gastrointestinal symptoms like diarrhea, nausea, and abdominal pain, which may require dose adjustment.
• Colchicine should be used cautiously in patients with hepatic or renal dysfunction and is contraindicated during pregnancy.
• For optimal effectiveness, treatment should begin immediately after the procedure and continue for the prescribed duration to ensure adequate protection during the highest risk period for developing post-procedural pericarditis.

Dosage and Administration

• The recommended dose of colchicine is 0.5 mg twice daily for patients weighing 70 kg or more, and 0.5 mg once daily for patients weighing less than 70 kg or those with renal impairment, as stated in the guidelines 1.
• The duration of treatment is typically 1-3 months post-procedure, but may vary depending on individual patient factors and the specific procedure performed.

Clinical Evidence

• The 2015 ESC guidelines for the diagnosis and management of pericardial diseases provide evidence-based recommendations for the use of colchicine in preventing post-procedural pericarditis 1.
• The guidelines suggest that colchicine be used in addition to standard anti-inflammatory therapy, such as aspirin or NSAIDs, to improve the response to medical therapy and prevent recurrences.

From the Research

Empiric Colchicine after Ablation

• The role of empiric colchicine in preventing post-procedural pericarditis after ablation procedures has been investigated in several studies 2, 3, 4, 5, 6.
• A study published in JACC: Clinical electrophysiology found that prophylactic colchicine therapy initiated after the ablation procedure in patients with atrial fibrillation did not affect the incidence of post-ablation pericarditis and was associated with an increased incidence of gastrointestinal side effects 2.
• Another study published in the Journal of cardiovascular electrophysiology found that prophylactic colchicine was not associated with a significant reduction in the incidence of postablation chest pain, pericarditis, or atrial fibrillation recurrence after high-power short-duration ablation 3.
• A randomized, placebo-controlled trial published in Circulation: Arrhythmia and electrophysiology found that colchicine administered for 10 days following catheter ablation did not reduce atrial arrhythmia recurrence or atrial fibrillation-associated clinical events, but did reduce postablation chest pain and increase diarrhea 4.
• A prospective multicenter study published in JACC: Clinical electrophysiology found that the combination of intrapericardial steroids instillation and colchicine resulted in a nonsignificant trend of lower rates of pericarditis after epicardial ventricular tachycardia ablation 5.
• A study published in JACC: Clinical electrophysiology found that colchicine monotherapy starting 7 days before to 1 month after the ablation procedure was associated with a significantly lower risk of acute pericarditis and related hospitalization, as well as a higher arrhythmia-free survival rate in paroxysmal atrial fibrillation patients 6.

Key Findings

• Colchicine may not be effective in preventing post-procedural pericarditis after ablation procedures 2, 3.
• Colchicine may reduce postablation chest pain, but is associated with an increased incidence of gastrointestinal side effects 2, 4.
• The combination of intrapericardial steroids instillation and colchicine may be effective in reducing pericarditis after epicardial ventricular tachycardia ablation 5.
• Colchicine monotherapy starting 7 days before to 1 month after the ablation procedure may be effective in reducing acute pericarditis and related hospitalization, as well as improving arrhythmia-free survival rate in paroxysmal atrial fibrillation patients 6.