What is the treatment for recurrent pericarditis?

From the Guidelines

Treatment for recurrent pericarditis should start with high-dose NSAIDs like ibuprofen (600-800mg three times daily) or indomethacin (25-50mg three times daily) combined with colchicine (0.5mg twice daily for patients >70kg or 0.5mg once daily for patients <70kg) for at least 3-6 months, as recommended by the European Society of Cardiology guidelines 1, 2, 3, 4, 5. The goal of treatment is to control inflammation, relieve symptoms, and prevent further recurrences by addressing the underlying autoimmune and autoinflammatory mechanisms that perpetuate pericardial inflammation.

• Key treatment components include: + High-dose NSAIDs to reduce inflammation and relieve symptoms + Colchicine to reduce recurrence rates by about 50% + Corticosteroids like prednisone (0.25-0.5mg/kg/day) may be added if symptoms persist, but should be tapered slowly over months to avoid rebound + Immunotherapies such as anakinra (100mg daily subcutaneous injection) or other IL-1 inhibitors for patients with multiple recurrences or steroid-dependence + Pericardiectomy (surgical removal of the pericardium) may be considered in severe cases refractory to medical therapy
• Treatment should be continued until complete resolution of symptoms and normalization of inflammatory markers (CRP, ESR) 1, 2, 3, 4, 5.
• Rest and activity restriction are recommended during acute phases, with gradual return to normal activities as symptoms improve, as suggested by the guidelines 2, 4, 5.
• The use of CRP dosage to guide treatment duration and assess response to therapy is also recommended 1, 2, 3, 4, 5.
• It is essential to educate the patient and their caregivers about the clinical risks related to immunomodulatory/immunosuppressive drugs and the safety measures to adopt during treatment, as highlighted in the guidelines 5.

From the Research

Treatment Options for Recurrent Pericarditis

• The mainstay of therapy for recurrences is aspirin or NSAIDs, with the adjunct of colchicine 6.
• Corticosteroids are a second-line option to be considered for specific indications, such as connective tissue disease or pregnancy; contraindications or intolerance to aspirin, NSAIDs, and/or colchicine; or insufficient response to these medications 6.
• Alternative treatment options include azathioprine, intravenous human immunoglobulins, and anakinra for patients who do not respond adequately to conventional therapies 6.

Role of Colchicine in Treatment

• Colchicine has been shown to reduce episodes of pericarditis in people with recurrent pericarditis over 18 months follow-up 7.
• The number needed to treat (NNT) with colchicine is 4 at 18 months 7.
• Colchicine led to a greater chance of symptom relief at 72 hours, but also increased the risk of adverse effects, mainly gastrointestinal 7.

Safety Considerations and Future Directions

• Current medical treatments for recurrent pericarditis range from non-steroidal anti-inflammatory drugs (NSAIDs), colchicine, and corticosteroids to biological agents, intravenous immunoglobulins, and immunosuppressive treatments 8.
• Therapy of recurrent pericarditis has evolved over years, leading to a more evidence-based and personalized treatment based on clinical presentation and pathophysiology 8.
• Colchicine and anti-IL-1 agents are especially efficacious and indicated for patients with an inflammatory phenotype, while corticosteroids, azathioprine, and immunoglobulins seem more indicated for those without evidence of systemic inflammation 8.

Treatment with Aspirin, NSAID, Corticosteroids, and Colchicine

• Empiric anti-inflammatory therapy for acute and recurrent pericarditis is warranted for viral and idiopathic cases 9.
• Aspirin and non-steroidal anti-inflammatory drugs (NSAID) are mainstay of therapy with the possible adjunct of colchicine, especially for recurrences 9.
• Medical therapy of pericarditis should be individualized as much as possible, providing the attack dose every 8 h to ensure full daily control of symptoms and till remission and C-reactive protein normalization, and then tapering should be considered 9.

Update on Diagnosis and Management

• Recurrent pericarditis seems to be caused by a pathological immune response, and an inadequate treatment can increase the risk of recurrences 10.
• First-line treatment is based on non-steroidal anti-inflammatory drugs (NSAIDs) and colchicine, while glucocorticoids are often used as second-line drugs 10.
• Interleukin-1 inhibitors, such as anakinra and rilonacept, significantly reduce the risk of recurrences in patients with recurrent pericarditis while on treatment 10.