What medications can cause acute pericarditis?

Medications That Cause Acute Pericarditis

Several medications can trigger acute pericarditis through various mechanisms including drug-induced lupus-like syndrome, hypersensitivity reactions, and direct cardiotoxicity. 1

Drug Categories Associated with Acute Pericarditis

Medications That Induce Lupus-like Syndrome

• Procainamide (antiarrhythmic) 1
• Hydralazine (antihypertensive) 1, 2
• Methyldopa (antihypertensive) 1
• Isoniazid (anti-tuberculosis) 1
• Phenytoin (anticonvulsant) 1

Antineoplastic Drugs

• Doxorubicin - can cause pericardiopathy often associated with cardiomyopathy 1
• Daunorubicin - similar cardiotoxic effects as doxorubicin 1

Cardiovascular Medications

• Amiodarone (antiarrhythmic) 1
• Minoxidil (vasodilator) 1
• Practolol (beta-blocker, now rarely used) 1

Anti-inflammatory and Immunomodulatory Drugs

• Mesalazine (5-ASA, used in inflammatory bowel disease) 1
• Phenylbutazone (NSAID) 1
• Anti-TNF agents (biologics used in autoimmune conditions) 1
• Cyclosporine (immunosuppressant) 1

Psychiatric Medications

• Clozapine (atypical antipsychotic) 1

Other Medications

• Methysergide (antimigraine) 1
• Dantrolene (muscle relaxant) 1
• Thiazide diuretics 1
• Streptomycin (antibiotic) 1
• Thiouracils (antithyroid drugs) 1
• Streptokinase (thrombolytic) 1
• p-Aminosalicylic acid (anti-tuberculosis) 1
• Sulfa drugs (antibiotics) 1
• Bromocriptine (dopamine agonist) 1
• Vaccines (various) 1
• GM-CSF (granulocyte-macrophage colony-stimulating factor) 1

Mechanisms of Drug-Induced Pericarditis

1. Lupus-like Syndrome: Medications like procainamide and hydralazine can induce autoimmune reactions resembling systemic lupus erythematosus, affecting the pericardium 1

2. Hypersensitivity Reactions: Some medications can cause eosinophilic pericarditis as part of a hypersensitivity reaction 1

3. Direct Cardiotoxicity: Antineoplastic drugs like doxorubicin can directly damage the pericardium 1

Clinical Presentation and Diagnosis

Drug-induced pericarditis presents similarly to other forms of acute pericarditis with:

• Sharp, pleuritic chest pain that worsens when lying down and improves when sitting forward 3, 4
• Pericardial friction rub (present in up to 85% of cases) 5
• ECG changes including widespread ST-segment elevation and PR depression 3, 4
• New or worsening pericardial effusion 1
• Elevated inflammatory markers (CRP, ESR, WBC) 3

Management Approach

1. Discontinue the Offending Medication when drug-induced pericarditis is suspected 4, 5

2. First-line Treatment:

   • NSAIDs at full doses (e.g., ibuprofen 600mg every 8 hours) until symptoms resolve 6, 4
   • Add colchicine (0.5mg twice daily for patients ≥70kg or 0.5mg daily for patients <70kg) for 3 months 6, 4

3. Second-line Treatment (if NSAIDs/colchicine contraindicated or ineffective):

   • Low-dose corticosteroids (prednisone 0.2-0.5 mg/kg/day) with slow tapering 1, 6

Pitfalls and Special Considerations

• Drug-induced pericarditis is relatively rare compared to idiopathic/viral causes 4, 5
• Recurrence risk is higher if the initial episode is not adequately treated 6
• Exercise restriction is recommended until symptoms resolve and CRP, ECG, and echocardiogram normalize 6
• For athletes, exercise restriction should last at least 3 months 6
• Monitor for complications such as cardiac tamponade, which is rare in drug-induced pericarditis but can be life-threatening when it occurs 6, 4