From the Guidelines
The latest treatment for recurrent pericarditis includes a stepwise approach starting with NSAIDs (such as ibuprofen 600-800mg three times daily or indomethacin 25-50mg three times daily) combined with colchicine (0.5-0.6mg twice daily) as first-line therapy, as recommended by the European Society of Cardiology guidelines 1.
Key Considerations
- Colchicine should be continued for at least 6 months to prevent recurrence, with a weight-adjusted dose of 0.5 mg once daily if body weight is <70 kg or 0.5 mg twice daily if it is ≥70 kg 1.
- For patients who don't respond adequately, corticosteroids like prednisone (0.25-0.5mg/kg/day) may be added, though they should be tapered slowly to avoid rebound, with a critical threshold for recurrences at a 10-15 mg/day dose of prednisone or equivalent 1.
- For refractory cases, newer targeted immunotherapies have shown significant promise, particularly IL-1 inhibitors such as anakinra (100mg daily subcutaneous injection) and rilonacept (loading dose of 320mg followed by 160mg weekly subcutaneous injections), although strong evidence-based data are lacking 1.
Treatment Approach
- The treatment approach should be individualized based on the patient's specific presentation, comorbidities, and previous treatment responses, with the goal of controlling symptoms and preventing further recurrences while minimizing side effects.
- Other immunosuppressants like azathioprine, IVIG, or hydroxychloroquine may be considered in specific cases, after careful assessment of the costs, risks, and consultation with multidisciplinary experts 1.
- Pericardiectomy remains a last resort for the most severe cases unresponsive to medical therapy, and should only be considered after a thorough trial of unsuccessful medical therapy, with referral to a center with specific expertise in this surgery 1.
From the Research
Treatment Options for Recurrent Pericarditis
The treatment for recurrent pericarditis typically involves a combination of medications, including:
- Non-steroidal anti-inflammatory drugs (NSAIDs) for pain control 2, 3
- Colchicine to reduce the risk of further recurrences 4, 2, 5
- Corticosteroids as a second-line option for specific indications, such as connective tissue disease or pregnancy 4, 3
- Interleukin-1 inhibitors, such as anakinra and rilonacept, for patients with an inflammatory phenotype 2, 6
- Azathioprine, intravenous human immunoglobulins, and other immunosuppressive treatments for patients without an inflammatory phenotype or with multiple resistant recurrences 4, 6
Safety Considerations
Safety is a major concern when treating recurrent pericarditis, as the disease often affects relatively young or middle-aged patients 6. The most common adverse effects of colchicine are gastrointestinal, including abdominal pain and diarrhea 5. Corticosteroids are associated with a high rate of recurrent events 2. Interleukin-1 inhibitors, such as anakinra and rilonacept, have been shown to be effective in reducing the risk of recurrences, but their long-term safety profile is still being studied 2, 6.
Future Directions
The treatment of recurrent pericarditis is evolving, with a focus on personalized and evidence-based therapies 6. Further research is needed to understand the pathogenesis of recurrences and to develop more effective and safe treatments for this condition 4, 2. The use of cardiac magnetic resonance and inflammatory biomarkers may help guide treatment decisions and monitor response to therapy 2.