Blocking interleukin-1 in pericarditis: Should we move earlier and stronger?

Acute pericarditis is generally a benign condition, yet 15-30% of patients will develop recurrent pericarditis. Standard first-line therapy combines non-steroidal anti-inflammatory drugs or aspirin with colchicine, which reduces but does not eliminate the risk of recurrence. Patients presenting with a high inflammatory burden, subacute evolution or large pericardial effusion are particularly prone to recurrence, and corticosteroid exposure - still frequent in clinical practice - further increases this risk. Over the last decade, the central role of interleukin-1 (IL-1) in pericardial inflammation has been demonstrated, and IL-1 inhibitors have emerged as the most effective treatment for colchicine-resistant or corticosteroid-dependent recurrent pericarditis. Anakinra, rilonacept and other IL-1-targeting agents provide rapid symptom resolution and dramatically reduce recurrences, thereby transforming the management of difficult-to-treat forms of the disease. This review summarizes current knowledge on the IL-1 pathway in pericarditis and examines whether earlier, targeted intervention could modify disease trajectory, particularly in patients identified as having a high risk of recurrence at presentation. Drawing parallels with Still's disease, in which early IL-1 inhibition improves long-term outcomes, these data support the need for high-quality trials evaluating IL-1 blockade as a first-line strategy in selected patients with acute pericarditis.