Researchers recommend low corticosteroid doses for recurrent pericarditis

12 August 2008

MedWire News: Patients with recurrent pericarditis would benefit from treatment with lower doses of prednisone than are commonly used, study findings suggest.

"Despite the fact that guidelines and reviews recommend limiting the use of corticosteroids in pericarditis, the use of these drugs is widespread," explain the study authors, led by Massimo Imazio from Maria Vittoria Hospital in Torino, Italy.

They also note that reviews and current European guidelines on the management of pericardial diseases have recommended the use of high doses of prednisone (1.0 to 1.5 mg/kg/day) for 1 month in patients with recurrent pericarditis when corticosteroids are considered, despite only a single small retrospective study supporting high-dose use.

Imazio and team compared the side effects, recurrences, and hospitalizations associated with low- and high-dose regimens of prednisone for recurrent pericarditis. They retrospectively reviewed all cases of recurrent pericarditis treated with corticosteroids in two Italian referral centers between January 1996 and June 2004.

A total of 100 patients (57 women; mean age 50.1 years) with recurrent pericarditis were included in the study, of whom 49 were treated with low doses (0.2 to 0.5 mg/kg/day) of prednisone and 51 were treated with high-dose (1.0 mg/kg/day) prednisone. Initial doses were maintained for 4 weeks and then slowly tapered.

Patients treated with high-dose prednisone had a higher rate of severe side effects, compared with patients who received lower doses (23.5% vs 2.0%; p=0.002).

Pericarditis recurrence was less frequent in patients treated with lower doses, compared with those who received high-dose prednisone (32.6% vs 64.7%; p=0.002), and minor side effects and disease-related hospitalizations were also less common with lower doses (8.2% vs 31.4%; p=0.005).

After adjustment for potential confounders (including age, female gender, and nonidiopathic origin), only high-dose prednisone was associated with severe side effects, recurrences, and hospitalizations, at a hazard ratio of 3.61 (p<0.001).

The researchers also noted that event-free survival was greater in patients treated with lower doses of prednisone than in those who received high-dose prednisone.

"Corticosteroid therapy is a double-edged weapon in patients with pericardial diseases; it may have specific but rare indications, but it should be used as a last resort," comment Imazio and colleagues in the journal Circulation.

According to Ralph Shabetai (Veterans Affairs Health Care System, La Jolla, California, USA), who authored an accompanying editorial in the same issue of Circulation, "physicians should be reluctant to use a corticosteroid for recurrent pericarditis but strive to treat the patients with a non-steroidal anti-inflammatory drug."

However, he added: "When it is clear that steroid use is inevitable, the duration of treatment and the schedule for tapering should be the ones recommended by Imazio et al. More data will be needed before the lower loading dose can be recommended, but with the data we do have, it would be a reasonable alternative."

Circulation 2008; 118: 667-671