How to manage pericarditis in a patient taking Eliquis (apixaban)?

Management of Pericarditis in Patients Taking Apixaban (Eliquis)

For patients with pericarditis who are taking apixaban, corticosteroids should be used as first-line therapy instead of NSAIDs due to the high bleeding risk associated with combining anticoagulants and NSAIDs. 1

Treatment Algorithm

First-line Treatment

• Use low to moderate dose corticosteroids (prednisone 0.2-0.5 mg/kg/day) as the primary anti-inflammatory agent 1
• Add colchicine as adjunctive therapy:
  • 0.5 mg twice daily for patients ≥70 kg
  • 0.5 mg once daily for patients <70 kg 1, 2
• Continue colchicine for at least 3 months to reduce recurrence risk 2, 3

Corticosteroid Dosing and Tapering

• Initial prednisone dose: 0.25-0.5 mg/kg/day 1
• Taper schedule based on initial dose: 1

  • 50 mg: Decrease by 10 mg/day every 1-2 weeks

  • 50-25 mg: Decrease by 5-10 mg/day every 1-2 weeks
  • 25-15 mg: Decrease by 2.5 mg/day every 2-4 weeks
  • <15 mg: Decrease by 1.25-2.5 mg/day every 2-6 weeks
• Only taper when patient is asymptomatic and CRP has normalized 1

Monitoring and Follow-up

• Assess response to therapy after 1 week 1
• Monitor CRP levels to guide treatment duration and assess response 2
• Continue treatment until symptoms resolve and CRP normalizes 1, 2

Special Considerations for Anticoagulated Patients

• Temporary interruption of apixaban may be necessary for specific procedures related to pericarditis management 1
• For procedures with low bleeding risk, discontinue apixaban 24 hours before 1
• For high bleeding risk procedures (e.g., pericardiocentesis):
  • Discontinue apixaban 3 days before if creatinine clearance >30 mL/min 1
  • Consider longer discontinuation (4-5 days) if renal function is impaired 1
• Resume apixaban at least 6 hours after the procedure if hemostasis is achieved 1

Management of Refractory Cases

• For patients not responding to corticosteroids and colchicine: 1
  • Consider immunomodulatory agents such as azathioprine or IVIG
  • IL-1 receptor antagonists (anakinra) have shown efficacy in refractory cases 4, 5
• Anakinra has demonstrated significant reduction in recurrence risk (18.2% vs 90% with placebo) in corticosteroid-dependent cases 5
• Consider pericardiectomy only as a last resort after failure of medical therapy 1

Potential Pitfalls and Caveats

• Avoid NSAIDs completely in patients on apixaban due to significantly increased bleeding risk 1
• Be aware that corticosteroids, while necessary in this setting, may promote chronicity and increase recurrence risk 2, 6
• Critical threshold for recurrences is at 10-15 mg/day of prednisone; use particularly slow tapering at this level 1
• Calcium (1,200-1,500 mg/day) and vitamin D (800-1,000 IU/day) supplementation should be provided to all patients receiving glucocorticoids 1
• Consider bisphosphonates for bone loss prevention in men ≥50 years and postmenopausal women on long-term glucocorticoid therapy 1