What is the next step in management for a patient with recurrent pericarditis who has failed treatment with Non-Steroidal Anti-Inflammatory Drugs (NSAID) and colchicine?

Management of Recurrent Pericarditis After Failed NSAID and Colchicine Treatment

For patients with recurrent pericarditis who have failed treatment with NSAIDs and colchicine, low-dose corticosteroids should be initiated as the next step in management, followed by consideration of immunomodulatory agents if corticosteroid therapy is ineffective or causes unacceptable side effects. 1

Diagnostic Workup Before Treatment Escalation

• Confirm the diagnosis of recurrent pericarditis by verifying at least 2 of 4 clinical criteria: pericardial chest pain, pericardial rubs, ECG changes, or pericardial effusion 1
• Measure C-reactive protein (CRP) levels to assess disease activity and guide treatment decisions 1
• Exclude infectious causes before initiating immunosuppressive therapy 1
• Consider cardiac MRI or CT to evaluate for evidence of pericardial inflammation in unclear cases 2

Second-Line Therapy: Corticosteroids

• Start with low-dose prednisone (0.25-0.50 mg/kg/day) after excluding infectious causes 1
• Maintain initial dose until symptoms resolve and CRP normalizes 1, 3
• Follow a gradual tapering schedule based on dose:

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

  • 50-25 mg: reduce by 5-10 mg/day every 1-2 weeks
  • 25-15 mg: reduce by 2.5 mg/day every 2-4 weeks
  • <15 mg: reduce by 1.25-2.5 mg/day every 2-6 weeks 1
• Provide calcium (1,200-1,500 mg/day) and vitamin D (800-1000 IU/day) supplementation to all patients on corticosteroids 1
• Consider bisphosphonates for bone loss prevention in men ≥50 years and postmenopausal women on long-term corticosteroids (≥5.0-7.5 mg/day of prednisone) 1

Third-Line Therapy: Immunomodulatory Agents

If corticosteroid therapy fails, causes dependency, or produces unacceptable side effects, consider one of the following options:

• Anakinra (IL-1 receptor antagonist): Effective for corticosteroid-dependent recurrent pericarditis 1, 3, 4
• Intravenous immunoglobulin (IVIG): Alternative for corticosteroid-dependent cases 1, 3
• Azathioprine: Option for patients not responding to other therapies 1, 3, 5

These agents should be initiated after careful assessment of costs and risks, ideally with consultation from immunologists and/or rheumatologists 1, 3

Fourth-Line Therapy: Surgical Intervention

• Pericardiectomy: Consider only as a last resort after thorough trials of unsuccessful medical therapy 1
• Refer patients to centers with specific expertise in this surgery 1

Monitoring and Follow-up

• Monitor CRP levels to guide treatment duration and assess response to therapy 1
• Continue exercise restriction until symptoms resolve and CRP normalizes 1
• For athletes, extend exercise restriction for a minimum of 3 months until symptom resolution and normalization of CRP, ECG, and echocardiogram 1
• When tapering therapies, stop one medication at a time, guided by symptoms and CRP levels 1

Important Considerations and Pitfalls

• Avoid rapid tapering of anti-inflammatory drugs, as this increases risk of recurrence 4, 6
• Reassure patients about prognosis—severe complications like constrictive pericarditis are rare (<1%) in idiopathic recurrent pericarditis 1, 6
• If symptoms recur during therapy tapering, do not increase corticosteroid dose; instead, maximize NSAID dosing (every 8 hours, possibly intravenously) and ensure colchicine is optimized 1
• IL-1 blockers may be considered earlier in the treatment algorithm for patients with multiple recurrences or markedly elevated inflammatory markers 4, 6
• Educate patients and caregivers about the risks associated with immunomodulatory/immunosuppressive drugs and necessary safety measures during treatment 1