What is the best treatment approach for an elderly female patient with post-percutaneous coronary intervention (PCI) pericarditis who developed diarrhea after starting colchicine?

Treatment of Post-PCI Pericarditis with Colchicine Intolerance

Switch to high-dose NSAIDs as monotherapy, specifically ibuprofen 600 mg every 8 hours for 1-2 weeks with gastroprotection and gradual tapering, avoiding indomethacin in this elderly patient due to coronary flow reduction risk. 1, 2

Immediate Management Strategy

First-Line Alternative: NSAID Monotherapy

Discontinue colchicine immediately and initiate ibuprofen as the preferred NSAID for this elderly post-PCI patient 2:

• Ibuprofen 600 mg every 8 hours (range 1200-2400 mg/day) for weeks to months 1
• Add gastroprotection (proton pump inhibitor) given NSAID use 3
• Avoid indomethacin specifically in elderly patients because it reduces coronary blood flow, posing particular risk in this population with coronary artery disease 2
• Aspirin 750-1000 mg every 8 hours is an alternative if ibuprofen is contraindicated 1, 3

Tapering Protocol

• Continue initial NSAID dose until symptoms resolve and CRP normalizes 1
• Taper ibuprofen by 200-400 mg every 1-2 weeks 1
• Only attempt tapering when symptoms are absent and CRP is normal 1
• Longer tapering times may be needed for resistant cases 1

Second-Line Option: Low-Dose Corticosteroids

If NSAIDs are contraindicated or fail, consider low-dose corticosteroids 1:

• Prednisone 0.2-0.5 mg/kg/day (typically 10-25 mg/day for most patients) 1
• Maintain initial dose until symptom resolution and CRP normalization 1
• Critical warning: Corticosteroids favor chronicity, more recurrences, and side effects compared to NSAIDs 1
• Use very slow tapering: at doses <15 mg/day, decrease by only 1.25-2.5 mg every 2-6 weeks 1

Corticosteroid Bone Protection (if used)

• Calcium supplementation 1200-1500 mg/day plus vitamin D 800-1000 IU/day 1
• Bisphosphonates for postmenopausal women on long-term glucocorticoids ≥5.0-7.5 mg/day 1

Colchicine Dose Reduction Alternative

Before completely abandoning colchicine, consider dose reduction for diarrhea management 4:

• Reduce to 0.5 mg once daily (or every other day if <70 kg) 1
• Diarrhea is the most common side effect, occurring in approximately 8% of patients, but is generally not serious 5, 4
• If diarrhea persists despite dose reduction, discontinue and proceed with NSAID monotherapy 4

Monitoring and Duration

• Monitor CRP to guide treatment duration and assess response 3, 6
• Treatment duration typically weeks to months based on clinical response 1
• Exercise restriction until symptoms resolve and CRP, ECG, and echocardiogram normalize 3, 6

Critical Pitfalls to Avoid

• Do not use indomethacin in this elderly post-PCI patient due to coronary flow reduction 2
• Avoid premature treatment discontinuation before CRP normalization—inadequate treatment duration is the most common cause of recurrence 3, 6
• Corticosteroid use is an independent risk factor for recurrences (OR 4.30,95% CI 1.21-15.25) and should be reserved for true NSAID contraindications 5
• Without colchicine, recurrence rates increase from 10.7% to 32.3% at 18 months, but NSAID monotherapy remains effective 5

Third-Line Options for Refractory Cases

If both NSAIDs and corticosteroids fail or are contraindicated 1, 6:

• Anakinra (IL-1 receptor antagonist) for corticosteroid-dependent disease 1, 6
• IVIG (intravenous immunoglobulin) 1, 6
• Azathioprine 1, 6
• These require consultation with immunology/rheumatology specialists 1