A Toolkit for Health Care Professionals Recurrent Pericarditis 17 Colchicine Colchicine binds to tubulin and inhibits its polymerization into microtubules, which consequently, decreases migration and phagocytosis of leukocytes. Colchicine also blocks the NLRP3 inflammasome complex, and thereby prevents the secretion of the key pro-inflammatory cytokines interleukin1beta and interleukin-18.65 As an adjunct to an NSAID or aspirin for acute pericarditis, colchicine therapy not only increases the remission rate at 7 days, but decreases the chances of incessant or recurrent pericarditis by about 50% with a number needed to treat (NNT) of 4.48 Recurrence is one of the most important complications of acute pericarditis. The role of colchicine and the need to continue this for 3 months regardless of symptoms should be clearly explained to patients to promote adherence and reduce the risks of patients stopping treatment prematurely when they start to feel better/improve. Colchicine has a long half-life, so at the end of a course, it can be stopped abruptly without the need for tapering. It is often prescribed twice daily, but if required to promote adherence, the total dose can be given once daily, assuming patient stability and no adverse effects, e.g., 0.5-0.6 mg twice daily can be taken as 1.0-1.2 mg once daily.49 Although colchicine is safe when used and dosed appropriately, it has a narrow therapeutic index, and dose adjustment is necessary for renal and hepatic impairment to Table 2. Significant drug interactions with colchicine CYP3A4 inhibitor P-gp inhibitor Clinical considerations Cardiovascular drugs amiodarone X X Avoid if possible. If agent must be used, consider colchicine dose reduction and monitor closely. dronedarone X X Avoid if possible. If agent must be used, consider colchicine dose reduction and monitor closely. non-dihydropyridine calcium channel blockers (diltiazem, verapamil) X X Avoid if possible. If agent must be used, consider colchicine dose reduction and monitor closely. Macrolide antibiotics azithromycin X Assess risk/monitor for colchicine toxicity. clarithromycin X X Avoid combination. Azole antifungals itraconazole X X Avoid if possible. If agent must be used, consider colchicine dose reduction and monitor closely. ketoconazole X X Avoid if possible. If agent must be used, consider colchicine dose reduction and monitor closely. fluconazole X Assess risk/monitor for colchicine toxicity. voriconazole X Assess risk/monitor for colchicine toxicity. Antiretrovirals protease inhibitors (atazanavir, darunavir, ritonavir) with or without cobicistat X X Avoid combination. Calcineurin inhibitors cyclosporine X X Avoid if possible. If agent must be used, consider colchicine dose reduction and monitor closely. tacrolimus X Assess risk/monitor for colchicine toxicity. Consider colchicine dose reduction. Clinical considerations provided do NOT take into account impaired renal/hepatic function. This table does not include all possible colchicine drug interactions and is not intended to supplant clinical judgment. Recommendations also vary based on manufacturer package insert and colchicine treatment indication.
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