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European Heart Journal Advance Access originally published online on October 4, 2005
European Heart Journal 2005 26(23):2600-2601; doi:10.1093/eurheartj/ehi567
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© The European Society of Cardiology 2005. All rights reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org

Recurrent pericarditis: therapy of refractory cases

Antonio Brucato

Department of Medicine and Rheumatology
Niguarda Hospital
Via Del Bollo 4
Milano 20123
Italy
Tel: +39 264442674
Fax: +39 264442615
E-mail address:
antonio.brucato{at}ospedaleniguarda.it

Giovanni Brambilla

Department of Emergency Medicine
Niguarda Hospital
Milano
Italy

Yehuda Adler

Cardiac Rehabilitation Institute
Sheba Medical Center
Tel-Hashomer
Israel

David H. Spodick

Department of Cardiovascular Medicine
University of Massachusetts Medical School
Worcester
MA
USA

We read with interest the excellent Editorial by Maisch1 referring to the article by Artom et al.2 in which we are co-authors. We take this opportunity to comment on a minor point that anyway might be clinically relevant. Maisch writes that in refractory cases, azathioprine (75–100 mg/day) or cyclophosphamide can be added. This is also suggested by the European Guidelines recently published3 and has been quoted by authoritative reviews.4 Unfortunately, there is only one old article describing the use of azathioprine in this condition in two patients,5 and those authors acknowledged that ‘to suggest that azathioprine therapy is indicated in the treatment of steroid responsive pericarditis would indeed be presumptuous on the basis of these two cases’; other authors described other three cases.6,7 Moreover, there is no single article concerning cyclophosphamide (only one case described by Marcolongo et al.6), whereas Raatikka et al.7 reported five cases treated with methotrexate and one with cyclosporine and Peterlana et al.8 described four cases treated with intravenous immunoglobulin. Rheumatologists commonly use azathioprine, cyclophosphamide, cyclosporine, methotrexate, hydroxychloroquine, and intravenous immunoglobulin; we agree that azathioprine is the preferred choice if tolerated (at the common dosage of 2–3 mg/kg/die), but we suggest that it would be more prudent to state that probably immunosuppressive agents and steroid sparing agents might be used very rarely in refractory cases, acknowledging that we have no evidence-based data, preferring the less toxic and less expensive drugs (e.g. azathioprine and methotrexate), and tailoring the therapy on the single patient (e.g. cyclophosphamide should be used only in severe cases and avoided in young fertile women because it can cause infertility) and, importantly, with the patient informed consent.

References

  1. Maisch B. Recurrent pericarditis: mysterious or not so mysterious? Eur Heart J 2005;26:631–633.[Free Full Text]
  2. Artom G, Koren-Morag N, Spodick DH, Brucato A, Guindo J, Bayes-de-Luna A, Brambilla G, Finkelstein Y, Granel B, Bayes-Genis A, Schwammenthal E, Adler Y. Pretreatment with corticosteroids attenuates the efficacy of colchicine in preventing recurrent pericarditis: a multi-center all-case analysis. Eur Heart J 2005;26:723–727.[Abstract/Free Full Text]
  3. Maisch B, Seferovich PM, Ristic AD, Erbel R, Rienmuller R, Adler Y, Thiene G, Tomkowsky W, Yacoub MH. The task force on the diagnosis and management of pericardial diseases of the European Society of Cardiology. Guidelines on the Diagnosis and Management of Pericardial Diseases. Executive summary. Eur Heart J 2004;25:587–610.[Free Full Text]
  4. Troughton RW, Asher CR, Klein AL. Pericarditis. Lancet 2004;363:717–727.[CrossRef][Web of Science][Medline]
  5. Asplen CH, Levine HD. Azathioprine therapy of steroid-responsive pericarditis. Am Heart J 1970;80:109–111.[CrossRef][Web of Science][Medline]
  6. Marcolongo R, Russo R, Laveder F, Noventa F, Agostini C. Immunosuppressive therapy prevents recurrent pericarditis. J Am Coll Cardiol 1995;26:1276–1279.[Abstract]
  7. Raatikka M, Pelkonen PM, Karjalainen J, Jokinen EV. Recurrent pericarditis in children and adolescents: report of 15 cases. J Am Coll Cardiol 2003;42:759–764.[Abstract/Free Full Text]
  8. Peterlana D, Puccetti A, Simeoni S, Tinazzi E, Corrocher R, Lunardi C. Efficacy of intravenous immunoglobulin in chronic idiopathic pericarditis: report of four cases. Clin Rheumatol 2005;24:18–21.[CrossRef][Web of Science][Medline]

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This Article
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