21 A Toolkit for Health Care Professionals Recurrent Pericarditis precipitants of rekindled inflammation such as exercise, may be a harbinger for a more complicated clinical course.69 There may be an increased frequency of pericardial complications such as constriction, a phenomenon that is rarely seen in acute idiopathic (presumed viral) pericarditis or recurrent pericarditis. An incessant disease trajectory has been reported to occur in up to 12% of patients presenting to a tertiary pericardial service.69 The evidence base for managing these patients is limited. However, incessant disease may prompt the need for more exhaustive investigations for: An underlying etiology to the pericarditis Treatment of any underlying cause identified Escalation of the intensity and duration of anti-inflammatory therapies Heightened surveillance for constriction. Multimodality imaging and particularly CMR may play a role in identifying potentially reversible constriction by delineating ongoing inflammation, which has the potential to respond to immunosuppression. Assuming an infectious bacterial etiology has been excluded, approaches to inducing remission include: The addition of corticosteroids The use of higher doses of colchicine (typically increased by 500-600 mcg a day at no less than weekly intervals titrated to response up to a maximum of 3 mg per day, assuming tolerated and no relevant contraindications/drug interactions/ impairment of hepatic or renal drug clearance) The use of intravenous immunoglobulin (IVIG) or IL-1 blockade. (See “Recurrent Pericarditis” on page 22.) Notes:
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