LETTER TO THE EDITOR
Reply
Marja Raatikka, MD,
Pirkko M. Pelkonen, MD,
Eero Jokinen, MD and
Jouko Karjalainen, MD
Central Military Hospital, Box 50, 00301, Helsinki, Finland
jouko.karjalainen{at}pp.inet.fi
We appreciate the interest of Dr. Brucato and his colleagues in our study on recurrent pericarditis in children and adolescents (1). We agree that the treatment of this condition is often problematic and frustrating. The goals of the therapy are to control the pain, to prevent tamponade, and to stop recurrences. In our series, threatening tamponade was not encountered after first attacks and pericardial effusion diminished in later relapses irrespective of the given therapy. Thus, the control of pain remains the main task in therapy during a recurrence of the disease. This is possible in most cases with nonsteroidal anti-inflammatory drugs (NSAIDs) in sufficient doses, added with other pain killers if needed. Even recurrences with high C-reactive protein values usually settle down with such treatment within 7 to 10 days. It is tempting to use corticosteroids as they are very effective in suppressing the pain and in relieving the pericardial effusion. However, in our patients steroid treatment tended to increase the number of relapses. Further, the well-known side effects of corticosteroids are especially undesirable in growing children and adolescents. Therefore, we would spare the corticosteroid treatment for the most severe cases only.
Colchicine treatment for preventing relapses has raised considerable expectations because of the good results published by Adler et al. (2). Sadly, this treatment failed to prevent recurrences in all four of our patients in whom colchicine was added to corticosteroid treatment. One possible reason for the contradicting results may lie in the different genetic characteristics of the study populations and the heterogeneous etiology of the recurrent pericarditis. Clearly, there is a need for an international, randomized study to test the effectiveness of colchicine and other treatments, for example, intrapericardial triamcinolone administration tested by Maisch et al. (3). The evaluation of the effectiveness of treatments is difficult on the basis of single cases, as the course of recurrent pericarditis is unpredictable although gradually "burning out." The chronicity of the condition is exemplified by two of our patients believed to be cured of the disease, but who after the acceptance of our article have had new relapses after 9 and 11 years' quiescence, respectively.
Similar to Dr. Brucato and his colleagues, we find it important to use as nontoxic drugs as possible during the acute phases of pericarditis. However, our experience in young patients does not support their recommendation of routine multidrug therapy including long-term corticosteroids, colchicine, and NSAIDs. In our hands, mere NSAID treatment was in the long run at least as effective as the treatment with different immunosuppressive drugs.
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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. Adler Y, Finkelstein Y, Guindo J, et al. Colchicine treatment for recurrent pericarditis: a decade of experience. Circulation. 1998;97:2183–2185[Abstract/Free Full Text]
3. Maisch B, Ristic AD, Pancuweit S. Intrapericardial treatment of autoreactive pericardial effusion with triamcinolone. The way to avoid side effects of systemic corticosteroid therapy. Eur Heart J. 2002;23:1503–1508[Abstract/Free Full Text]
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