Recurrent pericarditis: is Anakinra the only solution? Diagnostic and therapeutical insights from long-term follow-up of a large monocentric cohort

Abstract Background Recurrence is the most frequent pericarditis complication. Although Anakinra, an anti-IL-1 agent, has become standard of care for acute idiopathic recurrent pericarditis, no evidence exists on the best selection criteria for its use. Moreover, the prognostic role of non-guideline-based initial therapy in pericarditis has not been studied. Purpose 1) to analyse the real-world use of guideline-based medical therapy in pericarditis, 2) to compare patients with a complicated (recurrent, incessant or chronic) and uncomplicated pericarditis presentation, 3) to describe how a readjustment of first-line medical therapy may reduce Anakinra use. Methods Pericarditis patients followed-up at our Cardio-immunology outpatient clinic were included. Patients were classified among uncomplicated and complicated pericarditis presentation. After referral to our center, medical tratment for pericarditis was considered non—guideline based based on these criteria: 1) inadequately low dosage without contraindications, 2) inadequate drug combinations (i.e. omitting colchicine or using corticosteroids as first-line), 3) excessively fast tapering. Medical therapy was readjusted when appropriate and subsequent pericarditis recurrences were recorded. Univariable regression models were used to assess for pericardtis recurrence predictors. Results We retrospectively included 248 pericarditis patients (median age 49 years old, 59% male); 104 (42%) were referred with a history of complicated pericarditis. Idiopathic or presumed viral aetiology was the most common (78%). Fist-line pericarditis treatment included colchicine (74%), non-steroidal anti-inflammatory drugs (NSAIDs, 86%), and steroids (23%), and was not in line with ESC guidelines in 24%. After 18 months median follow-up, persistent chest pain was reported in only 5.2% cases. Treatment at last follow-up had changed significantly after referral to our centre: 76% patients were on colchicine, 13% on NSAIDs and 13% on steroids. Remarkably, out of the 248 total patients, and of the 104 previously classified complicated pericarditis patients, after medical therapy readjustment only 26 (6%) patients required treatment with anakinra. Patients with complicated pericarditis had been less frequently treated with colchicine (71% vs. 87% p=0.035), and more frequently with steroids (38% vs. 13%. p0.001) than uncomplicated patients. On univariable analysis, appropriate NSAID treatment was significantly associated with lower recurrence risk (OR = 0.22, 95% CI: 0.08–0.58, p = 0.002), suggesting that guideline-based NSAID use is protective. Conclusions First-line treatment for acute pericarditis is not in line with ESC guidelines in a relevant proportion of cases. For the first time, a predictive role of inappropriate first-line NSAID treatment for recurrence has been identified. A simple readjustment of treatment, i.e. re-challenge of guideline-based first-line drugs, may reduce the need for Anakinra.