Serial cardiac magnetic resonance imaging for guidance of therapy management in patients treated with anakinra due to recurrent pericarditis

Abstract Aims To determine the utility of serial cardiac magnetic resonance (CMR) imaging for guidance of therapy management in patients treated with anakinra due to recurrent pericarditis (RP), compared with c-reactive protein (CRP) assay alone. Methods and results In 2018-21, we enrolled 18 (14.5±1.8-year-old, 72% males) consecutive RP patients treated with anakinra (100 mg/day in patients ≥ 18 years old; 2 mg/kg/day < 18 years old) due to RP corticosteroid-dependent, or not responsive to colchicine or non-steroidal anti-inflammatory drugs. After hospitalization, they were 1:1 randomized to CMR [no pericardial edema and/or late gadolinium enchantment (LGE)] or CRP (<0.6 mg/dL). Tests were repeated every 3-months until negative to halve the anakinra dosage and cessation. The idiopathic etiology was the most prevalent (n=8, 44%), followed by postpericardiotomy (n=6, 33%). After a median treatment period of 8.7±3.6 months, CRP-guided RP patients experienced more recurrences than CMR-guided ones (6 vs. 1, P=0.016), with the worst prognosis in terms of recurrences (Log-rank, P= 0.025) and significant increased time of treatment (12.7±2 vs. 16.1±3.4 months, P=0.019). In a multivariable exploratory Cox regression model, the number of previous recurrences and the idiopathic etiology were independent predictors of RP during the anakinra treatment. New recurrences were subsequently directed to CMR imaging, and therapy modified according to the LGE/edema trend. After 1-year follow-up, no further recurrence was detected. Conclusions Among patients with RP and treated with anakinra, serial CMR imaging of the pericardium can be utilized as an imaging biomarker, more informative for therapy duration than the solely CRP assessment. ClinicalTrials.gov ID NCT06071156