Schwier Nicholas C, Hale Genevieve M, Davies Marie L
Department of Pharmacy: Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, Oklahoma City, Oklahoma.
Department of Pharmacy Practice, Nova Southeastern University College of Pharmacy, Palm Beach Gardens, Florida.
Pharmacotherapy. 2017 Mar;37(3):305-318. doi: 10.1002/phar.1897. Epub 2017 Feb 7.
Idiopathic recurrent pericarditis (IRP) can be challenging to treat. Even after guideline-directed first-line treatment consisting of aspirin (ASA) or a nonsteroidal antiinflammatory drug (NSAID) in combination with colchicine therapy, recurrences still occur in greater than 20% of patients. Many patients then require treatment with long-term corticosteroids, which is not a favorable option due to their short- and long-term adverse effects. Because it is theorized that the pathophysiology of IRP may possess autoimmune sequelae, the use of immunotherapy for the treatment of IRP has emerged. In this review, we describe the literature associated with immunotherapy used to treat IRP in an adult population as well as provide an overview of the safety and monitoring parameters for each agent. The most common immunotherapies used after patients have had multiple recurrences of IRP are anakinra, intravenous immunoglobulin (IVIG), and azathioprine. In most cases, these immunotherapies are adjunctive therapy, with the goal of tapering and discontinuing immunosuppressive corticosteroids. After reviewing the data, anakinra resulted in more patients discontinuing corticosteroids and prevented further recurrences of pericarditis. IVIG resulted in symptom resolution and no further recurrences in most of the patients. Azathioprine was associated with more than half of patients becoming recurrence free; however, many patients required a restart of corticosteroids due to recurrence. Clinicians should be aware of the adverse effects of immunotherapy, ranging from mild gastrointestinal events to risk of infection and serious blood dyscrasias that may require diligent monitoring. The use of immunotherapy for the treatment of adults with IRP should be restricted to patients who have multiple recurrences. Ideally, immunotherapy would be adjunctive to first-line combination therapy with ASA/NSAID plus colchicine, with the goal of tapering and discontinuing immunosuppressive corticosteroids. Furthermore, clinicians should consider cost, drug-drug and drug-disease interactions, and safety, as well as the quality of the retrospective evidence before considering any immunotherapy.
特发性复发性心包炎（IRP）的治疗颇具挑战性。即便采用了以阿司匹林（ASA）或非甾体类抗炎药（NSAID）联合秋水仙碱治疗为导向的一线治疗方案，仍有超过20%的患者会复发。许多患者随后需要长期使用皮质类固醇进行治疗，但鉴于其短期和长期的不良反应，这并非理想选择。由于推测IRP的病理生理学可能存在自身免疫后遗症，免疫疗法已开始用于治疗IRP。在本综述中，我们描述了与用于治疗成年人群IRP的免疫疗法相关的文献，并概述了每种药物的安全性和监测参数。在IRP多次复发的患者中，最常用的免疫疗法是阿那白滞素、静脉注射免疫球蛋白（IVIG）和硫唑嘌呤。在大多数情况下，这些免疫疗法是辅助治疗，目的是逐渐减少并停用免疫抑制性皮质类固醇。在审查数据后发现，阿那白滞素使更多患者停用了皮质类固醇，并预防了心包炎的进一步复发。IVIG使大多数患者症状缓解且未再复发。硫唑嘌呤使超过一半的患者不再复发；然而，许多患者因复发需要重新开始使用皮质类固醇。临床医生应了解免疫疗法的不良反应，从轻微的胃肠道事件到感染风险以及可能需要密切监测的严重血液系统疾病。免疫疗法用于治疗成年IRP患者应仅限于多次复发的患者。理想情况下，免疫疗法应作为ASA/NSAID加秋水仙碱一线联合治疗的辅助治疗，目的是逐渐减少并停用免疫抑制性皮质类固醇。此外，临床医生在考虑任何免疫疗法之前，应考虑成本、药物相互作用和药物与疾病的相互作用、安全性以及回顾性证据的质量。
