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April 1, 2006

How can recurrent episodes of noninfectious pericarditis best be prevented?

How can recurrent episodes of noninfectious pericarditis best be prevented?

Patients with acute pericarditis often present initially to their primary care provider. If the inflammation results from bacterial or mycobacterial infection, it requires aggressive therapy, often with consultative assistance. Pericarditis that arises from another cause-such as idiopathic inflammation, viral infections, connective tissue diseases, and post-pericardiotomy syndrome-has traditionally been treated with aspirin.

Nonbacterial, acute pericarditis recurs in as many as 50% of the patients after the initial attack.1 Thus, the management approach is 2-fold:

  • First, treat the acute disease to decrease pain and inflammation.

  • Second, minimize recurrences, which are presumed to be autoimmune.

What if one drug could accomplish both goals with few adverse effects?

NEW USE FOR AN OLD STANDBY

Investigators in Italy studied colchicine-the anti-inflammatory standby used to treat gout-as an adjunct to aspirin for the management of acute pericarditis.1 The COPE (COlchicine for acute PEricarditis) trial included 120 patients with acute, noninfectious pericarditis who had at least 2 of the following criteria: typical chest pain, pericardial friction rub, and widespread ST-segment elevation on ECG. The participants were randomized to receive either aspirin alone (800 mg orally every 6 to 8 hours for 7 to 10 days with tapering over 3 to 4 weeks) or aspirin at the same dosage with colchicine (1 to 2 mg for the first day and then 0.5 to 1 mg daily for 3 months). Corticosteroids were reserved for patients who were intolerant of aspirin.

The design of the study was randomized, open-label, and parallel. The participants and their primary care providers were aware of which medications the patients were taking. However, clinical validation of a response to therapy was provided by a panel of cardiologists who were blinded to the treatment group.

During nearly 3000 months of patient follow-up, the addition of colchicine to aspirin therapy reduced acute symptoms at 72 hours (11.7% vs 36.7% in the aspirin-alone group) and recurrence at 18 months (10.7% vs 32.3%). No serious adverse effects of colchicine occurred. It was discontinued in 5 patients because of diarrhea, a side effect often seen when colchicine is used to treat acute gouty arthritis. Corticosteroid therapy for acute pericarditis increased the risk of recurrence (the odds ratio was 4.3, which means that about 4.3 times as many recurrences would occur in the corticosteroid-treated group).

IMPLICATIONS FOR YOUR PRACTICE

The addition of colchicine to aspirin therapy can help diminish the symptoms of acute noninfectious pericarditis and decrease the risk of recurrence. Avoid corticosteroids if at all possible because they can increase the likelihood of recurrence.

References:

REFERENCE:


1.

Imazio M, Bobbio M, Cecchi E, et al. Colchicine in addition to conventional therapy for acute pericarditis: results of the COlchicine for acute PEricarditis (COPE) trial.

Circulation.

2005;112:2012-2016.