We read with great pleasure the work by Imazio,1 which is, as usual, another of his excellent contributions to pericardial disease research. Imazio discussed the treatment of recurrent pericarditis and emphasized the importance of colchicine in addition to the standard treatment modalities. This is backed up by randomized controlled evidence from CORP-12 and CORP-23 trials, which constitute the pioneer work on this subject.
One aspect of this disease remains frustrating for both clinicians and patients: multiple recurrences leading to refractory pericarditis. According to the recent data from the CORP-2 trial, at least 22% of patients experienced a recurrence despite receiving 6 months of colchicine therapy for recurrent pericarditis.3 Such patients often experience debilitating symptoms and may progress to develop refractory pericarditis. A polypharmacy approach is utilized in such patients, which often includes a combination treatment with NSAIDs, colchicine, and steroids. Despite polypharmacy use, a large subgroup of these patients may experience recurrent symptoms. Anecdotal clinical experience of utilizing interleukin-1 inhibitors has proven beneficial in patients with refractory symptoms. Anakinra (an interleukin-1 inhibitor) was recently used in a small prospective investigation, mostly involving a pediatric population.4 The results showed that anakinra could be a potential treatment modality for patients with refractory symptoms of pericarditis. Anakinra has not been significantly utilized in the United States for this indication. Since this was an Italian study, we wonder if Imazio et al have utilized anakinra in their clinical experience for adult patients with refractory pericarditis.
Therapeutic surgical modalities like pericardiectomy are often used as the last resort for management of recurrent pericarditis. It remains an option for patients with constrictive physiology, recurrent pericardial tamponade, or unacceptable complications with respect to standard medical therapy; however, despite pericardiectomy, patients may often experience relapse of chest pain symptoms. In contrast, percutaneous balloon pericardiotomy is a minimally invasive procedure that can be effectively used in the management of recurrent neoplastic pericardial effusions earlier in the disease course. It offers an excellent palliative benefit and improves quality of life in patients with recurrent symptoms due to malignant pericardial effusions.5
Nonetheless, the role of pharmacological agents such as anakinra warrants a further exploration. Future prospective investigations should be conducted in the subgroup of adult patients with recurrent pericarditis, which will help formulate standardized treatment strategies. We would greatly appreciate the authors’ response and expert opinion.
CONFLICTS OF INTERESTD. Spodick receives royalties from his textbook, “The Pericardium: A Comprehensive Textbook” (Fundamental and Clinical Cardiology), Marcel Dekker, New York 1997.