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Three Part Question

In [adult patients with a first episode of acute pericarditis] is [colchicine plus NSAIDs better than NSAIDSs alone] at [relieving pain and preventing recurrence]?

Clinical Scenario

A 32-year-old woman with no significant medical history presents to the emergency department with chest pain and dyspnoea. A pericardial friction rub is heard on examination. The ECG shows PR depression and widespread saddle shaped ST elevation. You diagnose acute pericarditis and prescribe a course of non-steroidal anti-inflammatory drugs (NSAIDs). However, recalling that colchicine may be useful for recurrent pericarditis, you wonder whether it is effective for a first episode of acute pericarditis.

Search Strategy

MEDLINE 1950–2010 November Week 2 and EMBASE 1980–2010 Week 46 via the Ovid interface. The Cochrane Library, November 2010-11-24.
MEDLINE and EMBASE: (exp colchicine/OR colchicine.mp) AND (exp pericarditis/OR exp pericarditis, constrictive/OR pericarditi$.mp.). Limit to human and English language. Cochrane: colchicine AND pericarditi*.

Search Outcome

One hundred and eighty-seven papers were identified in EMBASE, 76 in MEDLINE and six in the Cochrane Library, one of which was relevant to the three-part question

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Imazio et al, 2005, Italy	120 patients were randomised to aspirin alone or aspirin and colchicine	Randomised controlled trial	Recurrence rate (primary outcome)	Lower in colchicine group (10.7% vs 32.3%, p=0.003)	Open label design. End points subjective
			Symptom persistence at 72 h from treatment onset (secondary outcome)	Lower in colchicine group (11.7% vs 36.7%, p=0.003)

Comment(s)

Colchicine is commonly used for the treatment of gout. It exerts anti-inflammatory effects by inhibiting neutrophil adhesion, mobility and cytokine activity. Previous trials have demonstrated that, in patients presenting with recurrent pericarditis, colchicine may help to prevent further recurrences. Following this, published a case series of 19 patients with acute pericarditis who apparently responded well to treatment with colchicine with only two recurrences within 5 months.

The only randomised controlled trial to date has demonstrated lower rates of recurrence and symptom persistence after 72 h among patients treated with colchicine. In that study, five (8.3%) patients discontinued colchicine therapy owing to side effects (mainly diarrhoea and abdominal pain). The choice of aspirin alone as ‘standard therapy’ in contrast with more conventional NSAIDs is perhaps open to debate. Thus the beneficial effects of colchicine may be smaller than estimated in this study.

More evidence is clearly needed in order to provide a definitive answer to the three-part question. The forthcoming Investigation on Colchicine for Acute Pericarditis (ICAP) trial is a multicentre, randomised, placebo controlled trial that will help to provide this information. However, despite the potential shortcoming of the only published randomised controlled trial, colchicine in addition to NSAIDs would appear to be more effective at relieving symptoms and preventing recurrence of pericarditis than NSAIDs alone.

Clinical Bottom Line

Although evidence is still lacking, there is some evidence that colchicine may lead to faster resolution of symptoms and lower recurrence rates than NSAID therapy alone in patients with a first episode of acute pericarditis.

References

1. Imazio M, Cecchi E, Ierna S, et al. on behalf of the ICAP Investigators. Investigation on colchicine for acute pericarditis: A multicenter randomized placebo-controlled trial evaluating the clinical benefits of colchicine as adjunct to conventional therapy in the treatment and prevention of pericarditis; study design... J Cardiovasc Med (Hagerstown) 2007;8:613–17.
2. Imazio M, Bobbio M, Cecchi E, et al. Colchicine in addition to conventional therapy for acute pericarditis: Results of the COlchicine for acute PEricarditis (COPE) trial. Circulation 2005;112:2012–16.
3. Millaire A, Ducloux G, Guindo J, et al. Treatment of acute or recurrent pericarditis with colchicine Circulation 1991;83:1458–9.
4. Lotrionte M, Biondi-Zoccai G, Imazio M, et al. International collaborative systematic review of controlled clinical trials on pharmacologic treatments for acute pericarditis and its recurrences. Am Heart J 2010;160:662–70.
5. Imazio M, Brucato A, Trinchero R, et al. Colchicine for pericarditis: hype or hope? Eur Heart J 2009;30:532–9.