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Pryor K, Tarter L, Economy K, Honigberg MC, Valente AM, Garshick M, Weber B. Pericarditis Management in Individuals Contemplating Pregnancy, Currently Pregnant, or Breastfeeding. Curr Cardiol Rep 2023; 25:1103-1111. [PMID: 37632607 PMCID: PMC10872603 DOI: 10.1007/s11886-023-01930-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/24/2023] [Indexed: 08/28/2023]
Abstract
PURPOSE OF REVIEW Pericarditis complicates pregnancy planning, pregnancy, or the postpartum period, and the management approach requires special considerations. Here, we aim to summarize the latest research, diagnostic, and treatment strategies. RECENT FINDINGS Physiologic cardiovascular (CV) adaptations occurring during pregnancy complicate diagnosis, but for most patients, an electrocardiogram (ECG) and transthoracic echocardiogram (TTE) are sufficient to diagnosis pericarditis in the appropriate clinical context. Aspirin and non-steroidal anti-inflammatory drugs (NSAIDs) can be used until 20 weeks gestation as needed. The use of colchicine is encouraged at any time point to reduce the risk of recurrence. Glucocorticoids may be used at the lowest possible dose for the least amount of time throughout pregnancy and breastfeeding. For incessant, recurrent, or refractory pericarditis, or when the above therapies are contraindicated, there may be a consideration of the use of IL-1 inhibition during pregnancy, recognizing the limited data in pregnant patients. Finally, we encourage the use of a multidisciplinary team approach including OB-GYN, cardiology, and rheumatology when available. The diagnosis and treatment of pericarditis in female patients of reproductive age require special considerations. Although highly effective treatment options are available, there is a need for greater data and larger international registries to improve treatment recommendations.
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Affiliation(s)
- Katherine Pryor
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Laura Tarter
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Katherine Economy
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA, USA
| | - Michael C Honigberg
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Anne Marie Valente
- Boston Children's Hospital, Boston, MA, USA
- Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, USA
| | - Michael Garshick
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University Langone Health, NYU Grossman School of Medicine, New York, NY, 10016, USA
- Ronald O. Perelman Department of Dermatology, New York University Langone Health, NYU Grossman School of Medicine, New York, NY, 10016, USA
| | - Brittany Weber
- Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, USA.
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Imazio M, Mardigyan V, Andreis A, Franchin L, De Biasio M, Collini V. New Developments in the Management of Recurrent Pericarditis. Can J Cardiol 2023; 39:1103-1110. [PMID: 37075863 DOI: 10.1016/j.cjca.2023.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 04/11/2023] [Accepted: 04/11/2023] [Indexed: 04/21/2023] Open
Abstract
Recurrent pericarditis is a common and troublesome complication that affects 15%-30% of patients with a previous episode of pericarditis. However, the pathogenesis of these recurrences is not well understood, and most cases remain idiopathic. Recent advances in medical therapy, including the use of colchicine and anti-interleukin-1 agents like anakinra and rilonacept, have suggested an autoinflammatory rather than an autoimmune mechanism for recurrences with an inflammatory phenotype. As a result, a more personalized approach to treatment is now recommended. Patients with an inflammatory phenotype (fever and elevated C-reactive protein level) should receive colchicine and anti-interleukin-1 agents as first-line therapy, whereas those without systemic inflammation should receive low to moderate doses of corticosteroids (eg, prednisone 0.2-0.5 mg/kg/d as an initial dose) and consider azathioprine and intravenous human immunoglobulins in the case of corticosteroid failure. Tapering of corticosteroids should be slow after achieving clinical remission. In this article, we review the new developments in the management of recurrent pericarditis.
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Affiliation(s)
- Massimo Imazio
- Cardiology and Cardiothoracic Department, University Hospital Santa Maria della Misericordia, and Department of Medicine, University of Udine, Udine, Italy.
| | - Vartan Mardigyan
- Department of Medicine, Jewish General Hospital, Montreal, Quebec, Canada
| | - Alessandro Andreis
- University Cardiology, Cardiovascular Department, Città della Salute e della Scienza di Torino, Torino, Italy
| | - Luca Franchin
- Cardiology and Cardiothoracic Department, University Hospital Santa Maria della Misericordia, and Department of Medicine, University of Udine, Udine, Italy
| | - Marzia De Biasio
- Cardiology and Cardiothoracic Department, University Hospital Santa Maria della Misericordia, and Department of Medicine, University of Udine, Udine, Italy
| | - Valentino Collini
- Cardiology and Cardiothoracic Department, University Hospital Santa Maria della Misericordia, and Department of Medicine, University of Udine, Udine, Italy
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Goel A, Bandyopadhyay D, Malik AH, Gupta R, Frishman WH, Aronow WS. Rilonacept and Other Interleukin-1 Inhibitors in the Treatment of Recurrent Pericarditis. Cardiol Rev 2023; 31:225-229. [PMID: 36398320 DOI: 10.1097/crd.0000000000000476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Pericarditis is the commonest form of pericardial disease. Unfortunately, despite optimal treatment, approximately 15-30% of patients with acute pericarditis have recurrence. Many of these patients are refractory to colchicine, and become corticosteroid-dependent. Recurrent pericarditis severely impairs quality of life, and is associated with significant morbidity. Inflammasome formation and overproduction of interleukin (IL)-1 have been found to drive the systemic inflammatory response in recurrent autoinflammatory pericarditis. Several IL-1 inhibitors have been evaluated for their usefulness as therapeutic options. Rilonacept is a dimeric fusion protein that functions as a soluble decoy receptor that binds to both IL-1α and IL-1β, thereby inhibiting the IL-1 pathway. It is safe and efficacious in the treatment of recurrent pericarditis in the RHAPSODY II and III trials. Anakinra is a recombinant IL-1 receptor antagonist that blocks the action of circulating IL-1α and IL-1β. It has also been shown to be safe and efficacious in the AIRTRIP and IRAP studies. Canakinumab is a selective human monoclonal antibody against IL-1β, and data on its use in recurrent pericarditis is scarce. Several questions regarding IL-1 inhibitor therapy, such as the duration of treatment and the recommended tapering protocols, as well as their use in special populations like pregnant or lactating women, remain unanswered and need to be addressed in future studies.
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Affiliation(s)
- Akshay Goel
- Department of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, NY
| | | | - Aaqib H Malik
- Department of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Rahul Gupta
- Department of Cardiology, Lehigh Valley Health Network, Allentown, PA
| | - William H Frishman
- Department of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Wilbert S Aronow
- Department of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, NY
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Shahid R, Jin J, Hope K, Tunuguntla H, Amdani S. Pediatric Pericarditis: Update. Curr Cardiol Rep 2023; 25:157-170. [PMID: 36749541 PMCID: PMC9903287 DOI: 10.1007/s11886-023-01839-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/23/2022] [Indexed: 02/08/2023]
Abstract
PURPOSE OF REVIEW While there have now been a variety of large reviews on adult pericarditis, this detailed review specifically focuses on the epidemiology, clinical presentation, diagnosis, and management of pediatric pericarditis. We have tried to highlight most pediatric studies conducted on this topic, with special inclusion of important adult studies that have shaped our understanding of and management for acute and recurrent pericarditis. RECENT FINDINGS We find that the etiology of pediatric pericarditis differs from adult patients with pericarditis and has evolved over the years. Also, with the current COVID-19 pandemic, it is important for pediatric clinicians to be aware of pericardial involvement both due to the infection and from vaccination. Oftentimes, pericarditis maybe the only cardiac involvement in children with COVID-19, and so caregivers should maintain a high index of suspicion when they encounter children with pericarditis. Large-scale contemporary epidemiological data regarding incidence and prevalence of both acute and recurrent pericarditis is lacking in pediatrics, and future studies should focus on highlighting this important research gap. Most of the current management strategies for pediatric pericarditis are from experiences gathered from adult data. Pediatric multicenter trials are warranted to understand the best management strategy for those with acute and recurrent pericarditis. CASE VIGNETTE A 6-year-old child with a past history of pericarditis almost 2 months ago comes in with a 2-day history of chest pain and fever. Per mother, he stopped his steroids about 2 weeks ago, and for the last 2 days has had a temperature of 102F and has been complaining of sharp mid-sternal chest pain that gets worse when he lies down and is relieved when he sits up and leans forward. On examination, he is tachycardic (heart rate 160 bpm), with normal blood pressure for age. He appears to be in pain (5/10), and on auscultation has a pericardial friction rub. His lab studies are notable for elevated white blood cell count and inflammatory markers (CRP and ESR). His electrocardiogram reveals sinus tachycardia and diffuse ST-elevation in all precordial leads. His echocardiogram demonstrates normal biventricular function and a trace pericardial effusion. His cardiac MRI confirms recurrent pericarditis. He is started on indomethacin and colchicine. He has complete resolution of his symptoms by day 3 of admission and is discharged with close follow-up.
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Affiliation(s)
- Rida Shahid
- grid.239578.20000 0001 0675 4725Department of Pediatric Cardiology, Cleveland Clinic Children’s Hospital, Cleveland, OH USA
| | - Justin Jin
- grid.413808.60000 0004 0388 2248Division of Pediatric Cardiology, Northwestern Feinberg School of Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL USA
| | - Kyle Hope
- grid.39382.330000 0001 2160 926XLillie Frank Abercrombie Division of Pediatric Cardiology, Department of Pediatrics, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX USA
| | - Hari Tunuguntla
- grid.39382.330000 0001 2160 926XLillie Frank Abercrombie Division of Pediatric Cardiology, Department of Pediatrics, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX USA
| | - Shahnawaz Amdani
- grid.239578.20000 0001 0675 4725Department of Pediatric Cardiology, Cleveland Clinic Children’s Hospital, Cleveland, OH USA
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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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Schwier NC, Stephens K, Johnson PN. Management of Idiopathic Viral Pericarditis in the Pediatric Population. J Pediatr Pharmacol Ther 2022; 27:595-608. [DOI: 10.5863/1551-6776-27.7.595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 01/06/2022] [Indexed: 11/11/2022]
Abstract
Idiopathic (viral) pericarditis (IP) is one of the most common etiologies of acute and recurrent pericarditis in children. IP is associated with significant morbidity, and recurrence rates of IP are high and require treatment to decrease risk of recurrence and pericarditis-related chest pain. Despite significant morbidity, sparse guidance exists to comprehensively address management of IP in children. The purpose of this review is to provide an overview of the pharmacotherapy of IP in children, including clinical pearls for managing pediatric patients. Clinicians should consider using the combination of colchicine and nonsteroidal anti-inflammatory drugs (NSAIDs) as first-line therapy, in order to reduce the risk of recurrence and foster symptom improvement in IP. Colchicine dosing may vary depending on patient age, weight, concomitant pharmacotherapies, and disease states. Choice of NSAID should be based on cost, tolerability, and adverse drug events (ADEs). Children should receive higher NSAID attack dosing for >1 week to ensure a reduction in high sensitivity C-reactive protein concentrations and symptom relief. Corticosteroids should be considered last-line for treatment of IP in children, because they increase the risk of recurrence. Immunotherapies may be considered for children with multiple recurrences related to IP despite the use of NSAIDs, colchicine, and/or corticosteroids. Similar to adults, diligent monitoring should be implemented, to prevent drug-drug interactions, drug-disease interactions, and/or ADEs in children.
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Affiliation(s)
- Nicholas C. Schwier
- Department of Pharmacy Practice and the Office of Experiential Education (NCS), School of Pharmacy and Pharmaceutical Sciences, SUNY Binghamton, Johnson City, NY
| | - Katy Stephens
- Department of Pharmacy (KS), Oklahoma Children's Hospital at OU Health, Oklahoma City, OK
| | - Peter N. Johnson
- Department of Pharmacy: Clinical and Administrative Sciences (PNJ), College of Pharmacy, University of Oklahoma Health Sciences Center, Oklahoma City, OK
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Imazio M. Pharmacologic therapies for pericarditis: the past, the present, and the future. Trends Cardiovasc Med 2022:S1050-1738(22)00044-5. [DOI: 10.1016/j.tcm.2022.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Accepted: 02/27/2022] [Indexed: 10/18/2022]
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Klein A, Cremer P, Kontzias A, Furqan M, Forsythe A, Crotty C, Lim-Watson M, Magestro M. Clinical Burden and Unmet Need in Recurrent Pericarditis: A Systematic Literature Review. Cardiol Rev 2022; 30:59-69. [PMID: 32956167 PMCID: PMC8812421 DOI: 10.1097/crd.0000000000000356] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Inflammation of the pericardium (pericarditis) is characterized by excruciating chest pain. This systematic literature review summarizes clinical, humanistic, and economic burdens in acute, especially recurrent, pericarditis, with a secondary aim of understanding United States treatment patterns and outcomes. Short-term clinical burden is well characterized, but long-term data are limited. Some studies report healthcare resource utilization and economic impact; none measure health-related quality-of-life. Pericarditis is associated with infrequent but potentially life-threatening complications, including cardiac tamponade (weighted average: 12.7% across 10 studies), constrictive pericarditis (1.84%; 9 studies), and pericardial effusion (54.7%; 16 studies). There are no approved pericarditis treatments; treatment guidelines, when available, are inconsistent on treatment course or duration. Most recommend first-line use of conventional treatments, for example, nonsteroidal antiinflammatory drugs with or without colchicine; however, 15-30% of patients experience recurrence. Second-line therapy may involve conventional therapies plus long-term utilization of corticosteroids, despite safety issues and the difficulty of tapering or discontinuation. Other exploratory therapies (eg, azathioprine, immunoglobulin, methotrexate, anakinra) present steroid-sparing options, but none are supported by robust clinical evidence, and some present tolerability challenges that may impact adherence. Pericardiectomy is occasionally pursued in treatment-refractory patients, although data are limited. This lack of an evidence-based treatment pathway for patients with recurrent disease is reflected in readmission rates, for example, 12.2% at 30 days in 1 US study. Patients with continued recurrence and inadequate treatment response need approved, safe, accessible treatments to resolve pericarditis symptoms and reduce recurrence risk without excessive treatment burden.
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Affiliation(s)
- Allan Klein
- From the Department of Cardiovascular Medicine, Center for the Diagnosis and Treatment of Pericardial Diseases, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Paul Cremer
- From the Department of Cardiovascular Medicine, Center for the Diagnosis and Treatment of Pericardial Diseases, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Apostolos Kontzias
- Department of Medicine, Division of Rheumatology, Allergy and Immunology, Center of Autoinflammatory Diseases, State University of New York Stonybrook, New York, NY
| | - Muhammad Furqan
- From the Department of Cardiovascular Medicine, Center for the Diagnosis and Treatment of Pericardial Diseases, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
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Gupta M, Kaul S, Velazquez GR, Bandyopadhyay D, Fonarow GC, Klein A, Ghosh RK. A Brief Overview of Recurrent Pericarditis Management and the Potential of Rilonacept as a New Therapeutic Option. Am J Cardiovasc Drugs 2022; 22:27-33. [PMID: 34008144 DOI: 10.1007/s40256-021-00481-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/23/2021] [Indexed: 12/20/2022]
Abstract
Recurrent pericarditis affects 15-30% of patients after acute pericarditis. A large number of the patients with recurrent pericarditis can become corticosteroid dependent, leading to disease chronicity and drug dependence, with additional morbidity from long-term steroid use. Recent randomized trials indicate the efficacy of the interleukin-1 inhibitors anakinra and rilonacept in recurrent pericarditis, including colchicine-resistant and corticosteroid-dependent cases. In particular, rilonacept was assessed in the RHAPSODY clinical trial and found to be a potential treatment option that would decrease recurrent episodes, enabling patients to be weaned off steroids. Additionally, new data indicate that rilonacept should be considered as an option for patients with recurrent pericarditis, as add-on therapy to colchicine and nonsteroidal anti-inflammatory drugs, in place of steroids. We review the current management options for recurrent pericarditis as well as rilonacept as a prospective new addition to our armamentarium.
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Affiliation(s)
- Manasvi Gupta
- Department of Internal Medicine, University of Connecticut, Hartford, CT, USA
| | - Subuhi Kaul
- Department of Internal Medicine, John H. Stroger Hospital of Cook County, Chicago, IL, USA
| | | | - Dhrubajyoti Bandyopadhyay
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Gregg C Fonarow
- Department of Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Allan Klein
- Department of Cardiovascular Medicine, Center for Diagnosis and Treatment of Pericardial Diseases, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Raktim K Ghosh
- MedStar Heart and Vascular Institute, Union Memorial Hospital, Baltimore, MD, USA.
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Casteleyn V, Barzen G, Knebel F, Schneider U. Kardiale Beteiligungen bei rheumatologischen Erkrankungen –
eine Übersicht. AKTUEL RHEUMATOL 2021. [DOI: 10.1055/a-1552-3049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
ZusammenfassungRheumatische Erkrankungen gehen mit einem erhöhten
kardiovaskulären Risiko einher, können darüber hinaus
jedoch im Bereich aller kardialen Strukturen zu spezifischen
entzündlichen Veränderungen führen. Symptome wie
Dyspnoe, Tachykardie und Leistungsminderung stehen patientenseitig im
Vordergrund, wenngleich kardiale Beteiligungen nicht selten asymptomatisch
verlaufen. Diagnostisch werden neben der klinischen Untersuchung und
laborchemischen Verfahren apparative Diagnostiken wie Echokardiografie und
Kardio-MRT aber auch invasive Verfahren wie die Herzkatheteruntersuchung und
Myokardbiopsie angewendet. Die Therapie richtet sich nach der Grunderkrankung,
den betroffenen kardialen Strukturen und reicht von einer medikamentösen
Therapie bis zu interventionell-operativem Vorgehen.
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Affiliation(s)
- Vincent Casteleyn
- Rheumatologie, Charité Universitätsmedizin Berlin
Campus Charité Mitte, Berlin, Deutschland
| | - Gina Barzen
- Kardiologie, Charité Universitätsmedizin Berlin Campus
Charité Mitte, Berlin, Deutschland
| | - Fabian Knebel
- Kardiologie, Charité Universitätsmedizin Berlin Campus
Charité Mitte, Berlin, Deutschland
| | - Udo Schneider
- Rheumatologie, Charité Universitätsmedizin Berlin
Campus Charité Mitte, Berlin, Deutschland
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11
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Avondo S, Andreis A, Casula M, Biondi-Zoccai G, Imazio M. Pharmacologic treatment of acute and recurrent pericarditis: a systematic review and meta-analysis of controlled clinical trials. Panminerva Med 2021; 63:314-323. [PMID: 34738773 DOI: 10.23736/s0031-0808.21.04263-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Recurrence is the most frequent complication following acute pericarditis and may occur in 30% patients, rising to 50% in case of multiple recurrences, lack of colchicine treatment or use of glucocorticoids. Available treatments include aspirin or non-steroidal anti-inflammatory drugs (NSAIDs), colchicine, glucocorticoids, immunosuppressive agents, immunoglobulins, anti-interleukin-1 (IL-1) agents. EVIDENCE ACQUISITION This systematic review and meta-analysis of randomized controlled trials (RCTs) aimed to assess the efficacy of pharmacological treatments for acute and recurrent pericarditis. Bibliographic databases were searched (PubMed, MEDLINE, Embase, Scopus, and the Cochrane Library) using the terms "acute pericarditis" or "recurrent pericarditis" and "colchicine" or "NSAIDs" or "glucocorticoids" or "immunosuppressive agents" or "immunoglobulins" or "anti-IL1 agents." Random-effects meta-analysis was used to assess the risk of recurrent pericarditis. Publication bias was assessed using the Egger test, and meta-regression was performed to assess sources of heterogeneity. EVIDENCE SYNTHESIS Eleven RCTs assessed the efficacy of pharmacological treatments for acute and recurrent pericarditis (colchicine and anti-interleukin-1 agents). Colchicine, assessed in nine RCTs, was effective in the reduction of recurrent pericarditis, compared with standard treatment (17% vs .34%, RR=0.50; 95% CI 0.42-0.60, P<0.001), without any differences according to clinical setting (i.e. acute pericarditis, recurrent pericarditis, post-pericardiotomy syndrome; P=0.58). Anti-interleukin-1 agents (anakinra, rilonacept), assessed in two RCT, were effective in the reduction of recurrences, compared with placebo (10% vs.78%, RR=0.14; 95% CI 0.05-0.35, P<0.001). CONCLUSIONS A correct pharmacological management of pericarditis is key to prevent recurrences. Colchicine is the mainstay of treatment in acute and recurrent pericarditis, while anti-IL1 agents are a valuable option in case of recurrent pericarditis refractory to conventional drugs.
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Affiliation(s)
- Stefano Avondo
- Department of Cardiology, Città della Salute e della Scienza, Turin, Italy
| | - Alessandro Andreis
- Department of Cardiology, Città della Salute e della Scienza, Turin, Italy
| | - Matteo Casula
- Department of Cardiology, Città della Salute e della Scienza, Turin, Italy
| | - Giuseppe Biondi-Zoccai
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University, Latina, Italy.,Mediterranea Cardiocentro, Naples, Italy
| | - Massimo Imazio
- Department of Cardiology, Città della Salute e della Scienza, Turin, Italy - .,Unit of Cardiology, Cardiothoracic Department, University Hospital "Santa Maria della Misericordia", Udine, Italy
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12
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Roy MTHM, Loh CH, Sriranganathan M, Takano Pena AM, Raghuram J. Idiopathic recurrent serositis-Off the beaten track. Respirol Case Rep 2021; 9:e0859. [PMID: 34667614 PMCID: PMC8506259 DOI: 10.1002/rcr2.859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 08/19/2021] [Accepted: 09/15/2021] [Indexed: 11/07/2022] Open
Abstract
A 63-year-old female presented with chest pain and fever, and was found to have recurrent pleuropericardial effusions. Extensive investigations including infection screen and serologies, autoimmune screen and pleural and pericardial biopsy revealed no secondary aetiologies. She was diagnosed with idiopathic recurrent serositis (IRS). Our patient developed rash to naproxen, so she was started on colchicine monotherapy and responded well clinically. A review of the literature demonstrated that pleuropericardial effusions are rare occurrences, with patients occasionally being perceived as a medical enigma. This case study recommends an approach to guide physicians in their diagnosis and management of patients with pleuropericardial syndrome. Our case had an inflammatory phenotype, either autoimmune or seronegative serositis of unclear aetiology, which was recurrent and required pharmacological treatment. While the treatment for IRS lies in combined therapy with Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) and colchicine, monotherapy with colchicine was effective in the treatment and preventing recurrence in our unique case.
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Affiliation(s)
| | - Chee Hong Loh
- Department of Respiratory and Critical Care MedicineChangi General HospitalSingapore
| | | | | | - Jagadesan Raghuram
- Department of Respiratory and Critical Care MedicineChangi General HospitalSingapore
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13
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Lazarou E, Lazaros G, Antonopoulos AS, Imazio M, Vasileiou P, Karavidas A, Toutouzas K, Vassilopoulos D, Tsioufis C, Tousoulis D, Vlachopoulos C. A risk score for pericarditis recurrence. Eur J Clin Invest 2021; 51:e13602. [PMID: 34050527 DOI: 10.1111/eci.13602] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 04/10/2021] [Accepted: 05/11/2021] [Indexed: 01/02/2023]
Abstract
BACKGROUND Currently, we remain uncertain about which patients are at increased risk for recurrent pericarditis. We developed a risk score for pericarditis recurrence in patients with acute pericarditis. MATERIALS AND METHODS We prospectively recruited 262 patients with a first episode of acute pericarditis. Baseline patients' demographics, clinical, imaging and laboratory data were collected. Patients were followed up for a median of 51 months (interquartile range 21-71) for recurrence. Variables with <10% missingness were entered into multivariable logistic regression models with stepwise elimination to explore independent predictors of recurrence. The final model performance was assessed by the c-index whereas model's calibration and optimism-corrected c-index were evaluated after 10-fold cross-validation. RESULTS We identified six independent predictors for pericarditis recurrence, that is age, effusion size, platelet count (negative predictors) and reduced inferior vena cava collapse, in-hospital use of corticosteroids and heart rate (positive predictors). The final model had good performance for recurrence, c-index 0.783 (95% CI 0.725-0.842), while the optimism-corrected c-index after cross-validation was 0.752. Based on these variables, we developed a risk score point system for recurrence (0-22 points) with equally good performance (c-index 0.740, 95% CI 0.677-0.803). Patients with a low score (0-7 points) had 21.3% risk for recurrence, while those with high score (≥12 points) had a 69.8% risk for recurrence. The score was predictive of recurrence among most patient subgroups. CONCLUSIONS A simple risk score point system based on 6 variables can be used to predict the individualized risk for pericarditis recurrence among patients with a first episode of acute pericarditis.
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Affiliation(s)
- Emilia Lazarou
- First Cardiology Department, School of Medicine, Hippokration General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - George Lazaros
- First Cardiology Department, School of Medicine, Hippokration General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Alexios S Antonopoulos
- First Cardiology Department, School of Medicine, Hippokration General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Massimo Imazio
- Cardiology, Cardiothoracic Department,, University Hospital "Santa Maria della Misericordia", Udine, Italy
| | | | - Apostolos Karavidas
- First Cardiology Department, School of Medicine, Hippokration General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos Toutouzas
- First Cardiology Department, School of Medicine, Hippokration General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Vassilopoulos
- Second Department of Medicine and Laboratory, Clinical Immunology-Rheumatology Unit, School of Medicine, Hippokration General Hospital, National and Kapodistrian University, Athens, Greece
| | - Costas Tsioufis
- First Cardiology Department, School of Medicine, Hippokration General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitris Tousoulis
- First Cardiology Department, School of Medicine, Hippokration General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Charalambos Vlachopoulos
- First Cardiology Department, School of Medicine, Hippokration General Hospital, National and Kapodistrian University of Athens, Athens, Greece
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Lo Presti S, Elajami TK, Reyaldeen R, Anthony C, Imazio M, Klein AL. Emerging Therapies for Recurrent Pericarditis: Interleukin-1 inhibitors. J Am Heart Assoc 2021; 10:e021685. [PMID: 34569270 PMCID: PMC8649126 DOI: 10.1161/jaha.121.021685] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Recurrent pericarditis (RP) is a complex inflammatory disorder associated with adverse outcomes and poor quality of life. After the first episode of acute pericarditis, a non‐negligible group of patients will fail to achieve complete remission despite treatment and will be challenged by side effects from the chronic use of medications like corticosteroids. The cause of RP remains unknown in the majority of cases, mainly due to a gap in knowledge of its complex pathophysiology. Over the past 2 decades, the interleukin‐1 (IL‐1) pathway has been uncovered as a key element in the inflammatory cascade, allowing the development of pharmacological targets known as IL‐1 inhibitors. This group of medications has emerged as a treatment option for patients with RP colchicine‐resistance and steroid dependents. Currently, anakinra and rilonacept, have demonstrated beneficial impact in clinical outcomes with a reasonable safety profile in randomized clinical trials. There is still paucity of data regarding the use of canakinumab in the treatment of patients with RP. Although further studies are needed to refine therapeutic protocols and taper of concomitant therapies, IL‐1 inhibitors, continue to consolidate as part of the pharmacological armamentarium to manage this complex condition with potential use as monotherapy. The aim of this review is to highlight the role of IL‐1 pathway in RP and discuss the efficacy, safety, and clinical applicability of IL‐1 inhibitors in the treatment of RP based on current evidence.
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Affiliation(s)
- Saberio Lo Presti
- Center for the Diagnosis and Treatment of Pericardial Diseases Section of Cardiovascular Imaging Department of Cardiovascular Medicine Heart, Vascular, and Thoracic InstituteCleveland Clinic Cleveland OH
| | - Tarec K Elajami
- Columbia University Division of CardiologyMount Sinai Heart Institute Miami Beach FL
| | - Reza Reyaldeen
- Center for the Diagnosis and Treatment of Pericardial Diseases Section of Cardiovascular Imaging Department of Cardiovascular Medicine Heart, Vascular, and Thoracic InstituteCleveland Clinic Cleveland OH
| | - Chris Anthony
- Center for the Diagnosis and Treatment of Pericardial Diseases Section of Cardiovascular Imaging Department of Cardiovascular Medicine Heart, Vascular, and Thoracic InstituteCleveland Clinic Cleveland OH
| | - Massimo Imazio
- University CardiologyA.O.U. Città della Salute e della Scienza di Torino Turin Italy
| | - Allan L Klein
- Center for the Diagnosis and Treatment of Pericardial Diseases Section of Cardiovascular Imaging Department of Cardiovascular Medicine Heart, Vascular, and Thoracic InstituteCleveland Clinic Cleveland OH
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15
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Imazio M, Andreis A, Lubian M, Lazaros G, Lazarou E, Brucato A, Adler Y, Giustetto C, Rinaldi M, De Ferrari GM. The Torino Pericarditis Score: a new-risk stratification tool to predict complicated pericarditis. Intern Emerg Med 2021; 16:1921-1926. [PMID: 34275095 DOI: 10.1007/s11739-021-02803-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 07/03/2021] [Indexed: 10/20/2022]
Abstract
Current guidelines on the management of pericardial diseases suggest to identify high-risk features associated with an increased risk of non-idiopathic aetiology and complications. The aim of this study is to evaluate a "pericarditis score" to assess potential complicated pericarditis in order to facilitate initial clinical triage. Consecutive patients with pericarditis were included in a prospective cohort study from January 2017 to December 2018. Complicated pericarditis was defined as pericarditis with a non-idiopathic aetiology, and/or complications, and/or requiring hospitalization. A clinical and echocardiographic follow-up were performed at 1, 3, 6 months and then every 6 months. The study population was randomized in derivation and validation cohorts. In the derivation cohort, female gender (HR 2.57, p = 0.016), fever > 38 °C (HR 2.86, p = 0.005), previous lack of colchicine use (HR 3.16, p = 0.006), previous use of corticosteroids (HR 3.01, p = 0.009), and echocardiographic signs of constriction (HR 2.26, p = 0.018) were selected by a stepwise procedure in a Cox regression model and constituted the score showing a C-statistics of 0.81. In the validation group, the score was significantly associated with the risk of complicated pericarditis (HR 1.438 per 10-points increase, 95% CI 1.208-1.711, p < 0.001) and showed an increase in event rate with increasing score (low risk ≤ 20 points: complicated pericarditis in 4/19 patients, incidence 21%, p = 0.003, high risk > 40 points: complicated pericarditis in 18/24 patients, incidence 75%, p = 0.006). In this study, we developed and tested a simple score to efficiently identify at presentation patients at high risk of developing complicated pericarditis.
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Affiliation(s)
- Massimo Imazio
- University Cardiology, A.O.U. Città della Salute e della Scienza di Torino, Corso Bramante 88, 10126, Turin, Italy.
| | - Alessandro Andreis
- University Cardiology, A.O.U. Città della Salute e della Scienza di Torino, Corso Bramante 88, 10126, Turin, Italy
- University Cardiac Surgery, A.O.U. Città della Salute e della Scienza di Torino, Turin, Italy
| | - Marta Lubian
- University Cardiology, A.O.U. Città della Salute e della Scienza di Torino, Corso Bramante 88, 10126, Turin, Italy
- University Cardiac Surgery, A.O.U. Città della Salute e della Scienza di Torino, Turin, Italy
| | - George Lazaros
- First Cardiology Clinic, School of Medicine, Hippokration General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Emilia Lazarou
- First Cardiology Clinic, School of Medicine, Hippokration General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Antonio Brucato
- Dipartimento Scienze Biomediche e Cliniche Luigi Sacco, ASST Fatebenefratelli-Sacco, Università degli Studi di Milano, Milan, Italy
| | - Yehuda Adler
- College of Law and Business, Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Mayanei Hayeshua Medical Center, BneiBrak, Israel
| | - Carla Giustetto
- University Cardiology, A.O.U. Città della Salute e della Scienza di Torino, Corso Bramante 88, 10126, Turin, Italy
| | - Mauro Rinaldi
- University Cardiac Surgery, A.O.U. Città della Salute e della Scienza di Torino, Turin, Italy
| | - Gaetano Maria De Ferrari
- University Cardiology, A.O.U. Città della Salute e della Scienza di Torino, Corso Bramante 88, 10126, Turin, Italy
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16
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Disease and Economic Burden Associated with Recurrent Pericarditis in a Privately Insured United States Population. Adv Ther 2021; 38:5127-5143. [PMID: 34417724 PMCID: PMC8478772 DOI: 10.1007/s12325-021-01868-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 07/19/2021] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Approximately 30% of patients with a first acute pericarditis episode experience a recurrence ≤ 18 months; ~ 15% experience multiple recurrences. This study assessed the recurrence and economic burden among patients with multiple recurrences. METHODS Adults with idiopathic pericarditis were identified in the OptumHealth Care Solutions, Inc., database (2007-2017). Recurrent pericarditis (RP) was defined as ≥ 2 episodes of care separated by > 28 days; multiple recurrences were defined as ≥ 2 recurrences. RESULTS Among 944 patients with RP, 375 (39.7%) experienced multiple recurrences and were propensity score-matched 1:1 to 375 patients without recurrence. Among patients with multiple recurrences, median disease duration (time from first episode to end of last recurrence, confirmed by a 1.5-year recurrence-free period) was 2.84 years. The multiple recurrences cohort had higher rates of hospitalizations per-patient-per-month (PPPM) than the no recurrence cohort (rate ratio [95% confidence interval (CI)] = 2.22 [1.35-3.65]). Mean total healthcare costs were significantly higher in the multiple recurrences versus no recurrence cohort ($2728 vs. $1568 PPPM, cost ratio [95% CI] = 1.74 [1.29-2.32]), mainly driven by higher hospitalization costs in the multiple recurrences cohort (mean: $1180 vs. $420 PPPM, cost ratio [95% CI] = 2.81 [1.80-4.66]). Mean work loss costs were higher in the multiple recurrences versus no recurrence cohort ($696 vs. $169 PPPM, cost ratio [95% CI] = 4.12 [1.64-9.61]). In patients with multiple recurrences, mean cost of the first episode was $19,189; subsequent recurrences ranged from $2089 to $7366 (second recurrence = $6222). CONCLUSION In conclusion, among patients with multiple pericarditis recurrences, disease symptoms persisted several years, and healthcare and work loss costs were further compounded in this subset of patients.
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17
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Characterization of Pericarditis following Allogeneic Hematopoietic Cell Transplantation. Transplant Cell Ther 2021; 27:934.e1-934.e6. [PMID: 34339867 DOI: 10.1016/j.jtct.2021.07.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 07/17/2021] [Accepted: 07/25/2021] [Indexed: 11/23/2022]
Abstract
Pericarditis is an uncommon cardiac complication following allogeneic hematopoietic cell transplantation (alloHCT), with limited data characterizing its incidence, presentation, and management. The etiology of pericarditis in this setting is poorly understood and may include conditioning-related toxicity, infection, or graft-versus-host disease (GVHD). The objective of the present study was to characterize the clinical presentation, management, and outcomes of post-alloHCT pericarditis observed at a single center. This retrospective case-control study of consecutive adults undergoing alloHCT over 5 years was conducted to identify patients who developed pericarditis. Pericarditis was diagnosed using clinical, electrocardiography, and echocardiography findings. Identified cases were compared with a cohort of patients who underwent alloHCT during the same period but did not develop pericarditis. A total of 620 patients underwent alloHCT over the 5-year period, 20 of whom developed pericarditis (3.2% incidence). One patient had a pre-alloHCT history of pericarditis. All but 3 patients had received anthracycline therapy and 1 patient had received chest irradiation before undergoing alloHCT. Patients with pericarditis were more likely than patients without pericarditis to have received total body irradiation (odds ratio [OR], 4.57; P = .003) or cyclophosphamide (OR, 2.35; P = .07) as conditioning or GVHD prophylaxis. Fourteen patients experienced their initial episode of pericarditis before day +100 post-alloHCT, with a median time to onset at day +7. Six patients had their initial episode on day +100 or later, with a median time to onset at day +268. Only 1 patient had active, previously diagnosed GVHD, and 3 patients were on systemic steroid therapy at the time of pericarditis diagnosis. Pericarditis was treated primarily with colchicine (median duration 91 days). Seven episodes of recurrence occurred in 5 patients. Two patients experienced cardiac tamponade following their initial diagnosis, and 3 developed tamponade at recurrence. Recurrence was more common in patients who received no or <90 days of colchicine compared with those who received ≥90 days (45.5% vs 0%; P = .02). No cardiac-related deaths occurred. Overall survival was 85% at a median follow-up of 30 months post-alloHCT. Pericarditis occurred in 3.2% of patients in this single-center study, with cases observed both before and after day +100 and some cases occurring ≥1 year after alloHCT. Colchicine was an effective intervention, with ≥90 days of treatment associated with reduced recurrence. Pericarditis should be considered in patients presenting with chest pain following alloHCT.
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18
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Presti SL, Elajami TK, Reyaldeen R, Anthony C, Klein AL. The Role of Rilonacept in Recurrent Pericarditis. Heart Int 2021; 15:20-25. [PMID: 36277322 PMCID: PMC9524724 DOI: 10.17925/hi.2021.15.1.20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 03/09/2021] [Indexed: 08/29/2023] Open
Abstract
Recurrent pericarditis is associated with significant morbidity and adverse impact on quality of life. Contemporary studies have emphasized the key role of autoinflammatory pathways in its pathophysiology, mainly through the activation of inflammasomes and the production of interleukin (IL)-1α and IL-1β. The IL-1 pathway has emerged as a promising target for the treatment of these patients. A novel IL-1 inhibitor, rilonacept, functions as an IL-1 trap binding to the circulating IL-1α and IL-1β mitigating their inflammatory response. Recently, the RHAPSODY phase III clinical trial evaluated the use of rilonacept in patients with recurrent pericarditis, who were refractory to colchicine, or steroid-dependent. Rilonacept significantly reduced symptoms, inflammatory markers and recurrent episodes, and increased successful withdrawal of steroids. The safety profile of the medication is favourable and well tolerated by patients, with local injection site reaction being the most common side effect described. These results have shifted the paradigm of the understanding of the disease and promise to become part of the armamentarium of medications for the standard of care of these patients, with potential use as monotherapy. The changing landscape of therapeutics and pathophysiology warrants increased recognition and understanding from the international cardiology community about this novel drug and its implication in managing these complex patients.The objective of this review is to describe the bio-action of rilonacept in the treatment of recurrent pericarditis.
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Affiliation(s)
- Saberio Lo Presti
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Tarec K Elajami
- Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami Beach, FL, USA
| | - Reza Reyaldeen
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Chris Anthony
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Allan L Klein
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
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19
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Gong J, Drobni ZD, Zafar A, Quinaglia T, Hartmann S, Gilman HK, Raghu VK, Gongora C, Sise ME, Alvi RM, Zubiri L, Nohria A, Sullivan R, Reynolds KL, Zlotoff D, Neilan TG. Pericardial disease in patients treated with immune checkpoint inhibitors. J Immunother Cancer 2021; 9:jitc-2021-002771. [PMID: 34145031 PMCID: PMC8215235 DOI: 10.1136/jitc-2021-002771] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2021] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND There are limited data on the occurrence, associations and outcomes of pericardial effusions and pericarditis on or after treatment with immune checkpoint inhibitors (ICIs). METHODS This was a retrospective study at a single academic center that compared 2842 consecutive patients who received ICIs with 2699 age- and cancer-type matched patients with metastatic disease who did not receive ICI. A pericardial event was defined as a composite outcome of pericarditis and new or worsening moderate or large pericardial effusion. The endpoints were obtained through chart review and were blindly adjudicated. To identify risk factors associated with a pericardial event, we compared patients who developed an event on an ICI with patients treated with an ICI who did not develop a pericardial event. Cox proportional-hazard model and logistical regression analysis were performed to study the association between ICI use and pericardial disease as well as pericardial disease and mortality. An additional 6-week landmark analysis was performed to account for lead-time bias. RESULTS There were 42 pericardial events in the patients treated with ICI (n=2842) over 193 days (IQR: 64-411), yielding an incidence rate of 1.57 events per 100 person-years. There was a more than fourfold increase in risk of pericarditis or a pericardial effusion among patients on an ICI compared with controls not treated with ICI after adjusting for potential confounders (HR 4.37, 95% CI 2.09 to 9.14, p<0.001). Patients who developed pericardial disease while on an ICI had a trend for increased all-cause mortality compared with patients who did not develop a pericardial event (HR 1.53, 95% CI 0.99 to 2.36, p=0.05). When comparing those who developed pericardial disease after ICI treatment with those who did not, a higher dose of corticosteroid pre-ICI (>0.7 mg/kg prednisone) was associated with increased risk of pericardial disease (HR 2.56, 95% CI 1.00 to 6.57, p=0.049). CONCLUSIONS ICI use was associated with an increased risk of development of pericardial disease among patients with cancer and a pericardial event on an ICI was associated with a trend towards increase in mortality.
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Affiliation(s)
- Jingyi Gong
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Zsofia Dora Drobni
- Cardiovascular Imaging Research Center (CIRC), Department of Radiology and Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Amna Zafar
- Cardiovascular Imaging Research Center (CIRC), Department of Radiology and Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Thiago Quinaglia
- Cardiovascular Imaging Research Center (CIRC), Department of Radiology and Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sarah Hartmann
- Cardiovascular Imaging Research Center (CIRC), Department of Radiology and Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Hannah K Gilman
- Cardiovascular Imaging Research Center (CIRC), Department of Radiology and Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Vineet K Raghu
- Cardiovascular Imaging Research Center (CIRC), Department of Radiology and Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Carlos Gongora
- Cardiovascular Imaging Research Center (CIRC), Department of Radiology and Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Meghan E Sise
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Raza M Alvi
- Cardiovascular Imaging Research Center (CIRC), Department of Radiology and Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Leyre Zubiri
- Division of Oncology and Hematology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Anju Nohria
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Ryan Sullivan
- Division of Oncology and Hematology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kerry L Reynolds
- Division of Oncology and Hematology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Daniel Zlotoff
- Cardiovascular Imaging Research Center (CIRC), Department of Radiology and Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Tomas G Neilan
- Cardiovascular Imaging Research Center (CIRC), Department of Radiology and Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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20
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Abstract
Acute pericarditis accounts for ∼5% of presentations with acute chest pain. Tuberculosis is an important cause in the developing world, however, in the UK and other developed settings, most cases are idiopathic/viral in origin. Non-steroidal anti-inflammatory drugs (NSAIDs) remain the cornerstone of treatment. At least one in four patients are at risk of recurrence. The addition of 3 months of colchicine can more than halve the risk of this (number needed to treat = four). Low-dose steroids can be helpful second-line agents for managing recurrences as adjuncts to NSAIDs and colchicine but should not be used as first-line agents. For patients failing this approach and/or dependent on corticosteroids, the interleukin-1β antagonist anakinra is a promising option, and for the few patients who are refractory to medical therapy, surgical pericardiectomy can be considered. The long-term prognosis is good with <0.5% risk of constriction for patients with idiopathic acute pericarditis.
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Affiliation(s)
- Tevfik F Ismail
- King's College London and Guy's and St Thomas' NHS Foundation Trust, London, UK
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21
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Lazaros G, Antonopoulos AS, Lazarou E, Vlachopoulos C, Vogiatzi G, Vassilopoulos D, Tousoulis D. Age- and sex-based differences in patients with acute pericarditis. Eur J Clin Invest 2021; 51:e13392. [PMID: 32857868 DOI: 10.1111/eci.13392] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 08/18/2020] [Accepted: 08/20/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Acute pericarditis has a wide spectrum of clinical presentations largely depending on underlying aetiologies. We assessed the role of age and sex in the clinical features and outcome of acute pericarditis. MATERIALS AND METHODS A total of 240 consecutive patients hospitalized with a first episode of acute pericarditis were included. At baseline demographics, clinical features, laboratory and imaging findings and medical therapy were recorded. Patients were followed up for at least 18 months for complications. Data comparisons were performed according to sex and age (≤60 or >60 years). RESULTS The male/female ratio was 1.42, and 56% of patients were >60 years. Younger patients depicted more often chest pain (P = .001), fever and rubs (P < .001 for both), ST elevation and PR depression (P = .032 and .009, respectively), higher CRP values (P = .009) and less often dyspnoea (P = .046) and pericardial effusion (P = .036). Moreover, they received less often glucocorticoids (P < .001) and depicted less atrial fibrillation (P = .003) and a higher rate of recurrent pericarditis (P = .013). After multivariate adjustment for confounders, age >60 years remained an independent predictor for a lower risk of recurrent pericarditis (hazard ratio 0.60, 95% CI: 0.39-0.96, P = .033). Regarding sex, females were older (P = .007), showed less often ST elevation and PR depression (P < .001 and .002, respectively) and had a higher baseline heart rate (P = .02). Sex was not associated with recurrent pericarditis risk. CONCLUSIONS Patients with acute pericarditis have distinct presenting clinical, biochemical and prognostic features according to age and sex. Awareness of such differences is important for clinical decision-making.
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Affiliation(s)
- George Lazaros
- 1st Cardiology Clinic, School of Medicine, Hippokration General Hospital Athens, National and Kapodistrian University of Athens, Athens, Greece
| | - Alexios S Antonopoulos
- 1st Cardiology Clinic, School of Medicine, Hippokration General Hospital Athens, National and Kapodistrian University of Athens, Athens, Greece
| | - Emilia Lazarou
- 1st Cardiology Clinic, School of Medicine, Hippokration General Hospital Athens, National and Kapodistrian University of Athens, Athens, Greece
| | - Charalambos Vlachopoulos
- 1st Cardiology Clinic, School of Medicine, Hippokration General Hospital Athens, National and Kapodistrian University of Athens, Athens, Greece
| | - Georgia Vogiatzi
- 1st Cardiology Clinic, School of Medicine, Hippokration General Hospital Athens, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Vassilopoulos
- 2nd Department of Medicine and Laboratory, Clinhical Immunology-Rheumatology Unit, School of Medicine, Hippokration General Hospital Athens, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitris Tousoulis
- 1st Cardiology Clinic, School of Medicine, Hippokration General Hospital Athens, National and Kapodistrian University of Athens, Athens, Greece
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22
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Huang YS, Zhang JX, Sun Y. Chronic massive pericardial effusion: a case report and literature review. J Int Med Res 2020; 48:300060520973091. [PMID: 33233991 PMCID: PMC7705390 DOI: 10.1177/0300060520973091] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Chronic massive pericardial effusion without cardiac tamponade is relatively rare. Nearly half of all patients with chronic large pericardial effusion are asymptomatic. We report a case of a 77-year-old man who presented with an asymptomatic chronic massive pericardial effusion, with no evidence of cardiac tamponade or pericardial constriction during a 10-year follow-up. The patient had a complex history of lymph node tuberculosis, hypertension, hypothyroidism, and polycythemia vera, as well as high-dose 31P radiation exposure 45 years ago. There was no evidence of tuberculosis infection, hypothyroidism, malignant tumor, severe heart failure, uremia, trauma, severe bacterial or fungal infection, chronic myeloid leukemia, or bone marrow fibrosis after admission. The patient underwent pericardiocentesis twice. The pericardial effusion comprised exudate fluid with a high proportion of monocytes. The patient refused indwelling catheter drainage or pericardiectomy. The likely final diagnosis was recurrent chronic large idiopathic pericardial effusion.
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Affiliation(s)
- Ying-Shuo Huang
- Department of Research Ward, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Jian-Xiong Zhang
- Department of Research Ward, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Ying Sun
- Department of Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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23
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Klein AL, Lin D, Cremer PC, Nasir S, Luis SA, Abbate A, Ertel A, LeWinter M, Beutler A, Fang F, Paolini JF. Efficacy and safety of rilonacept for recurrent pericarditis: results from a phase II clinical trial. Heart 2020; 107:heartjnl-2020-317928. [PMID: 33229362 PMCID: PMC7925818 DOI: 10.1136/heartjnl-2020-317928] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 10/20/2020] [Accepted: 10/26/2020] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE Recurrent pericarditis (RP) incurs significant morbidity. Rilonacept inhibits both interleukin-1 alpha (IL-1α) and IL-1β; these cytokines are thought to play a major role in RP. This phase II study evaluated rilonacept efficacy and safety in RP. METHODS This multicentre, open-label study enrolled adult patients with idiopathic or postpericardiotomy RP, symptomatic (≥2 pericarditis recurrences) or corticosteroid (CS) dependent (≥2 recurrences prior).Patients received rilonacept 320 mg SC load/160 mg SC weekly maintenance in a 6-week base treatment period (TP) followed by an optional 18-week on-treatment extension period (EP) (option to wean background therapy). RESULTS Outcomes: pericarditis pain (numeric rating scale (NRS)) and inflammation (C reactive protein (CRP)) for symptomatic patients; disease activity after CS taper for CS-dependent patients. SECONDARY OUTCOMES health-related quality of life (HRQOL), pericarditis manifestations and additional medications. 25 unique patients enrolled, while 23 completed the EP (seven colchicine failures and five CS failures). In symptomatic patients, NRS and CRP decreased; response was observed after first rilonacept dose. NRS decreased from 4.5 at baseline to 0.7, and CRP decreased from 4.62 mg/dL at baseline to 0.38 mg/dL at end of TP. Median time to CRP normalisation: 9 days. Pericarditis manifestations resolved. 13 patients on CS at baseline completed the EP; 11 (84.6%) discontinued CS, and 2 tapered; CRP and NRS remained low without recurrence. Mean HRQOL scores improved in symptomatic patients. One serious adverse event (SAE) resulted in discontinuation of rilonacept. CONCLUSIONS Rilonacept led to rapid and sustained improvement in pain, inflammation (CRP and pericarditis manifestations) and HRQOL. CSs were successfully tapered or discontinued; safety was consistent with known rilonacept safety profile. TRIAL REGISTRATION NUMBER NCT03980522.
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Affiliation(s)
- Allan L Klein
- 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, Ohio, USA
| | - David Lin
- The Minneapolis HeartInstitute, Abbott Northwestern Hospital, Minneapolis, Minnesota, 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, Ohio, USA
| | | | - Sushil Allen Luis
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine, Rochester, Minnesota, USA
| | - Antonio Abbate
- Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Andrew Ertel
- Heart and Vascular Institute, Medstar Washington Hospital Center, Washington, DC, USA
| | - Martin LeWinter
- Cardiology Unit, University of Vermont Medical Center, Burlington, Vermont, USA
| | | | - Fang Fang
- Kiniksa Pharmaceuticals Corp, Lexington, Massachusetts, USA
| | - John F Paolini
- Kiniksa Pharmaceuticals Corp, Lexington, Massachusetts, USA
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Abstract
Postpericardiotomy syndrome (PPS) is a well-known complication after cardiac surgery. The syndrome results in prolonged hospital stay, readmissions, and invasive interventions. Previous studies have reported inconsistent results concerning the incidence and risk factors for PPS due to the differences in the applied diagnostic criteria, study designs, patient populations, and procedure types. In recent prospective studies the reported incidences have been between 21 and 29% in adult cardiac surgery patients. However, it has been stated that most of the included diagnoses in the aforementioned studies would be clinically irrelevant. This challenges the specificity and usability of the currently recommended diagnostic criteria for PPS. Moreover, recent evidence suggests that PPS requiring invasive intervention such as the evacuation of pleural and/or pericardial effusion is associated with increased mortality. In the present review, we summarise the existing literature concerning the incidence, clinical features, diagnostic criteria, risk factors, management, and prognosis of PPS. We also propose novel approaches regarding to the definition and diagnosis of PPS. Key messages: Current diagnostic criteria of PPS should be reconsidered, and the analyses should be divided into subgroups according to the severity of the syndrome to achieve more clinically applicable and meaningful results in the future studies. In contrast with the previous presumption, severe PPS - defined as PPS requiring invasive interventions - was recently found to be associated with higher all-cause mortality during the first two years after cardiac surgery. The association with an increased mortality supports the use of relatively aggressive prophylactic methods to prevent PPS. The risk factors clearly increasing the occurrence of PPS are younger age, pleural incision, and valve and ascending aortic procedures when compared to CABG.
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Affiliation(s)
- Joonas Lehto
- Heart Center, Turku University Hospital, University of Turku, Turku, Finland
| | - Tuomas Kiviniemi
- Heart Center, Turku University Hospital, University of Turku, Turku, Finland.,Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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25
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Abstract
Abstract Recent advances have shown impressive results by anti-interleukin 1 (IL-1) agents in refractory idiopathic recurrent pericarditis. Purpose of Review We critically discuss the current state of the art of therapy of relapsing pericarditis, with a focus on new pharmacological approaches and on specific clinical settings such as pregnancy, pediatric patients, and secondary forms of relapsing pericarditis. Recent Findings Antagonism of the IL-1 is highly effective in idiopathic recurrent pericarditis with autoinflammatory features. Currently, available anti-IL-1 agents are anakinra and canakinumab. Rilonacept is another IL-1 antagonist, currently studied in the phase-3 clinical trial RHAPSODY. Available data suggest similar efficacy and safety profiles of these three agents, although only anakinra has been tested in randomized clinical trials. These agents have slightly different pharmacological properties, being canakinumab a specific IL-1ß antagonist while anakinra and rilonacept are unselective IL-1α and IL-1ß blockers. To date, there is no evidence that specificity against IL-1ß affects safety and efficacy in patients with relapsing pericarditis, although it has been proposed that unspecific blockage might be useful in severe disease. Summary Anakinra is the first anti-IL-1 agent with well-documented efficacy and safety in adult and pediatric patients with idiopathic relapsing pericarditis. Other anti-IL-1 agents are currently under study. Future research should clarify the optimal duration of therapy and tapering schedule of treatment with these agents. Moreover, biomarkers would be required to understand which patients will benefit from early administration of IL-1 blockers due to refractoriness to conventional therapy and which others will suffer from recurrences during the tapering of these agents. Lastly, future studies should focus on the subjects with the autoimmune or the pauci-inflammatory phenotype of idiopathic refractory pericarditis.
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26
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Cacoub P, Marques C. Acute recurrent pericarditis: from pathophysiology towards new treatment strategy. Heart 2020; 106:1046-1051. [PMID: 32238419 DOI: 10.1136/heartjnl-2019-316481] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 02/12/2020] [Accepted: 03/13/2020] [Indexed: 12/22/2022] Open
Abstract
Acute idiopathic or so-called viral pericarditis is a frequent and usually benign disease, although recurrences are frequent. Data strongly suggest the presence of underlying autoinflammatory and/or autoimmune disorders. It has been reported that there is an inflammatory response of the innate immune system typical of 'autoinflammatory diseases', predominantly mediated by interleukin-1 (IL-1). This may result from the activation of the inflammasome by a cardiotropic virus or a non-specific agent. The inflammatory response of the adaptive immune system, typical of 'autoimmune diseases'-mainly mediated by autoantibodies or autoreactive T lymphocytes-seems also involved as anti-heart or anti-intercalated disk autoantibodies were associated with a higher number of recurrences and hospitalisations. Current guidelines recommend that aspirin/non-steroidal anti-inflammatory drugs for a few weeks should be associated to colchicine for 6 months in recurrent pericarditis. In refractory cases, low-dose corticosteroids or immunosuppressive drugs have been proposed with limited efficacy. Growing evidences suggest a place of IL-1 receptor antagonists in the treatment of recurrent pericarditis. Many retrospective studies, one recent randomised placebo-controlled study and data of a real-life large international registry showed the good efficacy of anakinra with a good safety profile. Other IL-1 receptor antagonists showed promising results (canakinumab, rilonacept). However, IL-1 receptor antagonists' position in the treatment algorithm of recurrent pericarditis needs further evaluation in larger prospective clinical trials to replicate initial findings as well as to assess safety, cost-effectiveness and long-term efficacy.
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Affiliation(s)
- Patrice Cacoub
- Department of Internal Medicine and Clinial Immunology, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Department of Internal Medicine, Paris, France .,Département Hospitalo-Universitaire I2, Sorbonne Université, UPMC Univ Paris 06, Paris, France.,CNRS, UMR 7211, Paris, France.,INSERM, UMR_S 959, F-75013, Paris, France
| | - Cindy Marques
- Department of Internal Medicine and Clinial Immunology, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Department of Internal Medicine, Paris, France.,Département Hospitalo-Universitaire I2, Sorbonne Université, UPMC Univ Paris 06, Paris, France.,CNRS, UMR 7211, Paris, France.,INSERM, UMR_S 959, F-75013, Paris, France
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27
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Management of Acute Idiopathic (Viral) Pericarditis in the Emergency Department. Adv Emerg Nurs J 2020; 42:17-29. [DOI: 10.1097/tme.0000000000000284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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28
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Lazaros G, Antonopoulos AS, Vlachopoulos C, Oikonomou E, Karavidas A, Chrysochoou C, Lazarou E, Vassilopoulos D, Imazio M, Tousoulis D. Predictors of switching from nonsteroidal anti-inflammatory drugs to corticosteroids in patients with acute pericarditis and impact on clinical outcome. Hellenic J Cardiol 2019; 60:357-363. [DOI: 10.1016/j.hjc.2018.04.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 04/16/2018] [Indexed: 10/17/2022] Open
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29
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Shin JH, Lee DH, Choi HJ. Colchicine for steroid-resistant recurrent pericarditis in a child. Yeungnam Univ J Med 2019; 35:222-226. [PMID: 31620598 PMCID: PMC6784700 DOI: 10.12701/yujm.2018.35.2.222] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 01/04/2018] [Accepted: 01/17/2018] [Indexed: 12/25/2022] Open
Abstract
Recurrent pericarditis is rare in children and is considered idiopathic in most cases. Its course is chronic, and preventing recurrences is important for the patient's quality of life. Although a treatment strategy in pediatric recurrent pericarditis has not yet been established, non-steroidal anti-inflammatory drugs (NSAIDs) are the most common treatment for management of this condition, followed by corticosteroids, colchicine, immunosuppressive agents, immunoglobulins, and interleukin-1β receptor antagonists (e.g. anakinra). Herein, we report a case of recurrent pericarditis with pericardial effusion in a 5-year-old child who presented with fever and epigastric pain. He responded poorly to NSAIDs and corticosteroid therapy, but was successfully treated with colchicine.
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Affiliation(s)
- Ju Hee Shin
- Department of Pediatrics, Keimyung University School of Medicine, Daegu, Korea
| | - Dong Hyun Lee
- Department of Pediatrics, Keimyung University School of Medicine, Daegu, Korea
| | - Hee Joung Choi
- Department of Pediatrics, Keimyung University School of Medicine, Daegu, Korea
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30
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Vukomanovic V, Prijic S, Krasic S, Borovic R, Ninic S, Nesic D, Bjelakovic B, Popovic S, Stajević M, Petrović G. Does Colchicine Substitute Corticosteroids in Treatment of Idiopathic and Viral Pediatric Pericarditis? MEDICINA-LITHUANIA 2019; 55:medicina55100609. [PMID: 31547038 PMCID: PMC6843123 DOI: 10.3390/medicina55100609] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 09/07/2019] [Accepted: 09/16/2019] [Indexed: 12/12/2022]
Abstract
Background and Objectives: Recurrence of pericarditis (ROP) is an important complication of the acute pericarditis. The aim of this study was to analyse the influence of aetiology, clinical findings and treatment on the outcome of acute pericarditis. Methods: Data were retrospectively collected from medical records of patients treated from 2011 to 2019 at a tertiary referent heart paediatric center. Results: Our investigation included 56 children with idiopathic and viral pericarditis. Relapse was registered in 8/56 patients, 2/29 (7.41%) treated with nonsteroidal anti-inflammatory drugs (NSAID) and 6/27 (28.57%) treated with corticosteroids (CS) and NSAID. Independent risk factors for ROP were viral pericarditis (p = 0.01, OR 31.46), lack of myocardial affection (p = 0.03, OR 29.15), CS use (p = 0.02, OR 29.02) and ESR ≥ 50 mm/h (p = 0.03, OR 25.23). In 4/8 patients the first recurrence was treated with NSAID and colchicine, while treatment of 4/8 patients included CS. Children with ROP treated with CS had higher median number of recurrence (5, IQR: 2–15) than those treated with colchicine (0, IQR: 0–0.75). Conclusions: Independent risk factors for recurrence are CS treatment, viral aetiology, pericarditis only and ESR ≥ 50 mm/h. Acute pericarditis should be treated with NSAID. Colchicine and NSAID might be recommended in children with the first ROP.
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Affiliation(s)
- Vladislav Vukomanovic
- Cardiology Department, Mother and Child Health Care Institute of Serbia "Dr.Vukan Cupic", 11070 Belgrade, Serbia.
- School of Medicine, University of Belgrade, 11000 Belgrade, Serbia.
| | - Sergej Prijic
- Cardiology Department, Mother and Child Health Care Institute of Serbia "Dr.Vukan Cupic", 11070 Belgrade, Serbia.
- School of Medicine, University of Belgrade, 11000 Belgrade, Serbia.
| | - Stasa Krasic
- Cardiology Department, Mother and Child Health Care Institute of Serbia "Dr.Vukan Cupic", 11070 Belgrade, Serbia.
| | - Ruzica Borovic
- Pediatrics Department, Hospital "Sveti Vracevi", 76300 Bijeljina, Bosnia and Herzegovina.
| | - Sanja Ninic
- Cardiology Department, Mother and Child Health Care Institute of Serbia "Dr.Vukan Cupic", 11070 Belgrade, Serbia.
| | - Dejan Nesic
- School of Medicine, University of Belgrade, 11000 Belgrade, Serbia.
- Institute of Medical Physiology "Rihard Burian", 11000 Belgrade, Serbia.
| | - Bojko Bjelakovic
- Clinic of Pediatrics, Clinical Center Nis, School of Medicine, University of Nis, 18000 Nis, Serbia.
| | - Sasa Popovic
- Cardiology Department, Mother and Child Health Care Institute of Serbia "Dr.Vukan Cupic", 11070 Belgrade, Serbia.
| | - Mila Stajević
- School of Medicine, University of Belgrade, 11000 Belgrade, Serbia.
- Cardiac Surgery Department, Mother and Child Health Care Institute of Serbia "Dr.Vukan Cupic", 11070 Belgrade, Serbia.
| | - Gordana Petrović
- Immunology Department, Mother and Child Health Care Institute of Serbia "Dr.Vukan Cupic", 11070 Belgrade, Serbia.
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31
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Chhabra L, Spodick DH. ¿Es hora de revertir el paradigma en el tratamiento de la pericarditis aguda idiopática? Rev Esp Cardiol (Engl Ed) 2019. [DOI: 10.1016/j.recesp.2019.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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32
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Chhabra L, Spodick DH. Is It Time for a "Reverse Paradigm Shift" in the Treatment of Acute Idiopathic Pericarditis? REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2019; 72:703-704. [PMID: 30948264 DOI: 10.1016/j.rec.2019.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 02/26/2019] [Indexed: 06/09/2023]
Affiliation(s)
- Lovely Chhabra
- Department of Cardiology, Heartland Regional Medical Center, Marion, IL, United States.
| | - David H Spodick
- Department of Medicine, Saint Vincent Hospital, Worcester, MA, United States
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33
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Peiffer-Smadja N, Domont F, Saadoun D, Cacoub P. Corticosteroids and immunosuppressive agents for idiopathic recurrent pericarditis. Autoimmun Rev 2019; 18:621-626. [DOI: 10.1016/j.autrev.2019.04.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Indexed: 12/20/2022]
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34
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Tombetti E, Giani T, Brucato A, Cimaz R. Recurrent Pericarditis in Children and Adolescents. Front Pediatr 2019; 7:419. [PMID: 31681717 PMCID: PMC6813188 DOI: 10.3389/fped.2019.00419] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 10/02/2019] [Indexed: 12/13/2022] Open
Abstract
Recurrent pericarditis (RP) is a clinical syndrome characterized by recurrent attacks of acute pericardial inflammation. Prognosis quoad vitam is good, although morbidity might be significant, especially in children and adolescents. Multiple potential etiologies result in RP, in the vast majority of cases through autoimmune or autoinflammatory mechanisms. Idiopathic RP is one of the most frequent diagnoses, that requires the exclusion of all known etiologies. Therapeutic advances in the last decade have been significant with the recognition of the effectiveness of anti IL1 therapy, but a correct diagnostic and therapeutic algorithm is of key importance. Unfortunately, most of evidence comes from studies in adult patients. Here we review the etiopathogenesis, diagnosis and management of RP in pediatric patients.
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Affiliation(s)
- Enrico Tombetti
- Department of Medicine, Azienda Socio Sanitaria Territoriale (ASST) Fetebenefratelli-Sacco and Department of "Biomedical and Clinical Sciences Luigi Sacco", Milan University, Milan, Italy
| | - Teresa Giani
- Rheumatology Unit, Department of Pediatrics, Anna Meyer Children's Hospital, University of Florence, Florence, Italy.,Department of Medical Biotechnology, University of Siena, Siena, Italy
| | - Antonio Brucato
- Department of Medicine, Azienda Socio Sanitaria Territoriale (ASST) Fetebenefratelli-Sacco and Department of "Biomedical and Clinical Sciences Luigi Sacco", Milan University, Milan, Italy
| | - Rolando Cimaz
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,Azienda Socio Sanitaria Territoriale (ASST) G.Pini, Milan, Italy
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35
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Guía de práctica clínica para el manejo del lupus eritematoso sistémico propuesta por el Colegio Mexicano de Reumatología. ACTA ACUST UNITED AC 2019; 15:3-20. [DOI: 10.1016/j.reuma.2018.03.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 03/20/2018] [Accepted: 03/21/2018] [Indexed: 12/31/2022]
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36
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Bonaventura A, Montecucco F. Inflammation and pericarditis: Are neutrophils actors behind the scenes? J Cell Physiol 2018; 234:5390-5398. [PMID: 30417336 DOI: 10.1002/jcp.27436] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 08/28/2018] [Indexed: 12/11/2022]
Abstract
The morbidity of acute pericarditis is increasing over time impacting on patient quality of life. Recent clinical trials focused especially on clinical aspects, with a modest interest in pathophysiological mechanisms. This narrative review, based on papers in English language obtained via PubMed up to April 2018, aims at focusing on the role of the innate immunity in pericarditis and discussing future potential therapeutic strategies impacting on disease pathophysiology. In developed countries, most cases of pericarditis are referred to as idiopathic, although etiological causes have been described, with autoreactive/lymphocytic, malignant, and infectious ones as the most frequent causes. Apart the known impairment of the adaptive immunity, recently a large body evidence indicated the central role of the innate immune system in the pathogenesis of recurrent pericarditis, starting from similarities with autoinflammatory diseases. Accordingly, the "inflammasome" has been shown to behave as an important player in pericarditis development. Similarly, the beneficial effect of colchicine in recurrent pericarditis confirms that neutrophils are important effectors as colchicine, which can block neutrophil chemotaxis, interferes with neutrophil adhesion and recruitment to injured tissues and abrogate superoxide production. Anyway, the role of the adaptive immune system in pericarditis cannot be reduced to a black or white issue as mechanisms often overlap. Therefore, we believe that more efficient therapeutic strategies have to be investigated by targeting neutrophil-derived mediators (such as metalloproteinases) and disentangling the strict interplay between neutrophils and platelets. In this view, some progress has been done by using the recombinant human interleukin-1 receptor antagonist anakinra.
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Affiliation(s)
- Aldo Bonaventura
- Department of Internal Medicine, First Clinic of Internal Medicine, University of Genoa, Genoa, Italy
| | - Fabrizio Montecucco
- Department of Internal Medicine, First Clinic of Internal Medicine, University of Genoa, Genoa, Italy
- Ospedale Policlinico San Martino, Genoa, Italy
- Centre of Excellence for Biomedical Research (CEBR), University of Genoa, Genoa, Italy
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37
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Gerardin C, Mageau A, Benali K, Jouan F, Ducrocq G, Alexandra JF, van Gysel D, Papo T, Sacre K. Increased FDG-PET/CT pericardial uptake identifies acute pericarditis patients at high risk for relapse. Int J Cardiol 2018; 271:192-194. [PMID: 29884293 DOI: 10.1016/j.ijcard.2018.05.126] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 05/19/2018] [Accepted: 05/30/2018] [Indexed: 02/07/2023]
Abstract
OBJECTIVES We aimed to evaluate the prognostic value of FDG pericardial uptake using FDG-PET/CT in patients admitted for acute pericarditis with pericardial effusion. METHODS In this monocentric retrospective cohort study, all patients admitted for idiopathic acute pericarditis with pericardial effusion from January 2009 to December 2016 who underwent a FDG-PET/CT at diagnosis were considered. Pericardial FDG uptake was measured by generating a volume of interest to calculate the maximal standardized uptake value. The primary outcome was the pericarditis relapse rate during follow-up. RESULTS FDG-PET/CT was performed 23 [7-99] days after diagnosis in 39 patients (52 [18-83] years, 43.6% of women) admitted for acute pericarditis with pericardial effusion. During a median follow-up period of 7.6 [2.4-77.2] months, 7 (17.9%) patients suffered pericarditis relapse that occurred 3.8 [1.6-14.6] months after FDG-PET CT. In the multivariable analysis, pericardial FDG uptake at diagnosis (OR: 16.6; 95% confidence interval [CI]: 1.25 to 220.8; p = 0.033) was independently associated with pericarditis relapse. Eventually, patients with pericardial FDG uptake at diagnosis had a higher recurrence rate during follow up (p = 0.047). CONCLUSIONS In acute pericarditis with pericardial effusion, increased FDG-PET/CT pericardial uptake is associated with a higher risk for relapse.
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Affiliation(s)
- Christel Gerardin
- Département de Médecine Interne, Hôpital Bichat, Université Paris Diderot, PRES Sorbonne Paris Cité, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Arthur Mageau
- Département de Médecine Interne, Hôpital Bichat, Université Paris Diderot, PRES Sorbonne Paris Cité, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Khadija Benali
- Département de Médecine Nucléaire, Hôpital Bichat, Université Paris Diderot, PRES Sorbonne Paris Cité, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Fanny Jouan
- Département de Médecine Interne, Hôpital Bichat, Université Paris Diderot, PRES Sorbonne Paris Cité, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Gregory Ducrocq
- Département de Cardiologie, Hôpital Bichat, Université Paris Diderot, PRES Sorbonne Paris Cité, Assistance Publique Hôpitaux de Paris, Paris, France; Département Hospitalo-Universitaire FIRE (Fibrosis, Inflammation and Remodelling in Renal and Respiratory Diseases), Paris, France; INSERM U1148, Paris, France
| | - Jean-Francois Alexandra
- Département de Médecine Interne, Hôpital Bichat, Université Paris Diderot, PRES Sorbonne Paris Cité, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Damien van Gysel
- Département d'Information Médicale, Hôpital Bichat, Université Paris Diderot, PRES Sorbonne Paris Cité, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Thomas Papo
- Département de Médecine Interne, Hôpital Bichat, Université Paris Diderot, PRES Sorbonne Paris Cité, Assistance Publique Hôpitaux de Paris, Paris, France; Département Hospitalo-Universitaire FIRE (Fibrosis, Inflammation and Remodelling in Renal and Respiratory Diseases), Paris, France; INSERM U1149, Paris, France
| | - Karim Sacre
- Département de Médecine Interne, Hôpital Bichat, Université Paris Diderot, PRES Sorbonne Paris Cité, Assistance Publique Hôpitaux de Paris, Paris, France; Département Hospitalo-Universitaire FIRE (Fibrosis, Inflammation and Remodelling in Renal and Respiratory Diseases), Paris, France; INSERM U1149, Paris, France.
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38
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Abstract
PURPOSE OF REVIEW This review article aims to provide a contemporary insight into the pathophysiological mechanisms of and therapeutic targets for pericarditis, drawing distinction between autoinflammatory and autoimmune pericarditis. RECENT FINDINGS Recent research has focused on the distinction between autoinflammatory and autoimmune pericarditis. In autoinflammatory pericarditis, viruses can activate the sensor molecule of the inflammasome, which results in downstream release of cytokines, such as interleukin-1, that recruit neutrophils and macrophages to the site of injury. Conversely, in autoimmune pericarditis, a type I interferon signature predominates, and pericardial manifestations coincide with the severity of the underlying systemic autoimmune disease. In addition, autoimmune pericarditis can also develop after cardiac injury syndromes. With either type of pericarditis, imaging can help stage the inflammatory state. Prominent pericardial delayed hyperenhancement on magnetic resonance imaging suggests ongoing inflammation whereas calcium on computed tomography suggests a completed inflammatory cascade. In patients with ongoing pericarditis, treatments that converge on the inflammasome, such as colchicine and anakinra, have proved effective in recurrent autoinflammatory pericarditis, though further clinical trials with anakinra are warranted. An improved understanding of the pathophysiological mechanisms of pericarditis helps unravel effective therapeutic targets for this condition.
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Affiliation(s)
- Bo Xu
- Section of Cardiovascular Imaging, Heart and Vascular Institute, Cleveland Clinic, Desk J1-5, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Serge C Harb
- Section of Cardiovascular Imaging, Heart and Vascular Institute, Cleveland Clinic, Desk J1-5, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Paul C Cremer
- Section of Cardiovascular Imaging, Heart and Vascular Institute, Cleveland Clinic, Desk J1-5, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
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Mager A, Talmor Y, Chezar Azzerad C, Iakobishvili Z, Porter A, Kornowski R, Hasdai D. Does colchicine decrease the rate of recurrence of acute idiopathic pericarditis treated with glucocorticoids? J Cardiol 2017; 71:409-413. [PMID: 29198919 DOI: 10.1016/j.jjcc.2017.10.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 09/22/2017] [Accepted: 10/11/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND The traditional treatment of acute pericarditis includes non-steroidal anti-inflammatory agents (NSAIDs) or glucocorticoids. The addition of colchicine has been found to reduce the rate of recurrences. Glucocorticoids, however, may attenuate this effect, although the available data are limited. We examined the impact of colchicine on the rate of recurrence of acute idiopathic pericarditis pretreated with prednisone. METHODS The frequency of recurrence in patients hospitalized for acute idiopathic pericarditis in a tertiary medical center in 2004-2014 who were treated with glucocorticoids or with non-steroidal therapy was assessed from the computerized hospital database. A retrospective design was used. RESULTS The cohort included 199 patients aged 18-86 years. Sixty-two (31%) were treated with prednisone, 42 with colchicine and 20 without, and 133 with non-steroidal therapy; in 4 patients, therapy was not detailed. Follow-up ranged from 13 to 147 months (median, 48 months). Fifty-three patients (26.6%) experienced at least one recurrence of pericarditis. The recurrence rate was significantly higher in patients who received prednisone and colchicine (17/42, 40.5%) than in patients who received NSAIDs or aspirin and colchicine (8/44, 18.2%, p=0.03) or any non-steroidal therapy (30/133, 22.6%, p=0.03). There was no difference between the rate of recurrence in patients who were treated with prednisone alone (5/20, 25%) and those treated with NSAIDs or aspirin and colchicine or with any non-steroidal therapy (p=NS). Baseline characteristics and duration of follow-up were similar in patients with and without recurrence. Hospital stay was longer in patients treated with prednisone alone as compared to patients treated with prednisone and colchicine. There were no other differences in baseline characteristics between these groups. CONCLUSIONS The addition of colchicine to prednisone in patients admitted for acute idiopathic pericarditis does not reduce the risk of recurrence. This finding suggests that prednisone blunts the salutary effects of colchicine.
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Affiliation(s)
- Aviv Mager
- Department of Cardiology, Rabin Medical Center - Beilinson Hospital, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Yeela Talmor
- Department of Cardiology, Rabin Medical Center - Beilinson Hospital, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Chava Chezar Azzerad
- Department of Cardiology, Rabin Medical Center - Beilinson Hospital, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Zaza Iakobishvili
- Department of Cardiology, Rabin Medical Center - Beilinson Hospital, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Avital Porter
- Department of Cardiology, Rabin Medical Center - Beilinson Hospital, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ran Kornowski
- Department of Cardiology, Rabin Medical Center - Beilinson Hospital, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - David Hasdai
- Department of Cardiology, Rabin Medical Center - Beilinson Hospital, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Kumar A, Sato K, Yzeiraj E, Betancor J, Lin L, Tamarappoo BK, Kwon DH, Hachamovitch R, Klein AL. Quantitative Pericardial Delayed Hyperenhancement Informs Clinical Course in Recurrent Pericarditis. JACC Cardiovasc Imaging 2017; 10:1337-1346. [DOI: 10.1016/j.jcmg.2016.10.020] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Revised: 10/04/2016] [Accepted: 10/06/2016] [Indexed: 11/27/2022]
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Abstract
Recurrent pericarditis is one of the most troublesome complications of pericarditis occurring in about one third of patients with a previous attack of pericarditis. The pathogenesis is presumed to be autoimmune and/or autoinflammatory in most cases. The mainstay of therapy for recurrences is physical restriction and anti-inflammatory therapy based on aspirin or NSAID plus colchicine. Corticosteroids at low to moderate doses (e.g., prednisone 0.2 to 0.5 mg/kg/day) should be considered only after failure of aspirin/NSAID (and more than one of these drugs) or for specific indications (e.g., pregnancy, systemic inflammatory diseases on steroids, renal failure, concomitant oral anticoagulant therapy). One of the most challenging issues is how to cope with patients who have recurrences despite colchicine. A small subset of patients (about 5 %) may develop corticosteroid-dependence and colchicine resistance. Among the emerging treatments, the three most common and evidence-based therapies are based on azathioprine, human intravenous immunoglobulin (IVIG), and anakinra. After failure of all options of medical therapy or for those patients who do not tolerate medical therapy or have serious adverse events related to medical therapy, the last possible option is the surgical removal of the pericardium. Total or radical pericardiectomy is recommended in these cases in experienced centers performing this surgery. A stepwise approach is recommended starting from NSAID and colchicine, corticosteroid and colchicine, a combination of the three options (NSAID, colchicine and corticosteroids), then azathioprine, IVIG, or anakinra as last medical options before pericardiectomy.
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Complicated Pericarditis: Understanding Risk Factors and Pathophysiology to Inform Imaging and Treatment. J Am Coll Cardiol 2017; 68:2311-2328. [PMID: 27884251 DOI: 10.1016/j.jacc.2016.07.785] [Citation(s) in RCA: 130] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 07/05/2016] [Accepted: 07/12/2016] [Indexed: 01/09/2023]
Abstract
Most patients with acute pericarditis have a benign course and a good prognosis. However, a minority of patients develop complicated pericarditis, and the care of these patients is the focus of this review. Specifically, we address risk factors, multimodality imaging, pathophysiology, and novel treatments. The authors conclude that: 1) early high-dose corticosteroids, a lack of colchicine, and an elevated high-sensitivity C-reactive protein are associated with the development of complicated pericarditis; 2) in select cases, cardiovascular magnetic resonance imaging may aid in the assessment of pericardial inflammation and constriction; 3) given phenotypic similarities between recurrent idiopathic pericarditis and periodic fever syndromes, disorders of the inflammasome may contribute to relapsing attacks; and 4) therapies that target the inflammasome may lead to more durable remission and resolution. Finally, regarding future investigations, the authors discuss the potential of cardiovascular magnetic resonance to inform treatment duration and the need to compare steroid-sparing treatments to pericardiectomy.
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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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Imazio M, Brucato A, Pluymaekers N, Breda L, Calabri G, Cantarini L, Cimaz R, Colimodio F, Corona F, Cumetti D, Cuccio CDBL, Gattorno M, Insalaco A, Limongelli G, Russo MG, Valenti A, Finkelstein Y, Martini A. Recurrent pericarditis in children and adolescents: a multicentre cohort study. J Cardiovasc Med (Hagerstown) 2017; 17:707-12. [PMID: 27467459 DOI: 10.2459/jcm.0000000000000300] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Limited data are available about recurrent pericarditis in children. We sought to explore contemporary causes, characteristics, therapies and outcomes of recurrent pericarditis in paediatric patients. METHODS A multicentre (eight sites) cohort study of 110 consecutive cases of paediatric patients with at least two recurrences of pericarditis over an 11-year period (2000-2010) [median 13 years, interquartile range (IQR) 5, 69 boys]. RESULTS Recurrences were idiopathic or viral in 89.1% of cases, followed by postpericardiotomy syndrome (9.1%) and familial Mediterranean fever (0.9%). Recurrent pericarditis was treated with nonsteroidal anti-inflammatory drugs (NSAIDs) in 80.9% of cases, corticosteroids in 64.8% and colchicine was added in 61.8%. Immunosuppressive therapies were administered in 15.5% of patients after subsequent recurrences. After a median follow-up of 60th months, 528 subsequent recurrences were recorded (median 3, range 2-25). Corticosteroid-treated patients experienced more recurrences (standardized risk of recurrence per 100 person-years was 93.2 for patients treated with corticosteroids and 45.2 for those without), side effects and disease-related hospitalizations (for all P < 0.05). Adjuvant therapy with colchicine was associated with a decrease in the risk of recurrence from 3.74 per year before initiation of colchicine to 1.37 per year after (P < 0.05). Anakinra therapy (n = 12) was associated with a drop in the number of recurrences from 4.29 per year before to 0.14 per year after (P < 0.05). Transient constrictive pericarditis developed in 2.7% of patients. CONCLUSION Recurrent pericarditis has an overall favourable prognosis in children, although it may require frequent readmissions and seriously affect the quality of life, especially in patients treated with corticosteroids. Colchicine or anakinra therapies were associated with significant decrease in the risk of recurrence.
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Affiliation(s)
- Massimo Imazio
- aCardiology Department, Maria Vittoria Hospital and University of Torino, Torino bInternal Medicine, Ospedale Papa Giovanni XXIII, Bergamo, Italy cMaastricht University, Faculty of Medicine, Maastricht, the Netherlands dPediatrics Department, University of Chieti, Chieti eRheumatology Department, University of Siena, Siena fMeyer Children Hospital, Firenze gUOS Reumatologia Pediatrica - Fondazione IRCCS Ca' Granda Milan, Milan, Italy hDivision of Rheumatology, Department of Paediatric Medicine, Bambino Gesù Children's Hospital, IRCCS, Rome iCardiology Department, Monaldi Hospital, Second University of Naples, Naples jUniversity of Genoa and Pediatria II Istituto Gianna Gaslini, Genova, Italy kDivisions of Emergency Medicine and Clinical Pharmacology and Toxicology, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada *Drs. Finkelstein and Martini are cosenior authors
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Schwier NC, Hale GM, Davies ML. Treatment of Adults with Idiopathic Recurrent Pericarditis: Novel Use of Immunotherapy. Pharmacotherapy 2017; 37:305-318. [PMID: 28079270 DOI: 10.1002/phar.1897] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Idiopathic recurrent pericarditis (IRP) can be challenging to treat. Even after guideline-directed first-line treatment consisting of aspirin (ASA) or a nonsteroidal antiinflammatory drug (NSAID) in combination with colchicine therapy, recurrences still occur in greater than 20% of patients. Many patients then require treatment with long-term corticosteroids, which is not a favorable option due to their short- and long-term adverse effects. Because it is theorized that the pathophysiology of IRP may possess autoimmune sequelae, the use of immunotherapy for the treatment of IRP has emerged. In this review, we describe the literature associated with immunotherapy used to treat IRP in an adult population as well as provide an overview of the safety and monitoring parameters for each agent. The most common immunotherapies used after patients have had multiple recurrences of IRP are anakinra, intravenous immunoglobulin (IVIG), and azathioprine. In most cases, these immunotherapies are adjunctive therapy, with the goal of tapering and discontinuing immunosuppressive corticosteroids. After reviewing the data, anakinra resulted in more patients discontinuing corticosteroids and prevented further recurrences of pericarditis. IVIG resulted in symptom resolution and no further recurrences in most of the patients. Azathioprine was associated with more than half of patients becoming recurrence free; however, many patients required a restart of corticosteroids due to recurrence. Clinicians should be aware of the adverse effects of immunotherapy, ranging from mild gastrointestinal events to risk of infection and serious blood dyscrasias that may require diligent monitoring. The use of immunotherapy for the treatment of adults with IRP should be restricted to patients who have multiple recurrences. Ideally, immunotherapy would be adjunctive to first-line combination therapy with ASA/NSAID plus colchicine, with the goal of tapering and discontinuing immunosuppressive corticosteroids. Furthermore, clinicians should consider cost, drug-drug and drug-disease interactions, and safety, as well as the quality of the retrospective evidence before considering any immunotherapy.
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Affiliation(s)
- Nicholas C Schwier
- Department of Pharmacy: Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, Oklahoma City, Oklahoma
| | - Genevieve M Hale
- Department of Pharmacy Practice, Nova Southeastern University College of Pharmacy, Palm Beach Gardens, Florida
| | - Marie L Davies
- Department of Pharmacy Practice and Administration, Western University of Health Sciences College of Pharmacy, Pomona, California
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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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Usefulness of Novel Immunotherapeutic Strategies for Idiopathic Recurrent Pericarditis. Am J Cardiol 2016; 117:861-6. [PMID: 26742476 DOI: 10.1016/j.amjcard.2015.12.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Revised: 12/01/2015] [Accepted: 12/01/2015] [Indexed: 12/31/2022]
Abstract
Idiopathic recurrent pericarditis (IRP) is a debilitating illness which leads to great suffering and multiple hospitalizations. Management of acute pericarditis and subsequent recurrences has evolved significantly as the use of colchicine-based strategies become more prevalent, yet there still remains a subset of patients who remain refractory to colchicine therapy, and these patients require prolonged corticosteroid (CS) therapy for the control of symptoms. Since the 1960s, there have been reports of successful management of these cases with immunosuppressive therapy. Current guidelines support the use of anakinra, intravenous immunoglobulins, and azathioprine for management of IRP, with the goals of both control of symptoms and withdrawal of CS. Recent reports supply evidence for both auto-inflammatory and autoimmune activity in these patients. We herein review the current available reports regarding the evidence regarding the pathophysiology and reported cases and case series of IRP cases managed with immunomodulation therapy.
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Yusuf SW, Hassan SA, Mouhayar E, Negi SI, Banchs J, O'Gara PT. Pericardial disease: a clinical review. Expert Rev Cardiovasc Ther 2016; 14:525-39. [PMID: 26691443 DOI: 10.1586/14779072.2016.1134317] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Pericardial disease is infrequently encountered in cardiovascular practice, but can lead to significant morbidity and mortality. Clinical data and practice guidelines are relatively sparse. Early recognition and prompt treatment of pericardial diseases are critical to optimize patient outcomes. In this review we provide a concise summary of acute pericarditis, constrictive pericarditis and pericardial effusion/tamponade.
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Affiliation(s)
- Syed Wamique Yusuf
- a Department of Cardiology , University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Saamir A Hassan
- a Department of Cardiology , University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Elie Mouhayar
- a Department of Cardiology , University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Smita I Negi
- a Department of Cardiology , University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Jose Banchs
- a Department of Cardiology , University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Patrick T O'Gara
- b Cardiovascular Medicine Division, Department of Medicine, Harvard Medical School , Brigham and Women's Hospital , Boston , MA , USA
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Tajdini M. Spontaneous myopericarditis in a patient under dexamethasone: A double-edged sword? J Saudi Heart Assoc 2015; 27:292-4. [PMID: 26557749 PMCID: PMC4614892 DOI: 10.1016/j.jsha.2015.03.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Revised: 09/23/2014] [Accepted: 03/21/2015] [Indexed: 11/29/2022] Open
Abstract
A majority of acute pericarditis cases have some degree of myocarditis. Viruses are the common etiological factor of this disease. Corticosteroids are considered for treatment, especially in recurrent models of the disease. In this article, we report the case of a 47-year-old man with myopericarditis who was under daily intra-muscular dexamethasone injection for an unknown reason. This is a unique case of spontaneous myopericarditis under corticosteroid abuse that has not been reported previously.
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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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