Abstract 9377: A Role for Targeted Colchicine Uptitration in Recurrent Pericarditis: A Ten-Year Experience of Treatment Refractory Disease at a Specialist Referral Center

Abstract

Introduction: Recurrent pericarditis (RP) carries significant morbidity, both direct and indirect through corticosteroid dependence. Uptake of highly effective anti-interleukin-1 agents, anakinra and rilonacept, is limited by expertise and cost, leading to widespread corticosteroid use in cases refractory to low dose colchicine. Thus, effective, accessible approaches that minimise iatrogenic harm are needed. Consensus guidance for other autoinflammatory diseases recommends colchicine uptitration prior to addition of biologics, providing a potential approach in treatment-refractory RP. Methods: Retrospective review of RP case records at a tertiary center 2012-2022. Treatment-refractory RP was defined as active disease despite colchicine 1mg/24h or disease requiring other prophylactic drugs, and corticosteroid dependence as daily corticosteroid use for 6 months. Results: Of 111 cases, 71 (64.0%) were treatment-refractory at 1 st review, of whom 32 (45.1%) were corticosteroid dependent. Median follow up was 15 months (IQR 4-35). Of treatment-refractory cases without corticosteroid dependence, 38/39 (97.4%) were treated with colchicine uptitration and 4/39 (10.3%) with anakinra; none became corticosteroid dependent. Of corticosteroid dependent cases, 27/32 (84.4%) were treated with colchicine uptitration and 11/32 (34.3%) with anakinra. Corticosteroids were discontinued in 18/32 (56.3%): 7/18 (38.9%) weaned with colchicine uptitration alone, 9/18 (50.0%) with anakinra and 2/18 (11.1%) with azathioprine. Median corticosteroid duration was 15.5 months (IQR 12-44.75) and corticosteroid toxicity occurred in 8/32 (25.0%). Among the 70/71 cases (98.6%) treated with colchicine (median maintenance dose 2 mg/24h (IQR 1.5-2)), permanent discontinuation was uncommon (3/70, 4.3%) and due to gastrointestinal symptoms; self-limiting liver transaminase elevation was common (28/70, 40.0%) but did not lead to discontinuation in any case. Conclusions: Colchicine uptitration enabled avoidance of new corticosteroid dependence, facilitated corticosteroid discontinuation and was well tolerated. This contrasts with the frequent toxicity seen with prolonged corticosteroid use and supports wider uptake of this approach in RP.