From the Guidelines
Pericarditis in a patient with small B-cell lymphoma on ibrutinib (Imbruvica) requires a comprehensive diagnostic workup, including a thorough history and physical examination, ECG, echocardiography, and laboratory tests, to determine the underlying cause and guide management. The initial evaluation should focus on identifying major risk factors, such as fever, subacute course, large pericardial effusion, cardiac tamponade, and failure of aspirin or NSAIDs, as outlined in the 2015 ESC guidelines for the diagnosis and management of pericardial diseases 1.
Diagnostic Approach
The diagnostic approach should include:
- Auscultation
- ECG to look for diffuse ST elevations, PR depression, and electrical alternans
- Transthoracic echocardiography to assess for pericardial effusion, tamponade, and cardiac function
- Chest X-ray
- Routine blood tests, including markers of inflammation (i.e., CRP and/or ESR) and myocardial lesions (CK, troponins)
- Consideration of viral studies and blood cultures if infection is suspected
- Chest imaging with CT to evaluate for pulmonary pathology and pericardial thickening
Management
Management may require temporary discontinuation of ibrutinib in consultation with oncology. Treatment typically includes:
- NSAIDs (ibuprofen 600-800mg TID or indomethacin 25-50mg TID) with gastroprotection
- Colchicine (0.5-0.6mg BID)
- Possibly corticosteroids if inflammation is severe
- Pericardiocentesis may be necessary for large effusions, tamponade, or diagnostic sampling to rule out malignant involvement, as recommended in the 2015 ESC guidelines 1 and supported by more recent studies 1.
Considerations
It is essential to determine if pericarditis is related to the lymphoma (malignant effusion), ibrutinib (drug-induced), infection (due to immunocompromise), or another cause. Ibrutinib can rarely cause cardiac complications, including arrhythmias and pericardial effusion. The diagnostic yield of tumor markers in pericardial fluid remains controversial, but analyses of pericardial fluid and pericardial or epicardial biopsies are essential for confirming malignant pericardial disease, as noted in the guidelines 1.
High-Risk Features
The presence of high-risk features, such as fever, subacute course, large pericardial effusion, cardiac tamponade, and failure of aspirin or NSAIDs, should prompt a more extensive diagnostic workup and consideration of hospitalization, as outlined in the guidelines 1.
Recent Guidelines
Recent studies and guidelines, such as those from 2015 and 2017, provide a framework for the diagnosis and management of pericardial diseases, including pericarditis in patients with malignancies and those on immunosuppressive therapies like ibrutinib 1.
By following this approach, clinicians can provide optimal care for patients with pericarditis, minimizing morbidity, mortality, and improving quality of life.
From the Research
Pericarditis Diagnosis and Workup
- Pericarditis is a known side effect of ibrutinib treatment, as reported in studies such as 2 and 3.
- A patient with small B cell on Imbruvica (ibrutinib) should be closely monitored for potentially serious complications such as pericardial effusion and cardiac tamponade, as seen in the case study 3.
- The diagnosis of pericarditis in a patient on ibrutinib may involve the evaluation of pericardial effusion, pericarditis, and tamponade, as reported in 2.
Clinical Characteristics and Mechanism
- The mechanism of ibrutinib-induced pericardial events is not fully understood, but it is thought to be related to the inhibition of Bruton's tyrosine kinase (BTK) and the subsequent effects on B-cell antigen receptor signalling, as discussed in 4.
- The incidence of ibrutinib-induced pericardial events can vary, and further studies are needed to fully understand the epidemiology and clinical characteristics of this adverse event, as noted in 5.
Management and Treatment
- The management of ibrutinib-induced pericardial events may involve the discontinuation of ibrutinib therapy, as seen in the case study 3.
- Colchicine may be administered to reduce pericardial effusion, as reported in 3.
- Patients on ibrutinib should be closely monitored for signs and symptoms of pericarditis, and healthcare professionals should be aware of the potential for this adverse event, as discussed in 6.