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Acute inflammation of
the pericardium is frequently of idiopathic etiology, nonetheless it can also be
secondary to systemic infection, acute myocardial infarction, cardiac
contusion, and autoimmune diseases. 1

Probably the most troublesome complication of acute pericarditis would be the
growth of recurrent episodes of pericardial inflammation,
occurring in 15% to 32% of cases. 2 3 4 5 Recurrent
pericarditis is, generally, idiopathic. The
pathophysiological process may involve the immune
system6,7: high titers of anti-myocardial
antibodies have been discovered in postopen heart surgery patients with
acute pericarditis. The perfect means for preventing
recurrences is not established. Therapeutic modalities
are nonspecific and include nonsteroidal anti-inflammatory drugs
(NSAIDs), corticosteroids, immunosuppressive agents,
and pericardiectomy. 1 8 Relapses also can occur
during reduction of drug doses (incessant pericarditis) or at varying
intervals after discontinuation of treatment (recurrent
pericarditis). 9 Because treatment methods are often
difficult and recurrences may occur for many
years,10 constant work is being directed
toward establishing better path for prevention. In light of recent
trial data, we'll study the evidence supporting the use of
colchicine in preventing recurrent episodes of pericarditis.

On such basis as proven efficacy of colchicine in preventing relapses of
systemic inflammatory processes in familial Mediterranean fever
(recurrent polyserositis),11 12 Rodriguez de la
Serna and colleagues13 suggested later that
colchicine be utilized to prevent recurrences of acute
pericarditis. They reported on 3 patients who had recurrent
pericarditis (2 idiopathic and 1 with systemic lupus
erythematosus), despite adequate treatment with
corticosteroids. All were helped by colchicine (1
mg/d) with tapering on the corticosteroids within 2
months. There was clearly no relapses over the follow-up duration of 15 to
35 months.

In a very later prospective study, Guindo and
colleagues14 reported on 9 patients (5
idiopathic, 2 postopen heart surgery, 1 with Dressler's syndrome,
and 1 with systemic lupus erythematosus) in
whom NSAIDs and corticosteroids did not prevent
relapses of pericarditis (mean of four years old. 3 episodes per patient). All were
treated with combined prednisone (20 to 60 mg/d), which has been tapered and
discontinued within 6 weeks, and colchicine (1 mg/d). Heart problems was
effectively relieved, no recurrences of pericarditis were
noted within a 10- to 54-month follow-up period.

Adler and coworkers10 reported on 8 patients with
recurrent pericarditis (5 idiopathic, 2 postopen heart surgery, 1
post chest trauma) who hadn't responded NSAIDs (6 patients),
corticosteroids (7 patients), and pericardiocentesis (3
patients). All replied to colchicine (1 mg/d) and
corticosteroids. The corticosteroids
were discontinued within 2 to months, without recurrences were
noted throughout the 18 to 34 months of follow-up. This result contrasts
with a total of 26 relapses of these 8 patients prior to the introduction
of colchicine. Four patients in whom colchicine was withdrawn
as a consequence of noncompliance or mild gastrointestinal negative effects
experienced a relapse within 1 to 3 months macrobid online without a prescription. With reinstitution of
colchicine therapy, they remained symptom-free with the 15 to Two years
of follow-up.

Millaire and coworkers15 reported on 19 patients
who had recurrent pericarditis and were helped by colchicine
(loading dose of 3 mg/d, reduced to just one mg/d). Fourteen had no
recurrences after a follow-up duration of 32 to 44 months. In 4
others, relapses were successfully given NSAIDs, these
patients remained symptom-free for one more 11 to 37 months. Only
1 patient had multiple relapses and needed
corticosteroids. The authors figured that colchicine
was an effective alternative therapy for recurrent pericarditis and
might even replace corticosteroids. In another report
by Adler et al,16 colchicine totally prevented
relapses in 56% of patients with previous episodes (range, 2 to fifteen
attacks) inside a long-term follow-up (mean, Three years per patient) study,
so when relapses did occur, these folks were usually mild and simply
controlled without steroids. These researchers suggested that
colchicine may be the first mode of therapy for
recurrent pericarditis, since most of the patients who experienced
relapses following the institution of colchicine or its withdrawal were
people that had previously been addressed with
corticosteroids. 16 Indeed,
several numerous studies have shown found out that corticosteroids may
have severe negative effects and lead to new recurrences of
pericarditis or prolong disease duration. 17 18 19 20
Thus, colchicine also can have a role in facilitating their
tapering-off process. 9 Still, some authors doubt
the efficacy of colchicine just because a double-blind, controlled study on
this issue is very to complete. 21 It was for
this reason that Fowler and Harbin22 examined the
natural good recurrent pericarditis to discover the frequency of
spontaneous remissions. With the 31 patients incorporated into their study,
only 8 stood a remission period that exceeded Twelve months; in 5 with the 8,
remission exceeded Couple of years.

A partial response to these doubts can be found in the largest
multicenter study on recurrent pericarditis and colchicine published to
date. 23 Fifty-one affected patients (36 men and
15 women; meanSD age, 40. 818. Many years) who were given
colchicine to stop further relapses were followed up for 10 years
(range, 6 to 128 months; mean, 36. 0 months). The pericarditis was
idiopathic in 33 patients and secondary in 18. Despite treatment with
NSAIDs (n=47), corticosteroids (n=29),
pericardiocentesis (n=8), or some combination thereof, 187
recurrences (mean, 3. 583. 64; range, 2 to 15) were noted
before colchicine therapy was initiated, which has a mean interval between
crises of two. 0 months (range, 0. 5 to 19 months). During 1004
patient-months of colchicine treatment, only 7 of 51 patients (13. 7%)
shown new recurrences. Colchicine was
discontinued in 39 patients, and 14 of which (35. 8%) experienced
relapses. These recurrences were generally minor and were
effectively controlled in all of the patients through the reinstitution of
colchicine therapy, sometimes which has a dose adjustment with the drug (2
mg/d). Gastrointestinal unwanted effects were mild (diarrhea and nausea)
and resolved in all of the patients. Through the 2333 patient-months of
follow-up, 31 patients (60. 7%) remained recurrence-free. Comparison on the symptom-free periods both before and after colchicine
treatment yielded significant statistical differences (3. 13. 3 versus
43. 035. 0 months, P<0. 0001). The authors concluded that
colchicine was effective and safe for the long-term prevention of
recurrent pericarditis.

The complete mechanism whereby colchicine prevents recurrences of
pericarditis remains to be not fully understood. Colchicine has been utilized
for a number of centuries being an anti-inflammatory agent for acute arthritis
and is the most specific known answer to acute attacks of gout. Colchicine binds to tubulin, blocks mitosis,9 and
inhibits a number of functions of polymorphonuclear leukocytes
in the vivo and in vitro. 24 Colchicine also
inhibits the transcellular movement of
collagen. 25 The close proximity of lymphoid
components and fibroblasts at inflammatory sites along with the
production of lymphokines, which influence fibroblast
chemotaxis, proliferation, and protein synthesis, are now well
recognized. 26 Thus, colchicine may reduce
immunopathic antifibroblastic properties. The peak power of
colchicine in white blood cells can be 16 times the peak
concentration in plasma. This preferential concentration of colchicine
in lymphocytes relates to its observed therapeutic
effect. 27

Cumulative anecdotal evidence indicates that colchicine can be
effective in the treatment of the original instances of acute
pericarditis. Millaire and Durlaux,28 in a study
of 19 patients, described the efficacy of colchicine with the first
episode of acute pericarditis, specially when it had been idiopathic,
viral, or postopen heart surgery. Colchicine effectively controlled
the acute phase of pericarditis the. Only two relapses
were noted in a mean follow-up duration of 5 months (range, 1 to 12
months), one due to discontinuation of treatment after 8 days and also the
other because of noncompliance.

Recently, we examined the usefulness of colchicine for the treatments for
large pericardial effusions as complications of idiopathic
pericarditis. 29 Colchicine (1 mg/d) was
administered to 2 patients (26 and a couple yrs old) with large acute or
chronic pericardial effusions who wouldn't respond well to therapy with
NSAIDs, corticosteroids, and pericardiocentesis. Response was immediate and dramatic in the two caser, with disappearance
on the pericardial effusion on echocardiography. Neither patient a break down relapse through the respective 24 and 6
months of follow-up.

Together with its apparently greater efficacy compared with
corticosteroids,9 16 colchicine
also can have a sparing affect on steroids, that contain severe systemic
negative effects after a while and might prolong disease
duration. 17 18 19 20 Furthermore, immunosuppressive
drugs and pericardiectomy are not appropriate and might be
life-threatening,21 whereas colchicine is normally
well tolerated, with only minor negative effects. Within a total of 1004
patient-months of colchicine treatment (mean, Calendar year per patient),
temporary discontinuation in the drug or maybe a decrease in its dose was
required in only 7 of 51 patients (13. 7%). 23 This
was because of mild gastrointestinal negative effects (diarrhea and nausea) in
every case, what are the common drawbacks of colchicine therapy. Drug
toxicity for long-term administration of colchicine might
be estimated from familial Mediterranean fever or gout patients. Azoospermia and chromosomal abnormalities have already been reported with
long-term treatment,30 but these findings are
debatable.

In summary, colchicine is very much a highly effective and safe agent for
preventing recurrent instances of pericarditis. Colchicine is definitely an
extremely promising adjunct to the conventional therapy for recurrent
pericarditis and may ultimately perform the duties of your initial mode of treatment,
especially in idiopathic cases. Considering that recurrent pericarditis
is not life threatening and that long-term medication is geared towards
enhancing the quality of life, we propose that
corticosteroids ought to be restricted to severely cases. Milder cases may initially be cured with colchicine together with with
NSAIDs (ibuprofen). The recommended dose of colchicine as outlined by
most studies is 1 mg/d for around 1 year, that has a gradual tapering
off. The need for a loading dose of 2 to three mg/d at the outset of
medication is unclear. Its well tolerated. Gastrointestinal side
effects develop in mere a small proportion of patients, usually are
minor, and don't require discontinuation of treatment in many
cases.

Inspite of the promising data on the efficacy and safety of colchicine for
recurrent pericarditis which have accumulated during the past decade, large,
controlled, prospective studies are needed to provide definitive
answers about the subject.