Internal Medicine Resident University of Ottawa Heart Institute Ottawa, Ontario, Canada
Background: One of the most troublesome complications of acute pericarditis is recurrence, as treatment is often challenging. Non-steroidal anti-inflammatory drugs (NSAIDs) and colchicine form the cornerstone treatment for pericarditis, with the addition of corticosteroids in cases of incomplete response. Recent evidence also suggests a role for interleukin-1 (IL-1) antagonists in challenging cases of recurrent pericarditis. However, with an increasing number of potential therapies to treat pericarditis, the relative efficacy of these anti-inflammatory therapies is unknown. The objective of this study was to examine the comparative efficacy of anti-inflammatory treatments for recurrent pericarditis risk reduction.
METHODS AND RESULTS: We searched Medline, Embase, and the Cochrane Central Register of Controlled Trials in October 2023. We included randomized controlled trials (RCTs) and prospective cohort studies of patients with pericarditis treated with a drug with anti-inflammatory properties compared with those treated with a control. The main outcome evaluated was pericarditis recurrence.
A total of 6,831 studies were screened, of which 25 articles were included (14 RCTs and 11 cohort studies). The total number of patients included in the study was 3,561. The mean age across studies was 53.49 years and the percentage of females was 45.1%. The average follow-up duration was 19.3 months. Bayesian network meta-analysis was performed to calculate risk estimates using a random effects model (Figure 1). In our analysis, goflikicept showed a significant reduction in recurrent pericarditis rates (OR: 0.00, 95% Credible Limits [Crl]: 0.00-0.08) and had the highest probability of being ranked best at reducing pericarditis rates (Surface Under the Cumulative Ranking Curve [SUCRA]: 0.9038, Figure 2). Similarly, anakinra (OR: 0.01, 95% Crl: 0.00-0.13), rilonacept (OR: 0.02, 95% Crl: 0.00-0.22) and colchicine (OR: 0.35, 95% Crl: 0.19-0.64) were associated with a significant reduction in recurrent pericarditis events, with anakinra ranking second best at reducing pericarditis events (SUCRA: 0.8140). High dose colchicine (OR: 0.70, 95% Crl: 0.13-4.12) was not superior to regular dose colchicine (1 mg vs 0.6 mg twice daily, respectively). Interestingly, there was not enough data to make a meaningful comparison between steroids and control.
Conclusion: In patients with pericarditis, goflikicept, rilonacept, and anakinra were most effective at reducing recurrent pericarditis. Our study also corroborates evidence regarding the efficacy of colchicine in reducing pericarditis recurrence. For a comprehensive analysis of the benefits and harms of anti-inflammatory therapies, larger comparative studies or network meta-analyses of patient-level data are required.
