Imaging advances, targeted therapies improve outlook for recurrent pericarditis
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Advances in imaging techniques and new treatments are changing the management of recurrent pericarditis, improving outcomes for patients with formerly treatment-resistant disease, researchers reported.
Recurrent pericarditis is a chronic debilitating condition that complicates up to one-third of acute pericarditis cases; patients often progress to have colchicine-resistant and corticosteroid-dependent disease, according to Allan L. Klein, MD, director of the Center for the Diagnosis and Treatment of Pericardial Diseases and a staff cardiologist in the section of CV imaging, the Robert and Suzanne Tomsich Department of Cardiovascular Medicine, at the Sydell and Arnold Miller Family Heart, Vascular & Thoracic Institute at Cleveland Clinic.
“After an acute episode of pericarditis, it is often undertreated,” Klein told Healio. “Patients get better for a short time while on therapy — 4 to 6 weeks — and then it comes back, often due to undertreatment treatment or prescribing the wrong anti-inflammatories. Often, patients are prescribed triple therapy including NSAIDs, colchicine and steroids, which is difficult to wean and brings all of the complications of steroids. We propose there might be a better way to diagnose and manage these patients.”
In a clinical review published in JAMA Cardiology, Klein and colleagues highlighted clinical trials and registry data that demonstrate the efficacy of interleukin-1 blockers in recurrent pericarditis. In addition, new observational data support use of cardiac MRI in the diagnosis, risk stratification and management of recurrent pericarditis.
Better use of imaging
For a diagnosis of recurrence, clinicians traditionally rely on symptomatology and inflammatory markers, which lack the desired accuracy, the researchers wrote. Cardiac MRI can provide more insight into the histopathology, progression and prognosis of pericarditis by providing pericardial tissue characterization, providing data on whether to continue, taper or intensify an anti-inflammatory regimen, Klein said.
“Cardiac MRI is able to provide information on how acute or subacute the case is,” Klein said in an interview. “For example, we look at edema around the heart and the severity of the late gadolinium enhancement. When you give the contrast medium, it lights up the pericardium due to neovascularization. From that combination, we can now predict how many drugs the patient will need and for how long they will have the disease. That should be part of the clinical criteria.”
Challenge of adequate treatment
There are limited therapeutic options to treat recurrent pericarditis and the adverse event profile of various anti-inflammatory agents can make treatment challenging, Klein said.
The researchers noted that interleukin-1 blockers are a “leap forward” in the treatment of colchicine-resistant, corticosteroid-dependent recurrent pericarditis. As Healio previously reported, in the RHAPSODY trial, rilonacept (Arcalyst, Kiniksa Pharmaceuticals), an interleukin (IL)-1-alpha and IL-1-beta cytokine trap, better resolved recurrent episodes and lowered risk for future episodes for patients with recurrent pericarditis compared with placebo.
“In our trial, we tested the utility of biologics, in particular rilonacept, to help improve patients who are steroid-dependent and colchicine-resistant,” Klein said. “We have to look carefully, because perhaps we can bypass prednisone. After the first-line treatments, you may consider moving on to the biologics, like rilonacept instead of steroids. This has not been uniformly tested, but that is what we are promoting, especially if you have an inflammatory phenotype with chest pain and elevated C-reactive protein.”
Klein said advances in imaging and targeted therapies have led to a change in thinking in the management of recurrent pericarditis. Rapidly evolving cardiac MRI techniques and novel targeted therapies now allow imaging-guided therapy for recurrent pericarditis. However, the optimal application of these recent advances remains unclear.
Klein said more research is needed on IL-1 blockers and duration of therapy.
“IL-1 blockers are relatively safe and when a patient fails ibuprofen and colchicine, these should be go-to drugs,” Klein told Healio. “What we do not know is for how long. I treat anywhere from 6 months to 1 year, but serious advanced cases may require treatment for more than 1 year. We need more trials with the IL-1 blockers and other drugs that affect the inflammasomes.”
For more information:
Allan L. Klein, MD, can be reached at kleina@ccf.org.
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