to help an achy heart: management of pericarditis alicia ridgewell pharmacy resident 2011/12
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To Help an Achy Heart:Management of Pericarditis
Alicia RidgewellPharmacy Resident
2011/12
Outline
Patient Case Drug related problems Goals of therapy Pathphysiology of pericarditis Treatment options Evidence for therapy Recommendations Follow-up
Objectives
Learn basic pathophysiology of acute pericarditis
Be able to list the different causes of pericarditis
Become familiar with treatment options for idiopathic/viral pericarditis
Be aware of the evidence behind use of colchicine
Our Patient: DMID DM, 45 year old male; 65 kg
Admitted Sept. 24th
CC 2-3 day hx of fever and increasing chest pain (feels like knife through rib cage, radiating to shoulders), interferes with work; 10/10 without medication
HPI July 2011, was admitted for chest pain; small pericardial effusion Dx: pericarditis, D/C on ibuprofen
DX CXR on admission small pericardial effusion and pleural effusion: Recurrent pericarditisCXR also shows atelectasis of left lower lobe: ?pneumonia
PMHx IBS – constipation predominate
Patient Case
Fam Hx
Not remarkable
SHx No alcohol or RDUSmokes 1-2 cigarettes/day (no interest in quitting)
Vaccine Hx
Allergies
No flu or pneumococcal vaccinations
Penicillin – anaphylaxis (30 yrs ago)
MPTA -Ibuprofen 400mg (4 tablets at a time – half a bottle in a day)-Oral sodium phosphate once per month
Review of Systems: Sept. 27thVitals Temp:356, HR: 74(reg), BP: 101/62, RR: 16, O2 sat
95 (RA)
CNS Not remarkable
HEENT Not remarkable
RESP Not remarkable; pain in chest when breaths deeply
CVS Chest pain when lying down (better if sitting up)
GI/GU Gas/bloating - constipated
MSK/DERM
Not remarkable
LABS WBC 9.9, Hgb 109, SrCr 63 (stable) – nothing else remarkable
Patient Case
Medical Condition Medications in hospital
?LL pneumonia Azithromycin 500mg IV daily (day 4)Cefuroxime 750mg IV q8hr (day 4)
Pericarditis Indomethacin 50mg po BID
Stomach protection Pantoprazole 40 mg po dailySucralfate 1g po QID
Pain Hydromorphone 5mg po/IV/SubQ q 3hr prn
Constipation/abdominal discomfort
Bowel protocol prnFleet enema daily prnBuscopan 10mg IV daily prn
Drug Related Problems DM is experiencing continued pericarditis
pain secondary to suboptimal therapy DM is experiencing unresolved
constipation secondary to not receiving regular treatment
DM is at risk of continued constipation secondary to narcotic analgesia
DM is at risk of experiencing adverse effects secondary to receiving unnecessary therapy (sucralfate, buscopan)
Goals of Therapy
Prevent mortality Prevent complications (i.e. cardiac
tamponade) Relieve/reduce pain Resolve pericarditis Prevent recurrance Minimize adverse effects from
medications
Pericarditis Pathophysiology
Viral Pericarditis
Coxsackievirus A & B, influenza virus, mumps, herpes simplex, CMV, epstein-barr
Previous viral infection (i.e. respiratory tract infection)
Can occur in all ages but usually young adults
Simultaneous development of fever and precordial pain 10 – 12 days after a viral illness
Acute Pericarditis Symptoms
Chest pain: acute, severe, retrosternal, precordial; refers to neck and shoulders– Pleuritic: sharp; aggravated by inspiration,
coughing, changes in body position Audible friction rub Modest increase in trops and CK Diffuse ST-segment elevations Pericardial effusion
Treatment options
Target underlying cause if possible For viral or idiopathic pericarditis:
– NSAIDs (ibuprofen, aspirin, indomethacin, ketorolac)
– Colchicine– Glucocorticoids (i.e. prednisone)
PICO
In a 45 year old male with recurrent pericarditis, what is the evidence for use of colchicine in combination with NSAID therapy?
Literature Search
Up-to-date: reference list Pubmed. Search terms used:
– Pericarditis– Colchicine– NSAIDs
Results: 2 RCT, open label – CORE and COPE
Evidence: CORE3
Design
Prospective, open label randomized trial
P Aults (≥18yrs), 1st episode of recurrent pericarditis, previous viral or idiopathic pericarditis, no contraindication to colchicine
I/C Group 1: Aspirin 800mg po q 6-8 hrs x 7-10 days (3-4 week taper)
Group 2: Aspirin at same dose + colchicine 1-2mg day 1 then 0.5-1mg daily x 6 months
O Primary: recurrence rate; secondary: symptoms persistence 72 hours after treatment onset
Evidence: CORE resultsRecurrence Rates % (at 18 months)
Symptom Persistence beyond 72 hr (%)
Adverse Drug Reactions
Serious adverse events
Group 1: 50.6
Group 2: 24
P = 0.02
ARR = 26.6%
Group 1: 31
Group 2: 10
P= 0.03
Group 1: 6 pts
Group 2: 3 pts(all 3 pts reported diarrhea – d/c therapy)
None reported
• Limitations: patients unable to take aspirin allowed to use prednisone; open label
Evidence: COPE4
Design
Prospective, open label randomized trial
P Aults (≥18yrs), 1st episode of acute pericarditis (due to viral, idiopathic, autoimmune causes), no contraindication to colchicine
I/C Group 1: Aspirin 800mg po q 6-8 hrs x 7-10 days (3-4 week taper)
Group 2: Aspirin at same dose + colchicine 1-2mg day 1 then 0.5-1mg daily x 3 months
O Primary: recurrence rate; secondary: symptoms persistence 72 hours after treatment onset
Evidence: COPE resultsRecurrence Rates % (at 18 months)
Symptom Persistence beyond 72 hr (%)
Adverse Drug Reactions
Serious adverse events
Aspirin: 23.5
Aspirin + colchicine: 8.8
Pred: 86.7
Pred + colchicine: 11.1
P < 0.001
Group 1: 36.7
Group 2: 11.7
P= 0.003
Group 1: 4 pts(abd pain, dyspepsia)
Group 2: 5 pts(all 5 pts reported diarrhea – d/c therapy)
None reported
• Limitations: did not report subgroups for secondary or outcome; open label
Alternatives
1) Increase indomethacin 50 mg po TID2) Addition of colchicine 0.6mg po BID3) Addition of prednisone 0.5 – 1
mg/kg/day4) D/C indomethacin; give aspirin 650mg
po q6 hr daily + colchicine 0.6 po BID5) D/C indomethacin; give aspirin6) D/C indomethacin; give prednisone +
aspirin
Recommendations
Addition of colchicine 0.6mg po BID– No improvement in 72hr d/c
indomethacin, start aspirin D/C hydromorphone
Other suggestions:– Abx step-down– D/C buscopan, fleet enema, sucralfate– Lactulose 30 mL po daily x 2 days– Docusate sodium 200mg po daily
Monitoring PlanParameter Degree of
ChangeFrequency Who will
monitor
Vitals: Temp, HR, BP, RR
Increase Daily Pharm/MD
Chest pain (PQRST)
Worsening/resolution
Daily Nurse/pharm/MD
Pleural Effusion
Worsening Daily - Weekly MD
Cardiac Tamponade
Occurrence Daily - Weekly MD
Side effects (N/V/D; abdominal pain, cramping)
Presence Daily Nurse/pharm
Constipation Resolution BID x 2 daysThen daily
Nurse/pharm
WBC, Hgb, SrCr, K+
Outside normal limits
q2days Pharm/MD
Patient Update
Sept. 27th therapy adjusted (colchicine added)
Sept. 28th Patient left AMA – Did not take discharge prescription (no
therapy continued)
Questions?
References
1). MD consult. Elsevier 2011. Available from URL: www.mdconsult.com. Accessed: Oct. 2, 2011.
2). Imazio M, LeWinter MM, Downey BC. Treatment of acute pericarditis. Up-to-Date 2011. www.uptodate.com. Accessed Sept. 27, 2011
3). Imazio M, Bobbio M et al. Colchicine as First-Choice Therapy for Recurrent Pericarditis: Results of the CORE trial. Arch Intern Med.2005;165:1987-91
4). Imazio M, Bobbio M et al. Colchicine in Addition to Conventional Therapy for Acute Pericarditis: Results of the COPE trial. Circulation.2005;112:2012-16
5). Maisch B, Seferovic PM et al. Guidelines on the Diagnosis and Management of pericardial diseases. European Heart Journal.2004;25:587-610
6). Fauci AS et al. Harrison’s Principles of Internal Medicine. 17th ed. McGraw Hill Medical. New York. 2008.p.1489-94
7). Lange RA, Hillis LD. Acute Pericarditis. N Engl J Med.2004;351:2195-2028). Imazio M, Brucato A et al. Medical therapy of pericardial diseases Part 1:
Idiopathic and infectious pericarditis. J Cardiovasc Med. 2010;11:712-22