For Idiopathic Pericarditis, Is Standard Therapy Still the Best?

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For Idiopathic Pericarditis, Is Standard Therapy Still the Best?

In 2004, the treatment guidelines for pericarditis issued by the European Society of Cardiology (ESC) were largely based on a single randomized trial and nonrandomized data; since then, the results of several major trials have added to the pharmacotherapeutic evidence surrounding idiopathic (viral) pericarditis treatment. A review in Pharmacotherapy explores both contemporary pharmacotherapeutic therapies and emerging treatments and management strategies for pericarditis.

Data from recent studies indicate that nonsteroidal anti-inflammatory drugs (NSAIDs) or aspirin (ASA) should be used as first-line therapy in combination with colchicine for relief of pain and resolution of inflammation, although NSAID/ASA therapy does not alter the natural history of pericarditis. No studies have compared the safety or efficacy of different NSAIDs for pericarditis, but because higher doses of NSAIDs/ASA should be used to achieve anti-inflammatory effects the potential for adverse effects should be considered with NSAID selection.

While colchicine is currently only indicated for the treatment and prophylaxis of gout flares and for the treatment of familial Mediterranean fever, it can decrease leukocyte motility and phagocytosis that in turn reduce the inflammatory response. Patients taking colchicine must adhere to treatment for a range of 3–12 months, with careful monitoring for adverse events such as diarrhea, nausea, and vomiting.

Limited use of corticosteroids is advised due to concerns about systemic adverse effects and a prolonged need for treatment, even though they initiate rapid symptom control and initial remission of symptoms. If corticosteroids are included in treatment, tapering and hs-CRP guided therapy is recommended.

Lastly, off-label use of anakinra, azathioprine, high-dose intravenous immunoglobulin (IVIG), methotrexate, and cyclophosphamide have shown to be beneficial in some studies but the risk of adverse events varies greatly. 

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