Background
Recurrent pericarditis is a difficult clinical problem1,2 that affects up to 30% of patients after a first episode of acute pericarditis, and up to 50% of those with a first recurrence, if not treated with colchicine.3-5 The optimal regimen for avoiding recurrences has not been clearly established. Treatment modalities in recurrent pericarditis include non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, colchicine, immunosuppressive agents, and pericardiectomy. Quality of life may be severely affected in frequently relapsing cases, and patients with frequent recurrences can develop corticosteroid-dependence.
Anakinra is an interleukin (IL)-1 beta recombinant receptor antagonist that has been proposed as a potential treatment for recurrent pericarditis. Anakinra was used first in pediatric patients and then evaluated in adults.6,7 Anakinra administered daily subcutaneously for several months showed in both children and adults a rapid response with corticosteroid withdrawal.7,8 Current evidence with anakinra is based entirely on case reports and retrospective series,9 and to our knowledge, no randomized controlled trials have been conducted.
Aim of the Randomised Clinical Trial
To evaluate the efficacy and tolerability of anakinra in adults and children with recurrent idiopathic pericarditis that was corticosteroid-dependent and colchicine-resistant.
Study design
The study was an investigator initiated, 8-month, multicenter, randomized, double-blind, placebo-controlled, medication-withdrawal study to evaluate the efficacy and tolerability of anakinra in adults and children with idiopathic recurrent pericarditis. This study was investigator-initiated. SOBI provided anakinra and placebo as part of unrestricted institutional grant and had no role in the design and conduct of the study and in preparation of the
manuscript. SOBI is currently evaluating the outcomes of this study and potential next steps.
It consisted of two parts: (1) an open-label treatment period in which anakinra was administered daily for 60 days followed by (2) a double-blind withdrawal period in which patients who had a sustained complete response in part 1 were randomized to anakinra or to placebo daily for up to 6 months. The end of the study was the end of part 2 (8 months after enrollment) or the time of relapse, whichever occurred first. Patients who had another pericarditis recurrence could have the option to be re-treated with anakinra. All the patients were then followed for other 4 months to assess safety.
Summary
- Out of 25 patients screened for entry in the study from 3 centers in Italy, 21 were enrolled. One patient was in the pediatric age-range (15 years old), and the remaining 20 patients were adults (age >18 years).
- Mean number of recurrences before the study was 6.8, with a clinical history of recurrent pericarditis lasting 27.8 months on average. Median duration of follow up was 14 months.
Open-Label Phase (Part 1)
At the time of study enrollment, all 21 patients were experiencing a recurrence of pericarditis with a mean VAS of pain of 7.7; mean CRP level was 4.2 mg/dL . Eighteen patients displayed a pericardial effusion, mild in all cases (<10mm).
All patients had a complete response to open-label anakinra treatment at day 8, according to the protocol definition, that was maintained until randomization (day 60).
CRP was normalized in all the patients at day 8, and remained normal at day 60. Pain VAS quickly dropped, and was 0.4 on average at day 60. Also patient/parent's global assessment of overall well-being on a 21 circle VAS greatly improved over time, being 5.8 at day 0 and 1.6 at day 60 (where 10 is the worst quality).
All patients successfully discontinued corticosteroids within 6 weeks and proceeded to part 2. At randomization (day 60) CRP was normal in all the 21 patients, mean pain VAS was 0.4, and all the 21 patients were without corticostertoids and NSAIDs
Double-Blind Withdrawal Phase (Part 2)
During the double-blind treatment, recurrence of pericarditis occurred in 9 of the 10 (90%) patients randomized to placebo and in 2 of the 11 (18.2%) patients randomized to anakinra (33 and 120 days after randomization). Median flare-free survival (time to flare) was 72 days (IQR 64-150) from randomization in the placebo group and it could not be calculated in the anakinra group (p=0.0002). Half the patients assigned to placebo were free of flare after 72 days from randomization, while more than half of patients assigned to anakinra were still free of recurrence at the end of the study. In patients with recurrences, the mean time to flare was 28.4 days versus 76.5 days in the placebo and the anakinra group, respectively.
Nine patients (4 randomized to placebo and 5 randomized to anakinra) discontinued colchicine and 12 (6 randomized to placebo and 6 randomized to anakinra) were maintained on colchicine (according to physician and patient decision). During the double-blind treatment, concurrent treatment with colchicine did not significantly affect recurrence rate: 7/12 (58,3%) in colchicine and 4/9 (44,4%) without colchicine, and time to flare (median flare-free survival 90 days in colchicine while it could not be calculated in the not-colchicine group), but the study did not have the power to compare monotherapy with anakinra vs. combined therapy with anakinra plus colchicine. In patients with recurrences, the mean time to flare was 52.7 days in the colchicine group versus 10 days in the non-colchicine group, respectively resulting in an absolute mean difference of -42.7 (95% CI: -97.1; 11.7).
Adverse Events
The most common side effect in anakinra-treated patients was a local reaction at the injection site, observed in 20 out of 21 patients (95%) during the initial open-label phase (first phase, part 1); generally they disappeared over one month; 3 patients temporarily discontinued anakinra in the first open-label phase, but resumed it after topical treatment and systemic antihistamines, and no patient discontinued the study for this side effect. Herpes Zoster occurred in one patient treated with anakinra during the first open-label phase of the study with temporary discontinuation of anakinra.
Three patients (14.3%) showed an elevation of transaminases (<x2 normal values) in the first open-label phase, reversible after temporary discontinuation or dose reduction of anakinra.
Conclusions
In this preliminary study of patients with recurrent pericarditis with colchicine resistance and corticosteroid dependence, the use of anakinra compared with placebo reduced the risk of recurrence over a median of 14 months. Larger studies are needed to replicate these findings, as well as to assess safety and longer-term efficacy.
Comment
Refractory recurrent pericarditis is a major management issue since it is corticosteroid-dependent and does not respond to colchicine, thus patients are unable to withdraw corticosteroids without a relapse. Corticosteroids impair the growth in children, and Picco described the first 3 patients, all children, successfully treated with anakinra.6 At present 10 reports describing 46 patients (adults and children) have been published 6-8,10-16. In the recent 2015 guidelines of the European Society of Cardiology17 it was stated that anakinra, azathioprine and high dose intravenous immunoglobulins may be considered in corticosteroid-dependent recurrent pericarditis that is resistant or intolerant to colchicine, but the level of evidence was low: C (case series and experts opinion).
This study is the first randomized placebo controlled trial of anakinra for idiopathic recurrent pericarditis, showing that anakinra is a potential option for this subset of patients. These findings also provide evidence that IL1 plays an important role in the pathogenesis of idiopathic recurrent pericarditis 6,18.
Anakinra use is associated with an increased risk of side effects especially related to injection site reactions. These generally occurred early after drug delivery and were relatively transient (generally few weeks) and can be managed by the use of oral antihistamines and topical corticosteroids.19 Warming the syringe to room temperature before use is advisable along with application of cold pack to the injection site approximately 2-3 minutes before and immediately after the injection. Patients should be informed in advance about the potentiality of such reactions, to prevent unjustified drug discontinuation. Additional potential side effects include transaminase elevation that was observed in 3/21 (14.3%) of patients, and was limited and transient. The most important potential side effect is an increased risk of infections: one patient (4.7%) developed Herpes zoster and required temporary discontinuation of the study drug.
First usage of anakinra dates 1996 20; serious infections are rare and in a review of 5 clinical trials, they appeared in 1.7% of patients in the active arm as compared to 0.7% observed in the placebo group.21 Finally, neutropenia has been reported in approximately 5% of cases without, however, evidence of association with clinical events 21-23.
Anakinra has both advantages and disadvantages to consider in treating patients similar to those in this study. The main advantages of the drug are a rapid onset of effect and the capability to allow a quick withdrawal of corticosteroids. The potential disadvantages include a long duration of therapy as well as its high costs. Strict selection of the patients is important: only patients with a clear inflammatory pattern are candidates for this therapy. Such patients usually have a history of high fever, strikingly elevated levels of CRP, pleural effusions, particularly in the pediatric age: these clinical signs are likely associated to a pivotal pathogenic role of IL-1. Conversely, patients with mild or doubtful symptoms, and/or normal or near normal levels of CRP are not good candidates for anti-IL1 therapy 24.
Study limitations
The main limitation of this study is its small sample size. However, given the large treatment effect, the current study had the statistical power to verify the initial study hypothesis.
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