LETTER TO THE EDITOR
Therapy of recurrent pericarditis
Antonio Brucato, MD
Department of Internal Medicine, Niguarda Hospital, Via Del Bollo 4, 20123 Milano, Italy
Giovanni Brambilla, MD and
Yehuda Adler, MD
antonio.brucato{at}ospedaleniguarda.it
We read with interest the paper by Raatikka et al. (1) that gives us a useful piece of information regarding pericarditis in children. The data are relevant, particularly regarding the good long-term outcome, with no instance of constriction, in agreement with our experience in adults. We would like to comment on some statements regarding therapy. The authors in fact conclude that corticosteroids, methotrexate, azathioprine, cyclosporine, and colchicine did not prevent recurrences. Should we conclude that no drug is effective, so that no drug should be employed? We have published case reports describing different experiences. A 14.5-year-old boy (2) previously treated with high-dose steroids, intravenous immunoglobulin, and indomethacin experienced an excellent response when colchicine 1 mg was added, while slowly tapering steroids and continuing indomethacin. In another 12-year-old boy (3) who did not respond well to nonsteroidal anti-inflammatory drugs (NSAIDs) and prednisone, the introduction of colchicine proved beneficial; thereafter, the patient presented with six relapses, each occurring 1 to 4 weeks after the discontinuation of colchicine on his own initiative. The excellent study by Raatikka et al. (1), in our opinion, was not designed to assess the problem of therapy, with the interactions between different drugs, dosages, and combinations: we have to wait for more definitive studies specifically addressing therapy. Moreover, we have to evaluate if efficacy of a drug means that it must work after discontinuing all the previous therapies (e.g., to stop steroids and NSAIDs and add de novo colchicine) or, probably more wisely, if a drug's efficacy means that it works when added to a previous active therapy (e.g., to add colchicine to steroids and NSAIDs).
In the meantime, even if it will be proved true that recurrent pericarditis has a chronic course irrespective of the therapy given, and that the activity of the disease gradually "burns out" spontaneously, it remains necessary to use some drugs, the less toxic ones, during the acute phases. In our opinion, this is best accomplished with a multidrug therapy including: 1) a very slow tapering of steroids (months), similar to what is often done in many rheumatologic conditions; 2) NSAIDs used at the recommended dosages; and 3) introduction of colchicine, if tolerated. In our experience, this therapy greatly ameliorates the quality of life of these patients, and possibly may reduce the number of recurrences. We acknowledge that it will be difficult to formally prove the efficacy of this therapy in the framework of a randomized, controlled trial.
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References
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1. Raatikka M, Pelkonen PM, Karjalainen J, Jokinen EV. Recurrent pericarditis in children and adolescents: report of 15 cases. J Am Coll Cardiol. 2003;42:759–764[Abstract/Free Full Text]
2. Brucato A, Cimaz R, Balla E. Prevention of recurrences of corticosteroid-dependent idiopathic pericarditis by colchicine in an adolescent patient. Pediatr Cardiol. 2000;21:395–396[CrossRef][Medline]
3. Adler Y, Finkelstein Y, Amir J. Recurrent episodes of pericarditis coincide with discontinuation of colchicine therapy. J Noninvasive Cardiol. 1999;3:65–66
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A Brucato, Y Shinar, G Brambilla, L Robbiolo, G Ferrioli, M C Patrosso, D Zanni, S Penco, E Boiani, A Ghirardello, et al.
Idiopathic recurrent acute pericarditis: familial Mediterranean fever mutations and disease evolution in a large cohort of Caucasian patients
Lupus,
September 1, 2005;
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[Abstract]
[PDF]
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