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Abstract
Immunomodulation by colchicine is a well-established therapy for targeting inflammatory pathways in gout, pericarditis and Behchet's disease. In more recent times, evidence has emerged demonstrating a potential role for colchicine in several cardiac conditions. This article aims to summarise the evidence behind the established guidelines for use of low-dose colchicine in pericarditis and examine the evolving evidence for its use in cardiovascular disease and most recently COVID-19.
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Abadie BQ, Cremer PC. Interleukin-1 Antagonists for the Treatment of Recurrent Pericarditis. BioDrugs 2022; 36:459-472. [PMID: 35639340 PMCID: PMC9152656 DOI: 10.1007/s40259-022-00537-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2022] [Indexed: 11/21/2022]
Abstract
Although most patients with acute pericarditis will recover, a minority will have recurrent, debilitating episodes. In these patients, refractory symptoms result in high morbidity, and typically require a prolonged duration of anti-inflammatory treatment. Initially, the efficacy of colchicine in both recurrent pericarditis and periodic fever syndromes suggested the central role of the inflammasome in pericarditis. Subsequently, the success of interleukin-1 antagonists in autoinflammatory diseases prompted further investigation in recurrent pericarditis. In current clinical practice, interleukin-1 antagonists include canakinumab, anakinra, and rilonacept. Both anakinra and rilonacept have demonstrated efficacy in randomized trials of patients with recurrent pericarditis. The aim of the current review is to explain the biological rationale for interleukin-1 antagonists in recurrent pericarditis, highlight supporting clinical evidence, and emphasizing future areas of investigation.
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Affiliation(s)
- Bryan Q Abadie
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Paul C Cremer
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA.
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Sambola A, Roca Luque I, Mercé J, Alguersuari J, Francisco-Pascual J, García-Dorado D, Sagristà-Sauleda J. Colchicina administrada en el primer episodio de pericarditis aguda idiopática: estudio multicéntrico abierto y aleatorizado. Rev Esp Cardiol 2019. [PMID: 30683494 DOI: 10.1016/j.recesp.2018.11.021] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Antonia Sambola
- Servei de Cardiologia, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca, Universitat Autònoma de Barcelona, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Barcelona, Spain
| | - Ivo Roca Luque
- Servei de Cardiologia, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca, Universitat Autònoma de Barcelona, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Barcelona, Spain
| | - Jordi Mercé
- Servei de Cardiologia. Hospital Universitari Joan XXII, Tarragona, Spain
| | - Joan Alguersuari
- Servicio de Cardiología. Hospital Son Espases, Palma de Mallorca, Baleares, Spain
| | - Jaume Francisco-Pascual
- Servei de Cardiologia, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca, Universitat Autònoma de Barcelona, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Barcelona, Spain
| | - David García-Dorado
- Servei de Cardiologia, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca, Universitat Autònoma de Barcelona, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Barcelona, Spain
| | - Jaume Sagristà-Sauleda
- Servei de Cardiologia, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca, Universitat Autònoma de Barcelona, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Barcelona, Spain.
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Sambola A, Roca Luque I, Mercé J, Alguersuari J, Francisco-Pascual J, García-Dorado D, Sagristà-Sauleda J. Colchicine Administered in the First Episode of Acute Idiopathic Pericarditis: A Randomized Multicenter Open-label Study. ACTA ACUST UNITED AC 2019; 72:709-716. [PMID: 30683494 DOI: 10.1016/j.rec.2018.11.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Accepted: 11/22/2018] [Indexed: 12/14/2022]
Abstract
INTRODUCTION AND OBJECTIVES There is a paucity of information about the real benefit of colchicine administration in the first episode of acute idiopathic pericarditis (AIP). The main objective of the present study was to assess the real efficacy of colchicine in patients with AIP who did not receive corticosteroids. METHODS Randomized multicenter open-label study. Patients with a first episode of AIP (not secondary to cardiac injury or connective tissue disease) were randomized into 2 groups: group A received conventional anti-inflammatory treatment plus colchicine for 3 months, and group B received conventional anti-inflammatory treatment only. None of the patients received corticosteroids. The primary endpoint was the appearance of recurrent episodes of pericarditis. The secondary endpoint was the time to first recurrence. Follow-up was extended to 24 months. RESULTS A total of 110 patients (83.6% men, age 44±18.3 years) were randomized to group A (n=59) and group B (n=51). No differences were found in baseline demographics or in the clinical features of the index episode or in the type of anti-inflammatory treatment administered in both groups. The follow-up was completed by 102 patients (92.7%). No differences were found in the rate of recurrent pericarditis between groups (12 patients [10.9%]; group A vs group B, 13.5% vs 7.8%; P=.34). The time to first recurrence (group A vs group B, 9.6±9.0 vs 8.3±10.5 months; P=.80) did not differ between groups. CONCLUSIONS Among patients with a first episode of AIP who had not received corticosteroids, the addition of colchicine to conventional anti-inflammatory treatment does not seem to reduce the recurrence rate. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrialsregister.eu. Identifier: EudraCT 2009-011258-16.
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Affiliation(s)
- Antonia Sambola
- Servei de Cardiologia, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca, Universitat Autònoma de Barcelona, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Barcelona, Spain
| | - Ivo Roca Luque
- Servei de Cardiologia, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca, Universitat Autònoma de Barcelona, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Barcelona, Spain
| | - Jordi Mercé
- Servei de Cardiologia. Hospital Universitari Joan XXII, Tarragona, Spain
| | - Joan Alguersuari
- Servicio de Cardiología. Hospital Son Espases, Palma de Mallorca, Baleares, Spain
| | - Jaume Francisco-Pascual
- Servei de Cardiologia, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca, Universitat Autònoma de Barcelona, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Barcelona, Spain
| | - David García-Dorado
- Servei de Cardiologia, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca, Universitat Autònoma de Barcelona, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Barcelona, Spain
| | - Jaume Sagristà-Sauleda
- Servei de Cardiologia, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca, Universitat Autònoma de Barcelona, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Barcelona, Spain.
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Yan BP, Tan GM. What's Old is New Again - A Review of the Current Evidence of Colchicine in Cardiovascular Medicine. Curr Cardiol Rev 2017; 13:130-138. [PMID: 27758695 PMCID: PMC5452147 DOI: 10.2174/1573403x12666161014094159] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Revised: 10/05/2016] [Accepted: 10/07/2016] [Indexed: 01/20/2023] Open
Abstract
Colchicine is a well-established drug approved by the Food and Drug Administration (FDA) for the prevention and treatment of gout. It possesses unique anti-inflammatory properties. Interests in the usage of colchicine in cardiovascular medicine have been rekindled recently with several large trials been carried out to investigate its efficacy in treatment of various cardiac conditions including pericarditis, postpericardiotomy syndrome, atrial fibrillation and coronary artery disease. In this review, the basic pharmacological properties of colchicine will be discussed, and the evidences of its benefits for different applications in cardiovascular medicine will be reviewed.
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Affiliation(s)
- Bryan P Yan
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Guang-Ming Tan
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
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Shah SR, Alweis R, Shah SA, Arshad MH, Manji AAK, Arfeen AA, Javed M, Shujauddin SM, Irfan R, Shabbir S, Shaikh S. Effects of colchicine on pericardial diseases: a review of the literature and current evidence. J Community Hosp Intern Med Perspect 2016; 6:31957. [PMID: 27406462 PMCID: PMC4942520 DOI: 10.3402/jchimp.v6.31957] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Accepted: 05/02/2016] [Indexed: 11/14/2022] Open
Abstract
Colchicine, extracted from the colchicum autumnale plant, used by the ancient Greeks more than 20 centuries ago, is one of the most ancient drugs still prescribed even today. The major mechanism of action is binding to microtubules thereby interfering with mitosis and subsequent modulation of polymorphonuclear leukocyte function. Colchicine has long been of interest in the treatment of cardiovascular disease; however, its efficacy and safety profile for specific conditions have been variably established in the literature. In the subset of pericardial diseases, colchicine has been shown to be effective in recurrent pericarditis and post-pericardiotomy syndrome (PPS). The future course of treatment and management will therefore highly depend on the results of the ongoing large randomized placebo-controlled clinical trial to evaluate the efficacy and safety of colchicine for the primary prevention of several postoperative complications and in the perioperative period. Also, given the positive preliminary outcomes of colchicine usage in pericardial effusions, the future therapeutical use of colchicine looks promising. Further study is needed to clarify its role in these disease states, as well as explore other its role in other cardiovascular conditions.
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Affiliation(s)
- Syed Raza Shah
- Department of Medicine, Dow University of Health Sciences (DUHS), Karachi, Pakistan;
| | - Richard Alweis
- Department of Internal Medicine, Reading Health System, West Reading, PA, USA
| | - Syed Arbab Shah
- Department of Medicine, Ziauddin Medical University Hospital, Karachi, Pakistan
| | | | - Adil Al-Karim Manji
- Department of Biological Sciences, Karachi Grammar School, Karachi, Pakistan
| | - Arham Amir Arfeen
- Department of Biological Sciences, Karachi Grammar School, Karachi, Pakistan
| | - Maheen Javed
- Department of Biological Sciences, Karachi Grammar School, Karachi, Pakistan
| | | | - Rida Irfan
- Department of Biological Sciences, The Lyceum, Karachi, Pakistan
| | - Sakina Shabbir
- Department of Biological Sciences, The Lyceum, Karachi, Pakistan
| | - Shehryar Shaikh
- Department of Biological Sciences, Beaconhouse College Campus Defense, Karachi, Pakistan
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Schwier NC. Pharmacotherapeutic considerations for using colchicine to treat idiopathic pericarditis in the USA. Am J Cardiovasc Drugs 2015; 15:295-306. [PMID: 26243656 DOI: 10.1007/s40256-015-0133-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The clinical significance of colchicine in the treatment of acute idiopathic (viral) pericarditis (IP) was only elucidated less than a decade ago. Multiple trials have shown the benefit of colchicine in decreasing the rate of recurrence, primarily in the European population. However, the colchicine formulation used in these trials is not available in Western countries such as the USA. In the USA, two formulations are available: the 0.6 mg capsule and the 0.6 mg tablet. As a result, higher doses than administered in the European trials must be utilized to treat IP. However, the use of these dosage forms has never been studied in the treatment of IP. Pharmacokinetic and pharmacodynamic knowledge of colchicine germane to clinicians such as drug disposition and drug-drug or drug-disease interactions have not been extensively reviewed in recent years. Furthermore, the safety of colchicine in the treatment of IP has not been extensively studied, and literature regarding adverse drug events originates from data in patients treated for familial Mediterranean fever and gout. This review will help the clinician understand pharmacotherapeutic considerations and thereby optimize therapy and ensure patient safety when using colchicine to treat IP.
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Affiliation(s)
- Nicholas C Schwier
- Department of Pharmacy, Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, 1110 N. Stonewall Avenue, CPB 214, Oklahoma City, OK, 73117, USA.
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Colchicine for pericarditis. Trends Cardiovasc Med 2015; 25:129-36. [DOI: 10.1016/j.tcm.2014.09.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2014] [Revised: 09/10/2014] [Accepted: 09/23/2014] [Indexed: 01/13/2023]
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Cantarini L, Lopalco G, Selmi C, Napodano S, De Rosa G, Caso F, Costa L, Iannone F, Rigante D. Autoimmunity and autoinflammation as the yin and yang of idiopathic recurrent acute pericarditis. Autoimmun Rev 2014; 14:90-7. [PMID: 25308531 DOI: 10.1016/j.autrev.2014.10.005] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Accepted: 09/23/2014] [Indexed: 12/27/2022]
Abstract
Autoimmunity and autoinflammation are generally considered as mutually exclusive mechanisms of diseases but may concur to specific syndromes. Idiopathic recurrent acute pericarditis (IRAP) is defined as the recurrence of pericardial symptoms at any point following the prior cessation of acute pericarditis, and the latency is generally 6 weeks. Manifestations of pericarditis such as pericardial friction rub, electrocardiographic changes, and pericardial effusion are less frequent in the subsequent episodes compared to the index attack, and in some cases the only clinical sign is represented by a suggestive chest pain. Several autoimmune diseases may manifest with pericarditis which is often related to viral infections, while postviral pericarditis may in turn display a nonspecific autoimmune background. Similarly, autoinflammatory syndromes such as familial Mediterranean fever and tumor necrosis factor receptor-associated periodic syndrome are characterized by self-limiting pericardial symptoms. Corticosteroids are generally effective, thus supporting the autoimmune nature of IRAP, but dramatic results are obtained with interleukin-1 blocking agents in corticosteroid-dependent cases, pointing to a pathogenic role for the inflammasome. Based on these observations, we submit that IRAP represents a paradigmatic example of the putative coexistence of autoimmunity and autoinflammation: the main aim of this review is to critically discuss the hypothesis as well as the current understanding of this enigmatic clinical condition.
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Affiliation(s)
- Luca Cantarini
- Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy.
| | - Giuseppe Lopalco
- Interdisciplinary Department of Medicine, Rheumatology Unit, Policlinic Hospital, University of Bari, Bari, Italy
| | - Carlo Selmi
- Division of Rheumatology and Clinical Immunology, Humanitas Research Hospital, Rozzano, Milan, Italy; BIOMETRA Department, University of Milan, Milan, Italy
| | | | - Gabriella De Rosa
- Institute of Pediatrics, Università Cattolica Sacro Cuore, Rome, Italy
| | - Francesco Caso
- Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy; Department of Clinical and Experimental Medicine, University of Padua, Padua, Italy
| | - Luisa Costa
- Rheumatology Unit, Department of Clinical Medicine and Surgery, University Federico II, Naples, Italy
| | - Florenzo Iannone
- Interdisciplinary Department of Medicine, Rheumatology Unit, Policlinic Hospital, University of Bari, Bari, Italy
| | - Donato Rigante
- Institute of Pediatrics, Università Cattolica Sacro Cuore, Rome, Italy
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Abstract
BACKGROUND Pericarditis is the inflammation of the pericardium, the membranous sac surrounding the heart. Recurrent pericarditis is the most common complication of acute pericarditis, causing severe and disabling chest pains. Recurrent pericarditis affects one in three patients with acute pericarditis within the first 18 months. Colchicine has been suggested to be beneficial in preventing recurrent pericarditis. OBJECTIVES To review all randomised controlled trials (RCTs) that assess the effects of colchicine alone or combined, compared to any other intervention to prevent further recurrences of pericarditis, in people with acute or recurrent pericarditis. SEARCH METHODS We searched the following bibliographic databases on 4 August 2014: Cochrane Central Register of Controlled Trials (CENTRAL, Issue 7 of 12, 2014 on The Cochrane Library), MEDLINE (OVID, 1946 to July week 4, 2014), EMBASE (OVID, 1947 to 2014 week 31), and the Conference Proceedings Citation Index - Science on Web of Science (Thomson Reuters) 1990 to 1 Aug 2014. We did not apply any language or time restrictions. SELECTION CRITERIA RCTs of people with acute or recurrent pericarditis who are receiving colchicine compared to any other treatment, in order to prevent recurrences. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials for inclusion, extracted data and assessed the risk of bias. The first primary outcome was the time to recurrence, measured by calculating the hazard ratios (HRs). The second primary outcome was the adverse effects of colchicine. Secondary outcomes were the rate of recurrences at 6, 12 and 18 months, and symptom relief. MAIN RESULTS We included four RCTs, involving 564 participants in this review. We compared the effects of colchicine in addition to a non-steroidal anti-inflammatory drug (NSAID) such as ibuprofen, aspirin or indomethacin to the effects of the NSAID alone. Two comparable trials studied the effects of colchicine in 204 participants with recurrent pericarditis and two trials studied 360 people with acute pericarditis. All trials had a moderate quality for the primary outcomes. We identified two on-going trials; one of these trials examines acute pericarditis and the other assesses recurrent pericarditis.There was moderate quality evidence that colchicine reduces episodes of pericarditis in people with recurrent pericarditis over 18 months follow-up (HR 0.37; 95% confidence interval (CI) 0.24 to 0.58). It is expected that at 18 months, the number needed to treat (NNT) is 4. In people with acute pericarditis, there was moderate quality evidence that colchicine reduces recurrence (HR 0.40; 95% CI 0.27 to 0.61) at 18 months follow-up. Colchicine led to a greater chance of symptom relief at 72 hours (risk ratio (RR) 1.4; 95% CI 1.26 to 1.56; low quality evidence). Adverse effects were mainly gastrointestinal and included abdominal pain and diarrhoea. The pooled RR for adverse events was 1.26 (95% CI 0.75 to 2.12). While the number of people experiencing adverse effects was higher in the colchicine than the control groups (9% versus 7%), the quality of evidence was low owing to imprecision, and there was no statistically significant difference between the treatment groups (P = 0.42). There was moderate quality evidence that treatment with colchicine led to more people stopping treatment due to adverse events (RR 1.87; 95% CI 1.02 to 3.41). AUTHORS' CONCLUSIONS Colchicine, as adjunctive therapy to NSAIDs, is effective in reducing the number of pericarditis recurrences in patients with recurrent pericarditis or acute pericarditis. However, evidence is based on a limited number of small trials. Patients with multiple resistant recurrences were not represented in any published or on-going trials, and it is these patients that are in the most need for treatment.
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Affiliation(s)
- Samer Alabed
- University of OxfordContinuing EducationOxfordUK
| | - Juan B Cabello
- Hospital General Universitario de AlicanteDepartment of Cardiology & CASP SpainPintor Baeza 12AlicanteAlicanteSpain03010
| | - Greg J Irving
- University of LiverpoolDivision of Primary CareLiverpoolUKL69 3GB
| | - Mohammed Qintar
- Cleveland Clinic FoundationInternal Medicine Department2835 Mafield RoadApt 206ClevelandOhioUSA44118
| | - Amanda Burls
- City University LondonSchool of Health SciencesMyddleton StreetLondonUKEC1V 0HB
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Norrid SE, Oliphant CS. Colchicine for the Treatment of Acute and Recurrent Pericarditis. Ann Pharmacother 2014; 48:1050-1054. [DOI: 10.1177/1060028014535907] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective: To evaluate the literature with colchicine for the acute treatment of pericarditis and prevention of recurrent pericarditis. Data Sources: Searches of MEDLINE (1966-March 2014) and Cochrane Database (1993-March 2014) were conducted using the search terms pericarditis and colchicine. Limits were set for articles written in English with human subjects. Additional data were identified through bibliographic reviews. Study Selection and Data Extraction: Case series and clinical trials identified from the data sources were evaluated. Data Synthesis: A total of 16 case series and 5 prospective controlled trials were identified in the search. Early observational studies examined the use of colchicine, as an adjunct to aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs), in patients with multiple cases of recurrent pericarditis. These studies showed decreased rates of recurrence after the initiation of colchicine therapy and formed the basis of the only available guidelines for the treatment of pericarditis. Since then, 5 randomized controlled trials have been published; 3 trials studied colchicine therapy for 6 months in patients with recurrent pericarditis, and the other 2 studied colchicine therapy for 3 months in patients with acute pericarditis. All 5 trials showed decreased rates of recurrence and symptom persistence, with similar rates of adverse events between study groups. Conclusions: Clinical controlled trials have shown that colchicine, as an adjunct to aspirin or NSAIDs, is effective in the prevention of recurrent pericarditis and in the management of acute symptoms. Colchicine was generally well tolerated with a low incidence of adverse events.
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Affiliation(s)
- Sarah E. Norrid
- The University of Tennessee College of Pharmacy, Memphis, TN, USA
| | - Carrie S. Oliphant
- The University of Tennessee College of Pharmacy, Memphis, TN, USA
- Methodist Healthcare–University Hospital, Memphis, TN, USA
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Imazio M, Brucato A, Trinchero R, Spodick D, Adler Y. Individualized therapy for pericarditis. Expert Rev Cardiovasc Ther 2014; 7:965-75. [DOI: 10.1586/erc.09.82] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Horai Y, Miyamura T, Takahama S, Sonomoto K, Nakamura M, Ando H, Minami R, Yamamoto M, Suematsu E. Influenza virus B-associated hemophagocytic syndrome and recurrent pericarditis in a patient with systemic lupus erythematosus. Mod Rheumatol 2014. [DOI: 10.3109/s10165-009-0241-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Markel G, Imazio M, Brucato A, Adler Y. Prevention of recurrent pericarditis with colchicine in 2012. Clin Cardiol 2013; 36:125-8. [PMID: 23404655 DOI: 10.1002/clc.22098] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2012] [Accepted: 01/02/2013] [Indexed: 11/11/2022] Open
Abstract
The most troublesome complication of acute pericarditis is recurrent pericardial inflammation, which occurs in 15%-32% of cases. The optimal method for prevention has not been fully established; accepted modalities include nonsteroidal anti-inflammatory drugs, corticosteroids, immunosuppressive agents, and pericardiectomy. Over the last years, objective clinical evidence has matured and clearly indicates the important role and beneficial clinical effect of colchicine therapy in preventing recurrent pericarditis caused by various etiologies. Colchicine-treated patients consistently display significantly fewer recurrences and longer symptom-free periods, and even when attacks occur, they are weaker and shorter in nature. Notably, pretreatment with corticosteroids substantially attenuates the efficacy of colchicine, causing significantly more recurrences and longer therapy periods. The safety profile seems superior to other drugs, such as corticosteroids and immunosuppressive drugs. Colchicine is a safe and effective modality for the treatment and prevention of recurrent pericarditis, especially as an adjunct to other modalities, because it provides a sustained benefit, superior to all current modalities.
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Affiliation(s)
- Gal Markel
- Ella Institute of Melanoma, Sheba Medical Center, Tel Hashomer, Israel
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Fernandes F, Ramires FJA, Ianni BM, Salemi VMC, Oliveira AM, Pessoa FG, Canzian M, Mady C. Effect of Colchicine on Myocardial Injury Induced by Trypanosoma cruzi in Experimental Chagas Disease. J Card Fail 2012; 18:654-9. [DOI: 10.1016/j.cardfail.2012.06.419] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Revised: 06/05/2012] [Accepted: 06/08/2012] [Indexed: 10/28/2022]
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Impact of colchicine on pericardial inflammatory syndromes--an analysis of randomized clinical trials. Int J Cardiol 2012; 161:59-62. [PMID: 22770895 DOI: 10.1016/j.ijcard.2012.06.040] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2012] [Accepted: 06/09/2012] [Indexed: 11/24/2022]
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Gillespie EF, Smith TJ, Douglas RS. Thyroid eye disease: towards an evidence base for treatment in the 21st century. Curr Neurol Neurosci Rep 2012; 12:318-24. [PMID: 22354545 PMCID: PMC3463137 DOI: 10.1007/s11910-012-0256-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Thyroid eye disease (TED) is the most common extrathyroidal manifestation of Graves' disease. Incomplete understanding of its pathogenesis has hindered development of targeted therapies that might alter the natural course of disease. Smoking cessation and maintenance of euthyroidism appear to reduce the rate of onset and severity of TED. Recent evidence suggests that selenium may lessen the inflammatory symptoms in mild disease. Corticosteroids remain the primary treatment for patients with moderate to severe active TED. Surgical decompression is commonly undertaken in the chronic stable phase, and only rarely in the active phase when vision is threatened by compressive optic neuropathy. Orbital radiotherapy remains an adjunctive strategy during active disease. Targeted immunotherapies have the potential to alter disease progression, but further evidence is needed to establish safety and efficacy. In this article, we review evidence from prospective therapeutic trials of several treatment modalities. We focus on moderate to severe active TED.
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Affiliation(s)
- Erin F. Gillespie
- Department of Ophthalmology and Visual Science, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Terry J. Smith
- Department of Ophthalmology and Visual Science, University of Michigan Medical School, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Raymond S. Douglas
- Department of Ophthalmology and Visual Science, University of Michigan Medical School, Ann Arbor, MI, USA
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Gianni F, Solbiati M. Colchicine is safe and effective for secondary prevention of recurrent pericarditis. Intern Emerg Med 2012; 7:181-2. [PMID: 22430920 DOI: 10.1007/s11739-012-0775-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2012] [Accepted: 03/01/2012] [Indexed: 10/28/2022]
Abstract
The CORP (COlchicine for Recurrent Pericarditis) trial [7]is a prospective, randomized, double-blind, placebo controlled, multicenter trial to evaluate the efficacy and safety of colchicine (1.0–2.0 mg on the first day, followed by a maintenance dose of 0.5–1.0 mg/day for 6 months) in association with conventional anti-inflammatory therapy for the secondary prevention of recurrence in patients with a first relapse of pericarditis. Patients were excluded if they were having their first episode of acute pericarditis, or their second or subsequent recurrence, or had pericarditis with tuberculous, purulent, or neoplastic causes. The primary study end point was the recurrence rate at 18 months. Secondary end points were symptom persistence after 72 h, remission rate at 1 week, number of recurrences, time to first recurrence, disease-related hospitalizations,cardiac tamponade, and constrictive pericarditis rates.120 patients (60 in the colchicine and 60 in the placebo group) were included in the analysis. The recurrence rate is 24 % in the colchicine group and 55 % in the placebo group (absolute risk reduction 0.31 [95 % CI 0.13–0.46];relative risk reduction 0.56 [0.27–0.73]; number needed to treat 3 [2–7]). Colchicine improves the persistence of symptoms at 72 h (absolute risk reduction 0.30 [95 % IC,0.13–0.45]; relative risk reduction 0.56 [0.27–0.74]). It also reduces the mean number of recurrences, increases the remission rate at 1 week and prolongs the time to subsequent recurrence. Colchicine and placebo groups have similar rates of side effects (7 %) and drug withdrawal (8 vs. 5 %, P = 0.89);no severe side effects occurred in any of the groups. Gastrointestinal intolerance was the main side effect during the study.
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Affiliation(s)
- Francesca Gianni
- Medicina Interna II, Azienda Ospedaliera L. Sacco, Università degli Studi di Milano, Milan, Italy
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Slovis N. Pericarditis: A clinical perspective during an epidemic of fibrinous pericarditis in central Kentucky. EQUINE VET EDUC 2011. [DOI: 10.1111/j.2042-3292.2010.00155.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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22
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Imazio M, Brucato A, Mayosi BM, Derosa FG, Lestuzzi C, Macor A, Trinchero R, Spodick DH, Adler Y. Medical therapy of pericardial diseases: part I: idiopathic and infectious pericarditis. J Cardiovasc Med (Hagerstown) 2010; 11:712-22. [PMID: 20736783 DOI: 10.2459/jcm.0b013e3283340b97] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The treatment of pericardial diseases is largely empirical because of the relative lack of randomized trials compared with other cardiovascular diseases. The main forms of pericardial diseases that can be encountered in the clinical setting include acute and recurrent pericarditis, pericardial effusion with or without cardiac tamponade, and constrictive pericarditis. Medical treatment should be targeted at the cause of the disease as much as possible. However, the cause of pericardial diseases may be varied and depends on the prevalence of specific diseases (especially tuberculosis). The search for an etiology is often inconclusive, and most cases are classified as idiopathic in developed countries where tuberculosis is relatively rare, whereas a tuberculous etiology is often presumed in developing countries where tuberculosis is endemic. The aim of the present article is to review current medical therapy for pericardial diseases, highlighting recent significant advances in clinical research, ongoing challenges and unmet needs. Following a probabilistic approach, the most common causes are considered (idiopathic, viral, tuberculous, purulent, connective tissue diseases and neoplastic pericardial disease). In this article, the therapy of idiopathic and more common forms of infectious pericarditis (viral and bacterial) is reviewed.
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Affiliation(s)
- Massimo Imazio
- Cardiology Department, Maria Vittoria Hospital, Torino, Italy.
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Cocco G, Chu DCC, Pandolfi S. Colchicine in clinical medicine. A guide for internists. Eur J Intern Med 2010; 21:503-8. [PMID: 21111934 DOI: 10.1016/j.ejim.2010.09.010] [Citation(s) in RCA: 160] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2010] [Revised: 09/07/2010] [Accepted: 09/15/2010] [Indexed: 12/24/2022]
Abstract
Colchicine (COL) has been used in medicine for a long time. It is well recognized as a valid therapy in acute flares of gouty arthritis, familial Mediterranean fever (FMF), Behçet's disease, and recurring pericarditis with effusion. It has also been used to treat many inflammatory disorders prone to fibrosis, mostly with disappointing therapeutic results. The pharmacotherapeutic mechanism of action of COL in diverse diseases is not fully understood, thought it is known that the drug accumulates preferentially in neutrophils, and this effect is useful in FMF. COL shows a large interindividual bioavailability. Furthermore, interactions with drugs interfering with CYP3A4 dependent enzymes and P-glycoprotein occur and are clinically important. The dosage of COL must be reduced in patients with relevant hepatic and/or renal dysfunction. However, when appropriately used and contraindications have been excluded, oral COL is a safe treatment.
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Sheth S, Wang DD, Kasapis C. Current and emerging strategies for the treatment of acute pericarditis: a systematic review. J Inflamm Res 2010; 3:135-42. [PMID: 22096363 PMCID: PMC3218740 DOI: 10.2147/jir.s10268] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Pericarditis is a common disorder that has multiple causes and presents in various primary-care and secondary-care settings. It is diagnosed in 0.1% of all hospital admissions and in 5% of emergency room visits for chest pain. Despite the advance of new diagnostic techniques, pericarditis is most commonly idiopathic, and radiation therapy, cardiac surgery, and percutaneous procedures have become important causes. Pericarditis is frequently benign and self-limiting. Nonsteroidal anti-inflammatory agents remain the first-line treatment for uncomplicated cases. Integrated use of new imaging methods facilitates accurate detection and management of complications such as pericardial effusion or constriction. In this article, we perform a systematic review on the etiology, clinical presentation, diagnostic evaluation, and management of acute pericarditis. We summarize current evidence on contemporary and emerging treatment strategies.
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Affiliation(s)
- Samar Sheth
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
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25
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Imazio M, Trinchero R, Brucato A, Rovere ME, Gandino A, Cemin R, Ferrua S, Maestroni S, Zingarelli E, Barosi A, Simon C, Sansone F, Patrini D, Vitali E, Ferrazzi P, Spodick DH, Adler Y. COlchicine for the Prevention of the Post-pericardiotomy Syndrome (COPPS): a multicentre, randomized, double-blind, placebo-controlled trial. Eur Heart J 2010; 31:2749-54. [PMID: 20805112 DOI: 10.1093/eurheartj/ehq319] [Citation(s) in RCA: 170] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
AIMS No drug has been proven efficacious to prevent the post-pericardiotomy syndrome (PPS), but colchicine seems safe and effective for the treatment and prevention of pericarditis. The aim of the COlchicine for the Prevention of the Post-pericardiotomy Syndrome (COPPS) trial is to test the efficacy and safety of colchicine for the primary prevention of the PPS. METHODS AND RESULTS The COPPS study is a multicentre, double-blind, randomized trial. On the third post-operative day, 360 patients (mean age 65.7 ± 12.3 years, 66% males), 180 in each treatment arm, were randomized to receive placebo or colchicine (1.0 mg twice daily for the first day followed by a maintenance dose of 0.5 mg twice daily for 1 month in patients ≥70 kg, and halved doses for patients <70 kg or intolerant to the highest dose). The primary efficacy endpoint was the incidence of PPS at 12 months. Secondary endpoint was the combined rate of disease-related hospitalization, cardiac tamponade, constrictive pericarditis, and relapses. Baseline characteristics were well balanced between the study groups. Colchicine significantly reduced the incidence of the PPS at 12 months compared with placebo (respectively, 8.9 vs. 21.1%; P = 0.002; number needed to treat = 8). Colchicine also reduced the secondary endpoint (respectively, 0.6 vs. 5.0%; P = 0.024). The rate of side effects (mainly related to gastrointestinal intolerance) was similar in the colchicine and placebo groups (respectively, 8.9 vs. 5.0%; P = 0.212). CONCLUSION Colchicine is safe and efficacious in the prevention of the PPS and its related complications and may halve the risk of developing the syndrome following cardiac surgery. ClinicalTrials.gov number, NCT00128427.
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Affiliation(s)
- Massimo Imazio
- Department of Cardiology, Maria Vittoria Hospital, Via Cibrario 72, 10141 Torino, Italy.
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Abstract
Colchicine has been effectively used in the treatment of several inflammatory conditions, such as gouty attacks, serositis related to familial Mediterranean fever, Behçet syndrome and more recently, in acute and recurrent pericarditis. Colchicine concentrates in white blood cells, particularly polymorphonuclear cells, inhibiting tubulin polymerization, thus interfering with migration and phagocytosis, and reducing the inflammatory cycle. Although the exact number of responders is unknown, the drug has been successfully used for the treatment and prevention of recurrences and to taper corticosteroids in patients with recurrent pericarditis in several retrospective studies and an open-label, randomized trial, where the recurrence rate was halved in the treatment arm. Less evidence supports the use of the drug for the treatment of acute pericarditis, where colchicine remains optional and requires further multicenter confirmatory studies. At present, colchicine has been recommended by the 2004 European guidelines on the management of pericardial diseases for acute (class IIa) and recurrent pericarditis (class I), but its use is still unlabeled and informed consent is required for prescription. A careful monitoring of possible contraindications, drug interactions and side effects is necessary. The aim of this paper is to review the evidence that supports the use of the drug in acute and recurrent pericarditis, as well as dosing and precautions for clinical use.
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Affiliation(s)
- Massimo Imazio
- Cardiology Department, Maria Vittoria Hospital, Torino, Italy.
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Khandaker MH, Espinosa RE, Nishimura RA, Sinak LJ, Hayes SN, Melduni RM, Oh JK. Pericardial disease: diagnosis and management. Mayo Clin Proc 2010; 85:572-93. [PMID: 20511488 PMCID: PMC2878263 DOI: 10.4065/mcp.2010.0046] [Citation(s) in RCA: 164] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Pericardial diseases can present clinically as acute pericarditis, pericardial effusion, cardiac tamponade, and constrictive pericarditis. Patients can subsequently develop chronic or recurrent pericarditis. Structural abnormalities including congenitally absent pericardium and pericardial cysts are usually asymptomatic and are uncommon. Clinicians are often faced with several diagnostic and management questions relating to the various pericardial syndromes: What are the diagnostic criteria for the vast array of pericardial diseases? Which diagnostic tools should be used? Who requires hospitalization and who can be treated as an outpatient? Which medical management strategies have the best evidence base? When should corticosteroids be used? When should surgical pericardiectomy be considered? To identify relevant literature, we searched PubMed and MEDLINE using the keywords diagnosis, treatment, management, acute pericarditis, relapsing or recurrent pericarditis, pericardial effusion, cardiac tamponade, constrictive pericarditis, and restrictive cardiomyopathy. Studies were selected on the basis of clinical relevance and the impact on clinical practice. This review represents the currently available evidence and the experiences from the pericardial clinic at our institution to help guide the clinician in answering difficult diagnostic and management questions on pericardial diseases.
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Affiliation(s)
| | | | | | | | | | | | - Jae K. Oh
- Address correspondence to Jae K. Oh, MD, Division of Cardiovascular Diseases, Mayo Clinic, 200 First St SW, Rochester, MN 55905 (). Individual reprints of this article and a bound reprint of the entire Symposium on Cardiovascular Diseases will be available for purchase from our Web site www.mayoclinicproceedings.com
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Imazio M, Spodick DH, Brucato A, Trinchero R, Adler Y. Controversial Issues in the Management of Pericardial Diseases. Circulation 2010; 121:916-28. [DOI: 10.1161/circulationaha.108.844753] [Citation(s) in RCA: 251] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
- Massimo Imazio
- From the Cardiology Department, Maria Vittoria Hospital, Torino, Italy (M.I., R.T.); Department of Medicine, St Vincent Hospital, University of Massachusetts, Worcester (D.H.S.); Internal Medicine, Ospedali Riuniti, Bergamo, Italy (A.B.); and Gertner Institute for Epidemiology and Health Policy Research, affiliated with the Sackler Faculty of Medicine, Tel-Aviv University, Cardiac Rehabilitation Institute, Chaim Sheba Medical Center, Tel-Hashomer and Misgav Ladach Hospital, Jerusalem, Kupat Holim
| | - David H. Spodick
- From the Cardiology Department, Maria Vittoria Hospital, Torino, Italy (M.I., R.T.); Department of Medicine, St Vincent Hospital, University of Massachusetts, Worcester (D.H.S.); Internal Medicine, Ospedali Riuniti, Bergamo, Italy (A.B.); and Gertner Institute for Epidemiology and Health Policy Research, affiliated with the Sackler Faculty of Medicine, Tel-Aviv University, Cardiac Rehabilitation Institute, Chaim Sheba Medical Center, Tel-Hashomer and Misgav Ladach Hospital, Jerusalem, Kupat Holim
| | - Antonio Brucato
- From the Cardiology Department, Maria Vittoria Hospital, Torino, Italy (M.I., R.T.); Department of Medicine, St Vincent Hospital, University of Massachusetts, Worcester (D.H.S.); Internal Medicine, Ospedali Riuniti, Bergamo, Italy (A.B.); and Gertner Institute for Epidemiology and Health Policy Research, affiliated with the Sackler Faculty of Medicine, Tel-Aviv University, Cardiac Rehabilitation Institute, Chaim Sheba Medical Center, Tel-Hashomer and Misgav Ladach Hospital, Jerusalem, Kupat Holim
| | - Rita Trinchero
- From the Cardiology Department, Maria Vittoria Hospital, Torino, Italy (M.I., R.T.); Department of Medicine, St Vincent Hospital, University of Massachusetts, Worcester (D.H.S.); Internal Medicine, Ospedali Riuniti, Bergamo, Italy (A.B.); and Gertner Institute for Epidemiology and Health Policy Research, affiliated with the Sackler Faculty of Medicine, Tel-Aviv University, Cardiac Rehabilitation Institute, Chaim Sheba Medical Center, Tel-Hashomer and Misgav Ladach Hospital, Jerusalem, Kupat Holim
| | - Yehuda Adler
- From the Cardiology Department, Maria Vittoria Hospital, Torino, Italy (M.I., R.T.); Department of Medicine, St Vincent Hospital, University of Massachusetts, Worcester (D.H.S.); Internal Medicine, Ospedali Riuniti, Bergamo, Italy (A.B.); and Gertner Institute for Epidemiology and Health Policy Research, affiliated with the Sackler Faculty of Medicine, Tel-Aviv University, Cardiac Rehabilitation Institute, Chaim Sheba Medical Center, Tel-Hashomer and Misgav Ladach Hospital, Jerusalem, Kupat Holim
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29
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Myocarditis and pericarditis. Infect Dis (Lond) 2010. [DOI: 10.1016/b978-0-323-04579-7.00046-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Kuo IF, Pearson GJ, Koshman SL. Colchicine for the primary and secondary prevention of pericarditis: an update. Ann Pharmacother 2009; 43:2075-81. [PMID: 19903861 DOI: 10.1345/aph.1m234] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To review the efficacy and safety of colchicine as primary and secondary prophylaxis for pericarditis. DATA SOURCES We searched MEDLINE, EMBASE, PubMed, BIOSIS Previews, International Pharmaceutical Abstracts, Web of Science, and CENTRAL for controlled studies from database inception date to July 2009. Search terms included colchicine, pericarditis, and postpericardiotomy syndrome (PPS). STUDY SELECTION AND DATA EXTRACTION Prospective, randomized, controlled trials investigating the use of colchicine in preventing pericarditis were included. Data extracted included design, inclusion criteria, demographics, interventions, background therapy, and pericarditis-related clinical outcomes. DATA SYNTHESIS Data were synthesized qualitatively, given variable study designs. Three trials were identified. A single trial examining primary prevention evaluated the use of colchicine versus placebo for preventing PPS in patients undergoing cardiopulmonary bypass grafting. No significant reduction in PPS was found. Two studies examined secondary prevention of pericarditis, comparing colchicine plus aspirin versus aspirin alone. One study examined using these comparators to treat a first episode of pericarditis. After 3 months, there was a significant reduction in recurrent pericarditis with colchicine plus aspirin (11.7% vs 33%; p = 0.009). Another study examined this same regimen in recurrent pericarditis, finding a significant reduction in recurrence after 6 months (21% vs 45%; p = 0.02). CONCLUSIONS Despite limitations in study designs, current evidence suggests a role for colchicine in the secondary prophylaxis for recurrent pericarditis. The evidence for use of colchicine as primary prophylaxis in PPS is indeterminate; therefore, colchicine cannot be recommended routinely. While colchicine should be recommended for the prevention of recurrent pericarditis, questions regarding the optimal regimen and long-term safety profile need to be further elucidated.
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Affiliation(s)
- I fan Kuo
- St. Paul's Hospital, Department of Pharmacy, Vancouver, British Columbia, Canada
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31
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Horai Y, Miyamura T, Takahama S, Sonomoto K, Nakamura M, Ando H, Minami R, Yamamoto M, Suematsu E. Influenza virus B-associated hemophagocytic syndrome and recurrent pericarditis in a patient with systemic lupus erythematosus. Mod Rheumatol 2009; 20:178-82. [PMID: 19898920 DOI: 10.1007/s10165-009-0241-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2009] [Accepted: 09/28/2009] [Indexed: 11/25/2022]
Abstract
We report a 24-year-old male with systemic lupus erythematosus (SLE) who developed influenza virus B-associated hemophagocytic syndrome and cardiac tamponade. Although the patient's general condition improved after steroid pulse therapy and pericardiocentesis, pericardial effusion re-accumulated. Colchicine and aspirin were administered, together with prednisolone, after which no further relapses occurred. This was a rare case of severe influenza-associated hemophagocytic syndrome and steroid-resistant pericardial effusion in an SLE patient.
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Affiliation(s)
- Yoshiro Horai
- Department of Internal Medicine and Rheumatology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-ku, Fukuoka, 810-8563, Japan.
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Abstract
Colchicine has been effectively used in the treatment of several inflammatory conditions, such as gouty attacks, serositis related to familial Mediterranean fever, Behçet syndrome, and more recently also in acute and recurrent pericarditis. Growing evidence has shown that the drug may be useful to treat an acute attack and may be a way to cope with the prevention of pericarditis in acute and recurrent cases and after cardiac surgery. Nevertheless, clinicians are often sceptical about the efficacy of the drug, and concerns have risen on possible side effects and tolerability. In this review, we analyse current evidence to support the use of the drug, as well as possible harms and risks related to drug interactions, reaching the conclusion that colchicine is safe and useful in recurrent pericarditis, if specific precautions are followed, although less evidence supports its use for the treatment of acute pericarditis, where colchicine remains optional and there is a need for further multicentre confirmatory studies. This paper also reviews specific dosing and precautions for the clinical use.
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Affiliation(s)
- Massimo Imazio
- Cardiology Department, Maria Vittoria Hospital, Torino, Italy.
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Imazio M, Cecchi E, Ierna S, Trinchero R. CORP (COlchicine for Recurrent Pericarditis) and CORP-2 trials--two randomized placebo-controlled trials evaluating the clinical benefits of colchicine as adjunct to conventional therapy in the treatment and prevention of recurrent pericarditis: study design and rationale. J Cardiovasc Med (Hagerstown) 2008; 8:830-4. [PMID: 17885522 DOI: 10.2459/jcm.0b013e3280110616] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Colchicine appears to be safe and effective in the treatment and prevention of recurrent pericarditis after failure of conventional therapies in case reports and non-randomized observational studies without control groups. On this basis, colchicine has been proposed as a therapeutic choice in the 2004 guidelines of the European Society of Cardiology. However, the exact number of responders is unknown, and no randomized placebo-controlled trial is available to guide the management of recurrent pericarditis. Moreover, some authors recommend the use of the drug at the first recurrence, whereas others propose to consider the drug only after failure of conventional therapies for the second or subsequent recurrence. STUDY DESIGN The CORP trial will enroll 120 patients in a prospective, randomized, double-blind, multicentre investigation of colchicine compared with placebo in patients with a first episode of recurrent pericarditis. In the CORP-2 trial, 240 patients will be enrolled in a prospective, randomized, double-blind, multicentre investigation of colchicine compared with placebo in patients with two or more recurrences. In both trials, the primary efficacy end-point is the recurrence rate at 18 months, the secondary end-points are symptom persistence at 72 h, remission rate at 1 week, number of recurrences, time to recurrence, disease-related hospitalization, cardiac tamponade and constrictive pericarditis. IMPLICATIONS The CORP and CORP-2 trials will be the first randomized placebo-controlled trials in this area. These trials will provide important evidence regarding the possible benefit of the early use of colchicine for the treatment and prevention of recurrent pericarditis.
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Affiliation(s)
- Massimo Imazio
- Cardiology Department, Maria Vittoria Hospital, Torino, Italy.
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Imazio M, Cecchi E, Demichelis B, Chinaglia A, Coda L, Ghisio A, Demarie D, Ierna S, Trinchero R. Rationale and design of the COPPS trial: a randomised, placebo-controlled, multicentre study on the use of colchicine for the primary prevention of postpericardiotomy syndrome. J Cardiovasc Med (Hagerstown) 2007; 8:1044-8. [DOI: 10.2459/jcm.0b013e32801da148] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Imazio M, Cecchi E, Ierna S, Trinchero R. Investigation on Colchicine for Acute Pericarditis: a multicenter randomized placebo-controlled trial evaluating the clinical benefits of colchicine as adjunct to conventional therapy in the treatment and prevention of pericarditis; study design amd rationale. J Cardiovasc Med (Hagerstown) 2007; 8:613-7. [PMID: 17667033 DOI: 10.2459/01.jcm.0000281702.46359.07] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Colchicine is safe and effective in the treatment and prevention of recurrent pericarditis after failure of conventional treatment. The recent guidelines of the European Society of Cardiology suggest that colchicine might be useful even in the treatment of the first episode. However, the use of the drug is not based on any strong evidence obtained from clinical trials, and no randomized placebo-controlled trial is available to guide the management of acute pericarditis. STUDY DESIGN The Investigation on Colchicine for Acute Pericarditis (ICAP) trial will enroll 240 patients in a prospective, randomized, double-blind, multicenter investigation of colchicine compared to placebo in patients with acute pericarditis. The primary efficacy end point is the recurrence rate at 18 months. The secondary end points are symptom persistence at 72 h, remission rate at 1 week, number of recurrences, time to first recurrence, disease-related hospitalization, cardiac tamponade, and constrictive pericarditis. IMPLICATIONS The ICAP trial will be the first randomized placebo-controlled trial in this area. This trial will provide important evidence regarding the possible benefit of the early use of colchicine in the treatment of acute pericarditis and the primary prevention of recurrences, the most troublesome and commonest complication of pericarditis.
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Affiliation(s)
- Massimo Imazio
- Cardiology Department, Maria Vittoria Hospital, Torino, Italy
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36
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Imazio M, Trinchero R, Shabetai R. Pathogenesis, management, and prevention of recurrent pericarditis. J Cardiovasc Med (Hagerstown) 2007; 8:404-10. [PMID: 17502755 DOI: 10.2459/01.jcm.0000269708.72487.34] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Recurrent pericarditis is one of the most troublesome complications of acute pericarditis and, despite recent advances, remains one of the most challenging problems in pericardial diseases. The exact recurrence rate is unknown, but a reasonable estimate is 30%. The diagnosis is based on clinical criteria, and only routine laboratory testing is required. In many, probably most cases, this is an autoimmune disease, but sometimes it is caused by reactivation of viral pericarditis, an unrelated infection, or is provoked by corticosteroid therapy. Therapeutic modalities are non-specific and varied, and usually the etiology is autoimmunity. Non-steroidal anti-inflammatory drugs with the possible addition of colchicine are the best first-choice treatment, before steroid therapy is tried. Corticosteroid therapy is an independent risk factor for recurrences. In order to provide an evidence-based clinical approach to management, we performed a systematic review of all publications on acute and recurrent pericarditis focusing on recent clinical trials.
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Affiliation(s)
- Massimo Imazio
- Cardiology Department, Maria Vittoria Hospital, Turin, Italy.
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37
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Vohra HA, Nanjaiah P, Been M, Dimitri WR. Resolution of large post-pericardiotomy pericardial effusion with colchicine. J Card Surg 2006; 21:307-8. [PMID: 16684071 DOI: 10.1111/j.1540-8191.2006.00236.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Betrián Blasco P, del Alcázar Muñoz R. Pericarditis recurrente, colchicina y dolor pericardítico sin patología objetivable. An Pediatr (Barc) 2006; 65:273-4. [PMID: 16956513 DOI: 10.1157/13092172] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Abstract
Colchicine is used chiefly in the treatment of gout but is also valuable in other inflammatory diseases such as familial Mediterranean fever (FMF). Three proteins play pivotal roles in colchicine pharmacokinetics: the colchicine receptor, tubulin, which governs the plasma elimination half-life of the drug; intestinal and hepatic CYP3A4, which is key to the biotransformation of colchicine; and P-glycoprotein, a cell efflux pump that regulates the tissue distribution of colchicine, as well as its excretion via the biliary tract and kidneys. Pharmacokinetic studies have been performed using a radioimmunology assay to measure blood colchicine levels. Absorption after oral ingestion varies widely (from 24% to 88% of the dose), the volume of distribution is extremely large (7 l/kg), and binding to albumin is moderate. Colchicine is excreted chiefly through the liver and has an elimination half-life of 20-40 hours. With repeated doses of about 1mg/day, the steady-state is achieved within 8 days and concentrations range from 0.3 to 2.5 ng/ml. Studies of associations between pharmacokinetic parameters and pharmacodynamics show that effects are correlated, not to plasma levels, but to levels in leukocytes. Adverse events are not uncommon, most notably when colchicine is used in combination with drugs that interact with CYP3A4 and/or P-glycoprotein, thereby decreasing the renal and/or hepatic elimination of colchicine. Careful monitoring in this situation is effective in preventing the development of toxicity.
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Affiliation(s)
- Elisabeth Niel
- Inserm U705, UMR CNRS 7157, Neuropsychopharmacologie des Addictions, Hôpital Fernand-Widal, Universités Paris-V et -VII, 200, rue du Faubourg-Saint-Denis, 75475 Paris cedex 10, France
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40
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Imazio M, Bobbio M, Cecchi E, Demarie D, Demichelis B, Pomari F, Moratti M, Gaschino G, Giammaria M, Ghisio A, Belli R, Trinchero R. Colchicine in addition to conventional therapy for acute pericarditis: results of the COlchicine for acute PEricarditis (COPE) trial. Circulation 2006; 112:2012-6. [PMID: 16186437 DOI: 10.1161/circulationaha.105.542738] [Citation(s) in RCA: 358] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Colchicine is effective and safe for the treatment and prevention of recurrent pericarditis and might ultimately serve as the initial mode of treatment, especially in idiopathic cases. The aim of this work was to verify the safety and efficacy of colchicine as an adjunct to conventional therapy for the treatment of the first episode of acute pericarditis. METHODS AND RESULTS A prospective, randomized, open-label design was used. A total of 120 patients (mean age 56.9+/-18.8 years, 54 males) with a first episode of acute pericarditis (idiopathic, viral, postpericardiotomy syndromes, and connective tissue diseases) were randomly assigned to conventional treatment with aspirin (group I) or conventional treatment plus colchicine 1.0 to 2.0 mg for the first day and then 0.5 to 1.0 mg/d for 3 months (group II). Corticosteroid therapy was restricted to patients with aspirin contraindications or intolerance. The primary end point was recurrence rate. During the 2873 patient-month follow-up, colchicine significantly reduced the recurrence rate (recurrence rates at 18 months were, respectively, 10.7% versus 32.3%; P=0.004; number needed to treat=5) and symptom persistence at 72 hours (respectively, 11.7% versus 36.7%; P=0.003). After multivariate analysis, corticosteroid use (OR 4.30, 95% CI 1.21 to 15.25; P=0.024) was an independent risk factor for recurrences. Colchicine was discontinued in 5 cases (8.3%) because of diarrhea. No serious adverse effects were observed. CONCLUSIONS Colchicine plus conventional therapy led to a clinically important and statistically significant benefit over conventional treatment, decreasing the recurrence rate in patients with a first episode of acute pericarditis. Corticosteroid therapy given in the index attack can favor the occurrence of recurrences.
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Affiliation(s)
- Massimo Imazio
- Cardiology Department, Maria Vittoria Hospital, University of Turin, Turin, Italy.
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Brucato A, Shinar Y, Brambilla G, Robbiolo L, Ferrioli G, Patrosso MC, Zanni D, Penco S, Boiani E, Ghirardello A, Caforio ALP, Bergantin A, Tombini V, Moreo A, Ashtamkar L, Doria A, Shoenfeld Y, Livneh A. Idiopathic recurrent acute pericarditis: familial Mediterranean fever mutations and disease evolution in a large cohort of Caucasian patients. Lupus 2005; 14:670-4. [PMID: 16218464 DOI: 10.1191/0961203305lu2197oa] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Idiopathic recurrent acute pericarditis (IRAP) is suspected to be an autoimmune phenomenon. We studied 46 consecutive patients. We looked for: 1) the occurrence of new diagnoses of autoimmune diseases during our follow up; 2) HLA typing; and 3) the presence of the most frequent mutations linked to familial Mediterranean fever (FMF gene or MEFV). HLA typing was done in 21 patients at loci B, DRB1, DQA1 and DQB1. MEFV gene was looked in 23 patients using specific primers. During the follow-up we made a new diagnosis of primary Sjögren's syndrome in four patients (8.7%) and of rheumatoid arthritis in one patient (2.2%). HLA B14, DRB1*01 and DQB1*0202 were significantly more prevalent, but we did not find a typical HLA typing. MEFV gene was searched: exon 10 was checked by sequence and the E148Q mutation by restriction site analysis. No mutations were found. In conclusion, the prevalence of definite immunorheumatological diseases and the absence of the mutations linked to FMF reinforce the notion that idiopathic acute recurrent pericarditis is an autoimmune condition.
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Affiliation(s)
- A Brucato
- Department of Medicine, Niguarda Hospital Milano, Italy.
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42
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Artom G, Koren-Morag N, Spodick DH, Brucato A, Guindo J, Bayes-de-Luna A, Brambilla G, Finkelstein Y, Granel B, Bayes-Genis A, Schwammenthal E, Adler Y. Pretreatment with corticosteroids attenuates the efficacy of colchicine in preventing recurrent pericarditis: a multi-centre all-case analysis. Eur Heart J 2005; 26:723-7. [PMID: 15755753 DOI: 10.1093/eurheartj/ehi197] [Citation(s) in RCA: 112] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS Effective prevention of recurrent pericarditis remains an important yet elusive goal. Corticosteroid therapy often needs to be continued for a prolonged period and causes severe side effects. We performed a multi-centre all-case analysis to investigate the efficacy of colchicine in preventing subsequent relapses of pericarditis, and addressed the hypothesis that pretreatment with corticosteroids may attenuate the beneficial effect of colchicine. METHODS AND RESULTS One hundred and forty published and unpublished cases of patients treated with colchicine after at least two relapses of pericarditis were aggregated from European centres. Of those, 119 were included in the study group. Only 18% of the patients had relapses under colchicine therapy, and 30% after its discontinuation. There were significantly more relapses among male patients after colchicine treatment (36 vs. 17%, P=0.046), and those with previous corticosteroid treatment (43 vs. 13%, P=0.02). Multivariate logistic regression analysis identified previous corticosteroid therapy (OR 6.68, 95% CI: 1.65-27.02) and male gender (OR 4.20, 95% CI: 1.16-15.21) as independent risk factors for recurrence following colchicine therapy. CONCLUSION Treatment with colchicine is highly effective in preventing recurrent pericarditis, while pretreatment with corticosteroids exacerbates and extends the course of recurrent pericarditis.
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Affiliation(s)
- Galit Artom
- Cardiac Rehabilitation Institute, Sheba Medical Centre, Tel-Hashomer 52621, Israel
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43
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Affiliation(s)
- Jordi Soler-Soler
- Servei de Cardiología, Hospital Universitari Vall d'Hebron, P. Vall d'Hebron, 119-129, 08035 Barcelona, Spain.
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44
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Tenenbaum A, Koren-Morag N, Spodick DH, Brucato A, Bayes-de-Luna A, Brambilla G, Fisman EZ, Artom G, Guindo J, Bayes-Genis A, Schwammenthal E, Adler Y. The Efficacy of Colchicine in the Treatment of Recurrent Pericarditis Related to Postcardiac Injury (Postpericardiotomy and Postinfarcted) Syndrome: A Multicenter Analysis. ACTA ACUST UNITED AC 2004. [DOI: 10.1159/000079123] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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46
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Harris R, Marx G, Gillett M, Kark A, Arunanthy S. Colchicine-induced bone marrow suppression: treatment with granulocyte colony-stimulating factor. J Emerg Med 2000; 18:435-40. [PMID: 10802421 DOI: 10.1016/s0736-4679(00)00160-8] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Bone marrow aplasia is a frequent complication of colchicine poisoning. This typically occurs on day 3 to 5 postexposure, and the blood cell counts remain depressed for a week or more. Unfortunately, because patients suffering from colchicine toxicity develop multiple organ complications and sepsis, the morbidity and mortality associated with bone marrow depression is high. In this article, we present three cases of colchicine toxicity in which granulocyte colony-stimulating factor (G-CSF) was used to treat bone marrow depression. In all three cases, there was a dramatic increase in the white cell count and, to a lesser extent, the platelet count. In view of the critical nature of the bone marrow depression and multi-organ toxicity induced by colchicine, we believe that consideration of the use of G-CSF to shorten the duration of neutropenia is warranted.
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Affiliation(s)
- R Harris
- Department of Emergency Medicine, Royal North Shore Hospital, St. Leonards, Sydney, Australia
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47
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Ercan Tutar H, Imamoglu A, Atalay S. Recurrent pericarditis as a manifestation of familial Mediterranean fever. Circulation 2000; 101:E71-2. [PMID: 10662763 DOI: 10.1161/01.cir.101.5.e71] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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48
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Pawsat DE, Lee JY. Inflammatory disorders of the heart. Pericarditis, myocarditis, and endocarditis. Emerg Med Clin North Am 1998; 16:665-81, ix. [PMID: 9739781 DOI: 10.1016/s0733-8627(05)70024-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The emergency physician frequently sees patients with cardiac complaints. Too often, ischemic heart disease is overwhelmingly considered to the exclusion of other diagnostic possibilities such as inflammatory cardiac disorders. These disorders can cause considerable discomfort, have long-term implications, or lead to more serious cardiac disorders. Emergency physicians must have a practical understanding of the diagnostic evaluation and therapeutic approach to patients with inflammatory cardiac disorders.
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Affiliation(s)
- D E Pawsat
- Michigan State University Emergency Medicine Residency, Ingham Regional Medical Center, Lansing, USA
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Gasser R, Horn S, Reisinger E, Fischer L, Pokan R, Wendelin I, Klein W. First description of recurrent pericardial effusion associated with borrelia burgdorferi infection. Int J Cardiol 1998; 64:309-10. [PMID: 9672415 DOI: 10.1016/s0167-5273(98)00046-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Lyme disease is well known for affecting the myocardium in the form of carditis and dilated cardiomyopathy. Pericardial effusion associated with Lyme disease has not been described as yet. This article demonstrates a case of a female patient, 54 years of age, with Borrelia burgdorferi infection and associated pericardial effusion. Recurrent pericardiocenteses as well as conventional treatment of the condition were without success. Diagnosis of Borrelia infection and subsequent treatment with ceftriaxone led to permanent restitution of the pericardial effusion.
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Affiliation(s)
- R Gasser
- The Borreliosis Study Group, Department of Medicine, University of Graz, Austria
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50
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Adler Y, Guindo J, Finkelstein Y, Khouri A, Assali A, Bayes-Genis A, Bayes de Luna A. Colchicine for large pericardial effusion. Clin Cardiol 1998; 21:143-4. [PMID: 9491960 PMCID: PMC6655796 DOI: 10.1002/clc.4960210220] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/1997] [Accepted: 09/08/1997] [Indexed: 02/06/2023] Open
Abstract
On the basis of our reported experience with colchicine for recurrent pericarditis, we administered colchicine to two patients with large pericardial effusions complicating idiopathic pericarditis. The first was a 26-year-old male who showed clinical deterioration following emergency pericardiocentesis and aspirin (3 g/day) for 10 days; the second was a 2-year-old girl who was unsuccessfully treated with aspirin (100 mg/kg/day) for 2 weeks, followed by corticosteroids for 7 months. Administration of colchicine (1 mg/day) instead of aspirin in the first case, and with a rapid tapering-off of the corticosteroids in the second case, led to complete regression of the pericardial effusion on echocardiography within 1 week and 1 month, respectively. Colchicine was discontinued after 1 month in the first patient and was continued for 6 months in the child. Neither has had a recurrence at 24 and 6 months of follow-up, respectively. No side effects of colchicine were observed. We conclude that colchicine may be effective in the treatment of large pericardial effusion when therapy with nonsteroidal anti-inflammatory drugs and/or corticosteroids fails.
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Affiliation(s)
- Y Adler
- Department of Cardiology, Rabin Medical Center, Beilinson Campus, Petah Tiqva, Israel
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