Department of Medicine and Rheumatology
Niguarda Hospital
Via Del Bollo 4
Milano 20123
Italy
Tel: +39 264442674
Fax: +39 264442615
E-mail address:
antonio.brucato{at}ospedaleniguarda.it
Department of Emergency Medicine
Niguarda Hospital
Milano
Italy
Cardiac Rehabilitation Institute
Sheba Medical Center
Tel-Hashomer
Israel
Department of Cardiovascular Medicine
University of Massachusetts Medical School
Worcester
MA
USA
We read with interest the excellent Editorial by Maisch1 referring to the article by Artom et al.2 in which we are co-authors. We take this opportunity to comment on a minor point that anyway might be clinically relevant. Maisch writes that in refractory cases, azathioprine (75100 mg/day) or cyclophosphamide can be added. This is also suggested by the European Guidelines recently published3 and has been quoted by authoritative reviews.4 Unfortunately, there is only one old article describing the use of azathioprine in this condition in two patients,5 and those authors acknowledged that to suggest that azathioprine therapy is indicated in the treatment of steroid responsive pericarditis would indeed be presumptuous on the basis of these two cases; other authors described other three cases.6,7 Moreover, there is no single article concerning cyclophosphamide (only one case described by Marcolongo et al.6), whereas Raatikka et al.7 reported five cases treated with methotrexate and one with cyclosporine and Peterlana et al.8 described four cases treated with intravenous immunoglobulin. Rheumatologists commonly use azathioprine, cyclophosphamide, cyclosporine, methotrexate, hydroxychloroquine, and intravenous immunoglobulin; we agree that azathioprine is the preferred choice if tolerated (at the common dosage of 23 mg/kg/die), but we suggest that it would be more prudent to state that probably immunosuppressive agents and steroid sparing agents might be used very rarely in refractory cases, acknowledging that we have no evidence-based data, preferring the less toxic and less expensive drugs (e.g. azathioprine and methotrexate), and tailoring the therapy on the single patient (e.g. cyclophosphamide should be used only in severe cases and avoided in young fertile women because it can cause infertility) and, importantly, with the patient informed consent.
References
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