Idiopathic Pericarditis Refractory to Glucocorticoids: Next-Line Management When Prednisone Fails

Clinical scenario

This protocol applies to idiopathic pericarditis that has progressed through sequential escalation — NSAIDs, colchicine, and a glucocorticoid — without achieving adequate symptom control. The expected outcome of the prior treatment step was not reached, and a further escalation is indicated.

Prior line — failure condition

A glucocorticoid (prednisone) was added for patients refractory to or intolerant of NSAID plus colchicine. This next-line protocol applies when prompt symptomatic relief has not been achieved with that approach.

Next-line approach (partial overview)

When the pericarditis remains refractory despite NSAID, colchicine, and glucocorticoid therapies, the next step involves escalation to an advanced immunosuppressive or targeted biologic class of agent. The complete agent selection, sequencing, and criteria are available in the full protocol.

Treatment goal

Improvement of symptoms.

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References

DOI: 10.1161/CIRCULATIONAHA.111.066365

For refractory pericarditis despite NSAID, colchicine, and glucocorticoid therapies, improved symptoms have been reported in small numbers of patients with the use of immunosuppressive agents (azathioprine or methotrexate), intravenous immunoglobulin, and the interleukin-1β receptor antagonist anakinra.

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