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Three Part Question

In [adult patients with a first episode of acute pericarditis] is [colchicine monotherapy],[safe and effective in preventing recurrence]?

Clinical Scenario

A 44-year-old diabetic male is diagnosed in the emergency department with acute pericarditis following a viral illness. He is allergic to nonsteroidal anti-inflammatory drugs. You wonder about the safety and efficacy of colchicine as stand-alone therapy for the prevention of recurrent pericarditis.

Search Strategy

Medline 1966-05/15 using OVID interface, Cochrane Library (2015), and Embase.


[(Exp Pericarditis/drug therapy) AND (exp Colchicine/therapeutic use)]. Limit to English language.

Search Outcome

50 papers were identified, none were relevant to the clinical question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses

Comment(s)

Over the last years, objective clinical evidence has matured and clearly indicates the important role and beneficial clinical effect of colchicine therapy in preventing recurrent pericarditis caused by various aetiologies. Colchicine-treated patients consistently display significantly fewer recurrences and longer symptom-free periods, and even initial primary attacks are weaker and shorter in nature. Recently there have been a multitude of studies investigating colchicine in combination with NSAIDS. These include landmark studies such as the COlchicine for acute PEricarditis (COPE) Trial, COlchicine for REcurrent pericarditis) Trial, Colchicine for Recurrent Pericarditis Trial (CORP), CORP-2 and ICAP. All of these have been evaluated in recent meta-analyses1 that show a clear benefit of adding colchicine to the standard NSAIDs treatment of acute pericarditis. None of the studies investigate colchicine as a solo treatment, however it is worthwhile to note that randomised control trials of NSAIDs as monotherapy are also lacking for acute viral pericarditis. Colchicine is an old medication with fatal toxicity at doses greater than 0.5 mg/kg. However at the studied dosage (0.5 mg twice daily) there was no difference in relative risk ratio for adverse outcomes compared with placebo. It is well tolerated with fewer side effects than NSAIDs. Its main side effect is diarrhoea and nausea. As noted there are no studies of colchicine as a monotherapy in acute viral pericarditis, but there are some indications that it could be efficacious: (1) Colchicine is used as monotherapy for the inflammatory diseases of gout, and familial Mediterranean fever; (2) The COPPS study of colchicine versus placebo had an number needed to treat (NNT)=8 to reduce postpericardiotomy syndrome, which is an entity similar to idiopathic pericarditis; (3) A small retrospective study of colchicine use in patients with systemic lupus erythematosus with acute pericarditis showed it may be steroid sparing in patients who cannot use NSAIDs;2 and (4) Colchicine as monotherapy is included in the 2004 European Society of Cardiology guidelines and was assigned the same level of evidence (B) and class (II), as monotherapy with NSAIDs.3

Clinical Bottom Line

There is no evidence supporting colchicine use as monotherapy, though inference suggests benefit and further studies are recommended.

References

1. Raval J, Nagaraja V, Eslick GD, et al. The role of colchicine in pericarditis—a systematic review and meta-analysis of randomised trials. Heart Lung Circ 2015;24:660–6.
2. Morel N, Bonjour M, Le Guern V, et al. Colchicine: a simple and effective treatment for pericarditis in systemic lupus erythematosus? A report of 10 cases. Lupus 2015;24:1479–85.
3. Maisch B, Seferović PM, Ristić AD, et al., 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; The Task force on the diagnosis and management of pericardial diseases of the European society of cardiology. Eur Heart J 2004;25:587–610