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Lazarou E, Koutsianas C, Vlachakis PK, Theofilis P, Vassilopoulos D, Tsioufis C, Lazaros G, Tousoulis D. Novel Treatments in Refractory Recurrent Pericarditis. Pharmaceuticals (Basel) 2024; 17:1069. [PMID: 39204174 PMCID: PMC11357540 DOI: 10.3390/ph17081069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2024] [Revised: 08/11/2024] [Accepted: 08/13/2024] [Indexed: 09/03/2024] Open
Abstract
Refractory recurrent pericarditis is a troublesome condition that severely impairs the quality of life of affected patients and significantly increases healthcare spending. Until recently, therapeutic options included only a few medications and most of the patients resorted to chronic glucocorticoid treatment with steroid dependence. In the most recent decade, the introduction of interleukin-1 blockers in clinical practice has revolutionized the treatment of glucocorticoid-dependent and colchicine-resistant recurrent pericarditis due to their excellent efficacy and good safety profile. The rationale for the introduction of this class of medications in clinical practice is the autoinflammatory nature of recurrent pericarditis in a substantial rate of cases, with interleukin-1 being the main pro-inflammatory cytokine involved in this context. This review aims to discuss the contemporary available evidence from original research and real-world data on interleukin-1 blocker use in refractory recurrent pericarditis, in terms of indications, mechanism of action, efficacy, side effects, and recommended treatment protocols. Moreover, novel treatment proposals, such as hydroxychloroquine, beta blockers, and cannabidiol, which showed encouraging preliminary results, are addressed. Finally, gaps in knowledge, unmet needs, and future perspectives related to recurrent pericarditis are thoroughly discussed.
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Affiliation(s)
- Emilia Lazarou
- First Cardiology Department, School of Medicine, Hippokration General Hospital, National and Kapodistrian University of Athens, Vas. Sofias 114, 11527 Athens, Greece; (E.L.); (P.K.V.); (P.T.); (C.T.); (G.L.)
| | - Christos Koutsianas
- Clinical Immunology-Rheumatology Unit, 2nd Department of Medicine and Laboratory, Joint Academic Rheumatology Program, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, 114 Vass. Sophias Ave, 11527 Athens, Greece; (C.K.); (D.V.)
| | - Panayotis K. Vlachakis
- First Cardiology Department, School of Medicine, Hippokration General Hospital, National and Kapodistrian University of Athens, Vas. Sofias 114, 11527 Athens, Greece; (E.L.); (P.K.V.); (P.T.); (C.T.); (G.L.)
| | - Panagiotis Theofilis
- First Cardiology Department, School of Medicine, Hippokration General Hospital, National and Kapodistrian University of Athens, Vas. Sofias 114, 11527 Athens, Greece; (E.L.); (P.K.V.); (P.T.); (C.T.); (G.L.)
| | - Dimitrios Vassilopoulos
- Clinical Immunology-Rheumatology Unit, 2nd Department of Medicine and Laboratory, Joint Academic Rheumatology Program, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, 114 Vass. Sophias Ave, 11527 Athens, Greece; (C.K.); (D.V.)
| | - Costas Tsioufis
- First Cardiology Department, School of Medicine, Hippokration General Hospital, National and Kapodistrian University of Athens, Vas. Sofias 114, 11527 Athens, Greece; (E.L.); (P.K.V.); (P.T.); (C.T.); (G.L.)
| | - George Lazaros
- First Cardiology Department, School of Medicine, Hippokration General Hospital, National and Kapodistrian University of Athens, Vas. Sofias 114, 11527 Athens, Greece; (E.L.); (P.K.V.); (P.T.); (C.T.); (G.L.)
| | - Dimitris Tousoulis
- First Cardiology Department, School of Medicine, Hippokration General Hospital, National and Kapodistrian University of Athens, Vas. Sofias 114, 11527 Athens, Greece; (E.L.); (P.K.V.); (P.T.); (C.T.); (G.L.)
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Imazio M. Medical therapy of pericarditis: tips and tricks for clinical practice. J Cardiovasc Med (Hagerstown) 2024; 25:420-425. [PMID: 38625826 PMCID: PMC11216374 DOI: 10.2459/jcm.0000000000001618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 03/15/2024] [Indexed: 04/18/2024]
Abstract
Medical therapy of pericarditis should be targeted at its aetiology. Unfortunately, many cases of pericarditis remain idiopathic after a complete diagnostic workup. In such cases, empiric anti-inflammatory therapy for pericarditis is aimed at controlling symptoms and preventing recurrences. The aim of the present clinical review is to summarize published evidence, guidelines, and to provide tips and tricks for clinical management of acute and recurrent pericarditis.
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Affiliation(s)
- Massimo Imazio
- Department of Medicine (DMED), University of Udine
- Cardiothoracic Department, University Hospital Santa Maria della Misericordia, ASUFC, Udine, Italy
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3
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Collini V, Andreis A, De Biasio M, De Martino M, Isola M, Croatto N, Lepre V, Cantarini L, Merlo M, Sinagra G, Abbate A, Lazaros G, Brucato A, Klein AL, Imazio M. Efficacy of colchicine in addition to anakinra in patients with recurrent pericarditis. Open Heart 2024; 11:e002599. [PMID: 38490715 PMCID: PMC10946365 DOI: 10.1136/openhrt-2023-002599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Accepted: 02/26/2024] [Indexed: 03/17/2024] Open
Abstract
AIM Anakinra, an anti IL-1 agent targeting IL-1 alfa and beta, is available for the treatment of recurrent pericarditis in cases with corticosteroid dependence and colchicine resistance after failure of conventional therapies. However, it is unclear if the combination with colchicine, a non-specific inhibitor of the inflammasome targeting the same inflammatory pathway of IL-1, could provide additional benefit to prevent further recurrences. The aim of the present observational study is to assess whether the addition of colchicine on top of anakinra could prolong the time to first recurrence and prevent recurrences better than anakinra alone. METHODS International, all-comers, multicentre, retrospective observational cohort study analysing all consecutive patients treated with anakinra for corticosteroid-dependent and colchicine-resistant recurrent pericarditis. The efficacy endpoint was recurrence rate and the time to the first recurrence. RESULTS A total of 256 patients (mean age 45.0±15.4 years, 65.6% females, 80.9% with idiopathic/viral aetiology) were included. 64 (25.0%) were treated with anakinra as monotherapy while 192 (75.0%) with both anakinra and colchicine. After a follow-up of 12 months, 56 (21.9%) patients had recurrences. Patients treated with colchicine added to anakinra had a lower incidence of recurrences (respectively, 18.8% vs 31.3%; p=0.036) and a longer event-free survival (p=0.025). In multivariable analysis, colchicine use prevented recurrences (HR 0.52, 95% CI 0.29 to 0.91; p=0.021). CONCLUSIONS The addition of colchicine on top of anakinra treatment could be helpful to reduce recurrences and prolong the recurrence-free survival.
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Affiliation(s)
- Valentino Collini
- Cardiothoracic Department, University Hospital "Santa Maria della Misericordia", Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), Udine, Italy
| | - Alessandro Andreis
- Division of Cardiology, Department of Medical Sciences, Azienda Ospedaliero Universitaria Citta della Salute e della Scienza di Torino, University of Torino, Torino, Italy
| | - Marzia De Biasio
- Cardiothoracic Department, University Hospital "Santa Maria della Misericordia", Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), Udine, Italy
| | - Maria De Martino
- Department of Medicine (DMED), University of Udine, Udine, Italy
| | - Miriam Isola
- Department of Medicine (DMED), University of Udine, Udine, Italy
| | - Nicole Croatto
- Department of Medicine (DMED), University of Udine, Udine, Italy
| | - Veronica Lepre
- Cardiology Specialty School, University of Trieste, Trieste, Italy
| | | | - Marco Merlo
- Cardiology Specialty School, University of Trieste, Trieste, Italy
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), Trieste, Italy
| | - Gianfranco Sinagra
- Cardiology Specialty School, University of Trieste, Trieste, Italy
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), Trieste, Italy
| | - Antonio Abbate
- Virginia Commonwealth University, Richmond, Virginia, USA
| | - George Lazaros
- Department of Cardiology, University of Athens Medical School, Hippokration Hospital, Athens, Greece
| | - Antonio Brucato
- Department of Biomedical and Clinical Sciences "Sacco", University of Milano, Milano, Italy
| | - Allan L Klein
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Massimo Imazio
- Cardiothoracic Department, University Hospital "Santa Maria della Misericordia", Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), Udine, Italy
- Department of Medicine (DMED), University of Udine, Udine, Italy
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Conte E, Agalbato C, Melotti E, Marchetti D, Schillaci M, Ratti A, Ippolito S, Pancrazi M, Perone F, Dalla Cia A, Pepi M, Pontone G, Imazio M, Brucato A, Chetrit M, Klein A, Andreini D. The Contemporary Role of Cardiac Computed Tomography and Cardiac Magnetic Resonance Imaging in the Diagnosis and Management of Pericardial Diseases. Can J Cardiol 2023; 39:1111-1120. [PMID: 36740019 DOI: 10.1016/j.cjca.2023.01.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 01/24/2023] [Accepted: 01/30/2023] [Indexed: 02/05/2023] Open
Abstract
Pericardial syndromes encompass different clinical conditions from acute pericarditis to idiopathic chronic pericardial effusion. Transthoracic echocardiography is the first and most important initial diagnostic imaging modality in most patients affected by pericardial disease. However, cardiac computed tomography (CCT) and cardiac magnetic resonance imaging (CMR) have recently gained a pivotal role in cardiology, and recent reports have supported the role of both of these advanced techniques in the evaluation and guiding therapy of pericardial disease. Most promising is the capability of CMR to identify the presence of pericardial inflammation, carrying both diagnostic and prognostic value in the setting of recurrent and chronic pericarditis. In addition, CCT permits accurate evaluation of the presence and extension of pericardial calcification, providing important information in confirming the diagnosis of constrictive pericarditis and during the preprocedural planning for patients undergoing pericardiectomy. Both CCT and CMR require specific expertise, especially for the evaluation of pericardial disease. The aim of the present review is to provide physicians an updated overview of CCT and CMR in pericardial disease, focusing on technical issues, recent research findings, and potential clinical applications.
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Affiliation(s)
- Edoardo Conte
- Clinical Cardiology and Cardiovascular Imaging Unit, Galeazzi-Sant'Ambrogio Hospital, IRCCS, Milan, Italy.
| | | | - Eleonora Melotti
- Clinical Cardiology and Cardiovascular Imaging Unit, Galeazzi-Sant'Ambrogio Hospital, IRCCS, Milan, Italy
| | - Davide Marchetti
- Clinical Cardiology and Cardiovascular Imaging Unit, Galeazzi-Sant'Ambrogio Hospital, IRCCS, Milan, Italy
| | - Matteo Schillaci
- Clinical Cardiology and Cardiovascular Imaging Unit, Galeazzi-Sant'Ambrogio Hospital, IRCCS, Milan, Italy
| | - Angelo Ratti
- Clinical Cardiology and Cardiovascular Imaging Unit, Galeazzi-Sant'Ambrogio Hospital, IRCCS, Milan, Italy
| | | | - Massimo Pancrazi
- Department of Internal Medicine, Fatebenefratelli Hospital, Milan, Italy
| | - Francesco Perone
- Cardiac Rehabilitation Unit, Rehabilitation Clinic "Villa delle Magnolie," Castel Morrone, Caserta, Italy
| | | | - Mauro Pepi
- Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | | | - Massimo Imazio
- Cardiothoracic Department, Santa Maria della Misericordia University Hospital, Udine, Friuli-Venezia Giulia, Italy
| | - Antonio Brucato
- Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Michael Chetrit
- Department of Medicine, McGill University Health Centre, Montréal, Québec, Canada
| | - Allan Klein
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Imaging, Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Daniele Andreini
- Clinical Cardiology and Cardiovascular Imaging Unit, Galeazzi-Sant'Ambrogio Hospital, IRCCS, Milan, Italy; Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
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Affiliation(s)
- George Lazaros
- 1st Cardiology Clinic, National and Kapodistrian University of Athens, School of Medicine, Hippokration General Hospital, Athens, Greece
| | - Costas Tsioufis
- 1st Cardiology Clinic, National and Kapodistrian University of Athens, School of Medicine, Hippokration General Hospital, Athens, Greece
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Kumar S, Khubber S, Reyaldeen R, Agrawal A, Cremer PC, Imazio M, Kwon DH, Klein AL. Advances in Imaging and Targeted Therapies for Recurrent Pericarditis: A Review. JAMA Cardiol 2022; 7:975-985. [PMID: 35976625 DOI: 10.1001/jamacardio.2022.2584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Pericarditis is the most common form of pericardial disease. Recurrence of pericarditis affects 15% to 30% of patients after the initial episode of pericarditis. Up to 50% of patients with the first recurrence have additional recurrences. These patients often progress to have colchicine-resistant and corticosteroid-dependent disease. Rapidly evolving cardiac magnetic resonance imaging techniques and novel targeted therapies have paved the way for imaging-guided therapy for recurrent pericarditis. However, the optimal application of these recent advances remains unclear. Observations A search was conducted using the PubMed and Cochrane databases for English-language studies, management guidelines, meta-analyses, and review articles published until April 2022 on recurrent pericarditis. Following the 2015 European Society of Cardiology guidelines for the diagnosis and management of pericardial diseases, new clinical trials and registry data have emerged that demonstrate the efficacy of interleukin-1 blockers in recurrent pericarditis. In addition, new observational data have come to light supporting the use of cardiac magnetic resonance imaging in the diagnosis, risk stratification, and management of such patients. Conclusions and Relevance Advances in imaging and targeted therapies have led to a paradigm shift in the management of recurrent pericarditis. This narrative review summarizes the established and emerging data on the diagnosis and treatment of recurrent pericarditis with special emphasis on the role of cardiac magnetic resonance imaging and interleukin-1 blockers in the current era of tailored therapy for recurrent pericarditis.
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Affiliation(s)
- Sachin Kumar
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Shameer Khubber
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Reza Reyaldeen
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ankit Agrawal
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Paul C Cremer
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Massimo Imazio
- Cardiology, Cardiothoracic Department, University Hospital Santa Maria della Misericordia, Udine, Italy
| | - Deborah H Kwon
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Allan L Klein
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
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Abstract
Purpose of Review Since 2015, when ESC guidelines for the diagnosis and management of pericardial diseases were published, ongoing research has enhanced the current state of knowledge on acute pericarditis. This review is an update on the latest developments in this field. Recent Findings In recurrent acute pericarditis, autoinflammation has been included among causative mechanisms restricting the vague diagnoses of “idiopathic” pericarditis. Cardiac magnetic resonance that detects ongoing pericardial inflammation may guide treatment in difficult-to-treat patients. Development of risk scores may assist identification of patients at high risk for complicated pericarditis, who should be closely monitored and aggressively treated. Treatment with IL-1 inhibitors has been proven efficacious in recurrent forms with a good safety profile. Finally, acute pericarditis has recently attracted great interest as it has been reported among side effects post COVID-19 vaccination and may also complicate SARS-CoV-2 infection. Summary Recent advancements in acute pericarditis have contributed to a better understanding of the disease allowing a tailored to the individual patient approach. However, there are still unsolved questions that require further research. Supplementary Information The online version contains supplementary material available at 10.1007/s11886-022-01710-8.
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Vecchié A, Del Buono MG, Mauro AG, Cremer PC, Imazio M, Klein AL, Abbate A, Dentali F, Bonaventura A. Advances in pharmacotherapy for acute and recurrent pericarditis. Expert Opin Pharmacother 2022; 23:681-691. [DOI: 10.1080/14656566.2022.2054327] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
| | - Marco Giuseppe Del Buono
- Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | | | - Paul C. Cremer
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Massimo Imazio
- Cardiology, Cardiothoracic Department, University Hospital “Santa Maria della Misericordia,” ASUFC, Udine, Italy
| | - Allan L. Klein
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Antonio Abbate
- Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Francesco Dentali
- Department of Medicine and Surgery, Insubria University, Varese, Italy
| | - Aldo Bonaventura
- Medicina Generale 1, Medical Center, Ospedale di Circolo e Fondazione Macchi, ASST Sette Laghi, Varese, Italy
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Lopalco G, Venerito V, Brucato A, Emmi G, Giacomelli R, Cauli A, Piga M, Parronchi P, Nivuori M, Malandrino D, Ruscitti P, Vitiello G, Fabiani C, Cantarini L, Iannone F. Anakinra effectiveness in refractory polyserositis: An Italian multicenter study. Joint Bone Spine 2021; 89:105299. [PMID: 34656754 DOI: 10.1016/j.jbspin.2021.105299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 10/01/2021] [Accepted: 10/04/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Polyserositis is an inflammatory condition involving different serosal membranes at the same time, specifically the pericardium, pleura, and peritoneum with exudates in the respective cavities. Treatment with non-steroidal anti-inflammatory drugs (NSAIDs), colchicine and glucocorticoids may be effective in patients with polyserositis, but relapses often occur when these drugs are tapered or discontinued. The interleukin (IL)-1 receptor antagonist anakinra has shown a beneficial effect in idiopathic recurrent pericarditis, mostly in unresponsive patients who develop steroid dependence and/or colchicine resistance. To date, there are no data suggesting the best therapy for managing acute episodes and/or relapses of polyserositis. On this basis, we performed a retrospective study aimed at evaluating the effectiveness and safety profile of anakinra in treating patients with refractory polyserositis. METHODS Patients with idiopathic polyserositis or rheumatic diseases presenting inflammation of 2 or more serous membranes were included. Serositis had to be confirmed by imaging tests comprising either echocardiography, abdominal ultrasound, chest or abdomen computed tomography and/or chest x-ray scan. We included patients with polyserositis who started anakinra from January 2011 to January 2019 due to a poorly controlled disease despite treatment with NSAIDs, conventional immunosuppressant drugs, or the need to minimize oral corticosteroids intake. Erythrocyte sedimentation rate (ESR), C reactive protein (CRP), and imaging tests, were recorded to monitor serositis at baseline and either at 3, 6 and 12-month follow-up. Patients with malignancies and infectious diseases were excluded from the analysis. RESULTS Forty-five patients with recurrent polyserositis (23 women) (mean age 43.2±15.8 years and mean disease duration 23.1±28 years) were analysed. Polyserositis was idiopathic in 26 (57.8%) patients. Thirteen patients suffered from autoinflammatory diseases, whereas 6 were affected by autoimmune diseases. Combination treatment with colchicine and NSAIDs at anakinra baseline was administered in 38/45 (84.4%) and 37/45 (82.2%) patients, respectively. After starting anakinra, 84.5% of patients experienced a resolution of serositis with a dramatic decrease in ESR and CRP (P<0.001, for both) already at 3 months, furthermore the same beneficial effect was observed up to 12 months. No relapse was seen at 3 months, whereas the median number of relapses at 6 and 12 months was 0 (interquartile range 0-1). Glucocorticoids were discontinued in 22/45 (48.9%) patients already after 3 months (P<0.001). After 12 months 32/37 (86.5%) patients were steroid-free. Similarly, NSAIDs use significantly was decreased at 3 months (7/45 [15.6%] patients, P<0.001), whereas at 12-month follow-up no patient was on NSAIDs. Urticarial rashes at anakinra injection site occurring in 3 patients were the most common adverse events. CONCLUSIONS Anakinra appeared to be a safe and useful therapeutic choice for patients refractory to optimal anti-inflammatory therapy (NSAIDs, colchicine and corticosteroids), allowing not only a dramatic reduction of recurrences but also of corticosteroids use. Anakinra was effective both in the idiopathic forms of polyserositis and in those with an underlying rheumatic disease, suggesting a common pathogenic pathway leading to serositis onset.
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Affiliation(s)
- Giuseppe Lopalco
- Department of Emergency and Organ Transplantation, Rheumatology Unit, University of Bari, Bari, Italy.
| | - Vincenzo Venerito
- Department of Emergency and Organ Transplantation, Rheumatology Unit, University of Bari, Bari, Italy
| | - Antonio Brucato
- Department of Biomedical and Clinical Sciences Luigi Sacco, Ospedale Fatebenefratelli, University of Milan, Milan, Italy
| | - Giacomo Emmi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Roberto Giacomelli
- Unit of Allergology, Immunology, Rheumatology, Department of Medicine, University of Campus Bio-Medico of Rome, Rome, Italy
| | - Alberto Cauli
- Rheumatology Unit, Department of Medical Sciences and Public Health, University of Cagliari and AOU University Clinic of Cagliari, Cagliari, Italy
| | - Matteo Piga
- Rheumatology Unit, Department of Medical Sciences and Public Health, University of Cagliari and AOU University Clinic of Cagliari, Cagliari, Italy
| | - Paola Parronchi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | | | - Danilo Malandrino
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Piero Ruscitti
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Gianfranco Vitiello
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Claudia Fabiani
- Ophthalmology Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Luca Cantarini
- Research Centre of Systemic Autoinflammatory Diseases, Behçet's Disease Clinic and Rheumatology-Ophthalmology Collaborative Uveitis Centre, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Florenzo Iannone
- Department of Emergency and Organ Transplantation, Rheumatology Unit, University of Bari, Bari, Italy
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Imazio M. Clinical Trials in Pericardial Disease: New Paradigm Shift. Curr Cardiol Rep 2021; 23:170. [PMID: 34633515 DOI: 10.1007/s11886-021-01587-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/05/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW Aim of the review is to discuss the results of major clinical trials and how they can have impact on clinical practice. RECENT FINDINGS Pericardial diseases have been the Cinderella of cardiovascular diseases for many years, but improvements in the knowledge of etiology and the pathophysiology especially of recurrent pericarditis have led to first clinical trials that have demonstrated the efficacy and safety of colchicine on top of standard anti-inflammatory therapies and of anti-IL-1 agents (anakinra and rilonacept) in corticosteroid-dependent and colchicine-resistant pericarditis. Current pooled data suggest that anti-IL-1 agents should be a first option for corticosteroid-dependent and colchicine-resistant recurrent pericarditis with evidence of systemic inflammation by means of elevated C-reactive protein. This could translate into an upgraded recommendation for these agents in future guidelines. Treatment of pericardial diseases is improving moving towards a more personalized therapy according to the presentation and etiology, and new or old drugs could be important to expand the therapeutic spectrum.
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Affiliation(s)
- Massimo Imazio
- Cardiology, Santa Maria Della Misericordia University Hospital, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC) , Cardiothoracic Dpt, Udine, Italy.
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Imazio M, Lazaros G, Gattorno M, LeWinter M, Abbate A, Brucato A, Klein A. Anti-interleukin-1 agents for pericarditis: a primer for cardiologists. Eur Heart J 2021; 43:2946-2957. [PMID: 34528670 PMCID: PMC9375710 DOI: 10.1093/eurheartj/ehab452] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 02/21/2021] [Accepted: 07/02/2021] [Indexed: 01/24/2023] Open
Abstract
Anti-interleukin (IL)-1 agents have been developed for the treatment of autoinflammatory and rheumatic conditions, where overproduction of IL-1 is an important pathophysiologic process. IL-1α and IL-1β are the most studied members of the IL-1 family of cytokines and have the strongest proinflammatory effects. A naturally occurring antagonist (IL-1Ra) mitigates their proinflammatory effects. Overproduction of both IL-1α (released by inflamed/damaged pericardial cells) and IL-1β (released by inflammatory cells) is now a well-recognized therapeutic target in patients with recurrent idiopathic pericarditis. Currently, there are three available anti-IL-1 agents: anakinra (recombinant human IL-1Ra), rilonacept (a soluble decoy receptor ‘trap’, binding both IL-1α and IL-1β), and canakinumab (human monoclonal anti-IL-1β antibody). For patients with corticosteroid-dependent and colchicine-resistant recurrent pericarditis with evidence of systemic inflammation, as evidenced by elevated C-reactive protein, the efficacy and safety of anakinra (2 mg/kg/day up to 100 mg/day subcutaneously usually for at least 6 months, then tapered) and rilonacept (320 mg subcutaneously for the first day followed by 160 mg subcutaneously weekly) have been clearly demonstrated in observational studies and randomized controlled clinical trials. Severe side effects are rare and discontinuation rates are very low (<4%). The most common reported side effect is injection site reactions (>50% of patients). In this article, we describe the historical and pathophysiological background and provide a comprehensive review of these agents, which appear to be the most significant advance in medical therapy of recurrent pericarditis in the last 5 years.
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Affiliation(s)
- Massimo Imazio
- Head of Cardiology, Cardiothoracic Department, University Hospital "Santa Maria della Misericordia", ASUFC, Piazzale Santa Maria della Misericordia 15, Udine 33100, Italy
| | - George Lazaros
- 1st Cardiology Clinic, National and Kapodistrian University of Athens, School of Medicine, Hippokration General Hospital, Athens, Greece
| | - Marco Gattorno
- Center for Autoinflammatory Diseases and Immunodeficiencies, IRCCS G. Gaslini, Genova, Italy
| | - Martin LeWinter
- Cardiology Unit, University of Vermont Medical Center, Burlington, VT, USA
| | - Antonio Abbate
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, USA
| | - Antonio Brucato
- Department of Biomedical and Clinical Sciences "Sacco", Fatebenefratelli Hospital, Università di Milano, Milan, Italy
| | - Allan Klein
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, USA
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12
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Schwier NC. Rilonacept: A Newly Approved Treatment for Recurrent Pericarditis. Ann Pharmacother 2021; 56:572-581. [PMID: 34459270 DOI: 10.1177/10600280211036499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To review the pharmacology, efficacy, and safety of rilonacept for the prevention and treatment of recurrent pericarditis (RP). DATA SOURCES A MEDLINE search was conducted between January 2006 and April 2021 using the following terms: rilonacept, pharmacology, pericarditis, recurrent pericarditis, interleukin (IL) antagonist, and pharmacology; prescribing information was also used. STUDY SELECTION AND DATA EXTRACTION English-language studies assessing pharmacology, efficacy, and safety of IL antagonists were reviewed. DATA SYNTHESIS Rilonacept traps IL-1α and IL-1β. In the Phase III trial, rilonacept was associated with a lower risk of recurrence, more persistent clinical response, and higher amount of days with no or minimal pericarditis symptoms, compared with placebo. The median time to pain response was 5 days, and median time to normalization of C-reactive protein was 7 days with rilonacept. All patients receiving rilonacept during the run-in period were able to be weaned off of standard background therapy, leading to transition to rilonacept monotherapy. The most common adverse effects were upper respiratory tract infections and injection site reactions. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE Rilonacept may be used for the prevention and treatment of multiple recurrences in patients receiving background therapy for RP, and reduction in risk of recurrence in adults and adolescents ≥12 years with elevated C-reactive protein. Rilonacept may be considered to wean patients from standard background therapy. CONCLUSION Rilonacept is a safe, once weekly, subcutaneously administered IL-1 "trap," indicated for the treatment of RP, and reduction in risk of recurrent pericarditis in adults and children ≥12 years of age.
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Affiliation(s)
- Nicholas C Schwier
- University of Oklahoma Health Sciences Center College of Pharmacy, Oklahoma City, OK, USA
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Imazio M. Current treatment of recurrent pericarditis: safety considerations and future directions. Expert Opin Drug Saf 2021; 21:183-190. [PMID: 34334059 DOI: 10.1080/14740338.2021.1960980] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Recurrent pericarditis is one of the most troublesome complications of pericarditis affecting a substantial amount of patients and often severely impairing the quality of life. Current medical treatments range from non-steroidal anti-inflammatory drugs (NSAIDs), colchicine and corticosteroids to biological agents (anti IL-1 agents, especially anakinra and rilonacept), intravenous immunoglobulins and immunosuppressive treatments. Safety is a major issue to deal with since the disease often affects relatively young or middle-aged patients. AREAS COVERED The review is aimed at providing an update on the efficacy and safety of current medical therapies for recurrent pericarditis including most recent advances represented by anti IL-1 agents. EXPERT OPINION Therapy of recurrent pericarditis has evolved over years leading to a more evidence-based and personalized treatment based on clinical presentation and pathophysiology. The main distinction is between patients with an inflammatory phenotype (e.g. fever, elevation of markers of inflammation, pericardial and/or pleural effusion) vs. those without an inflammatory phenotype. Colchicine and anti IL-1 agents are especially efficacious and indicated for those with an inflammatory phenotype, while corticosteroids, azathioprine and immunoglobulins seem more indicated for those without evidence of systemic inflammation.
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Affiliation(s)
- Massimo Imazio
- Cardiology, Cardiothoracic Department, Santa Maria della Misericordia University Hospital, Azienda Sanitaria Universitaria del Friuli Centrale (ASUFC), Udine, Italy
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14
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Anthony C, Collier P. Anti-interleukin-1 for recurrent pericarditis; maybe a fix (but prior studies do not really mix). Heart 2021; 107:1196-1198. [PMID: 33972359 DOI: 10.1136/heartjnl-2021-319282] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Affiliation(s)
- Chris Anthony
- Cardiovascular Imaging, Cleveland Clinic, Cleveland, Ohio, USA
| | - Patrick Collier
- Cardiovascular Imaging, Cleveland Clinic, Cleveland, Ohio, USA
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15
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Otto CM. Heartbeat: improved diagnosis of familial hypercholesterolaemia. Heart 2021; 107:1185-1187. [PMID: 37982698 DOI: 10.1136/heartjnl-2021-319928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Catherine M Otto
- Division of Cardiology, University of Washington, Seattle, Washington, USA
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