Péricardites aiguës récidivantes : mise au point et actualités 2011

Acute recurrent pericarditis: from pathophysiology towards new treatment strategy

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.

The Role of Colchicine in Pericarditis--A Systematic Review and Meta-analysis of Randomised Trials

INTRODUCTION

Colchicine has been used in diverse clinical settings. Primary idiopathic pericarditis is complicated by recurrence in 15 to 30% of cases. Aspirin, non-steroidal anti-inflammatory drugs, colchicine and steroids are the commonly prescribed medications. We synthesised the available evidence from the randomised trials to assess the efficacy and safety of colchicine in primary and recurrent pericarditis.

METHODS

A systematic search was conducted using MEDLINE, PubMed, EMBASE, Current Contents Connect, Cochrane library, Google Scholar, Science Direct, and Web of Science. Original data was abstracted from each study and used to calculate an odds ratio (OR) and 95% confidence interval (95% CI).

RESULTS

Seven randomised trials comprising 1275 patients met full criteria for analysis. Two open label randomised controlled trials and five double-blind randomised controlled trials were included. Colchicine was useful in reducing the incidence of primary pericarditis (OR: 0.38, 95% CI: 0.22- 0.65) as well as recurrent pericarditis (OR: 0.31, 95% CI: 0.22-0.44). The most common side-effects were related to the gastrointestinal system and no severe adverse events were observed. Colchicine cessation either by patient or physician was similar in both groups (OR: 1.53, 95% CI: 0.86-2.71).

CONCLUSION

Colchicine is effective in preventing both primary and recurrent episodes of pericarditis. The number needed to treat for preventing recurrent pericarditis was five. Gastrointestinal side-effects were the most common adverse events.