Title : Treatment and prevention of recurrent pericarditis
Recurrent pericarditis is one of the most common and notorious complications of acute pericarditis, and if not treated adequately can lead to serious complications such as arrhythmias, constrictive pericarditis, and cardiac tamponade. It affects about 20-30% of the patients diagnosed for pericarditis. Recurrent pericarditis is very difficult to treat and is intolerant to the standard of care. The mainstay treatment for recurrent pericarditis includes aspirin or NSAIDs (ibuprofen, indomethacin) plus colchicine, and corticosteroids or azathioprine in resistant disease. Interleukin-1β is a proinflammatory cytokine that is a downstream mediator of the NACHT LRR and PYD domains-containing protein 3 (NLRP3) inflammasome signaling pathways. IL-1β is a potent stimulant of pro-inflammatory molecules, such as cyclo-oxygenase and excessive synthesis of prostaglandins. Interleukin-1β, and prostaglandins are responsible for pericardial inflammation, hyperaemia, oedema, effusion, and fever in patient with recurrent pericarditis. Colchicine is a nonspecific inhibitor of NLRP3, and that is its pharmacotherapeutic rational for the treatment of pericarditis. Directly targeting IL-1 and its receptors is a more specific precision treatment for recurrent pericarditis. Anakinra is a recombinant form of naturally occurring IL-1 receptor antagonist (IL-1Ra), which inhibits the activity of both IL-1α and IL-1β. Treatment of acute pericarditis with anakinra has been shown to instantly relieve pericardial pain and ameliorate pericarditis, and allows patients to discontinue corticosteroids within 2 months of therapy. However, abrupt discontinuation of colchicine or anakinra is associated with relapse of pericarditis in 70% of the patients. Rilonacept is a chimeric recombinant fusion protein functioning as a soluble decoy protein that binds to IL-1α, IL-1β, and IL-1Ra. Treatment with rilonacept leads to rapid and sustained improvement in chest pain, and a decrease in C-reactive protein. Noteworthy, it is associated with prevention of pericarditis recurrence. Many patients treated with rilonacept are able to taper or discontinue corticosteroids and colchicine, without pericarditis recrudescence. Additionally, rilonacept significantly improves the quality of life. IL-1 and IL-1 receptor antagonist, including rilonacept should be administered early in the course of recurrent pericarditis in order to prevent the grave complications of pericarditis, such as constrictive pericarditis, cardiac tamponade, and surgical complications of pericardiectomy.
- The audience will be able to obtain the latest information on the treatment of recurrent pericarditis
- They will learn how to prevent this recurrent disease which carries significant morbidity and mortality if not treated adequately
- They will be able to understand that surgical pericardiectomy is not necessary if acute pericarditis is treated with IL-1 receptor antagonists