We read with interest the report by Schmitz et al1 describing management of acute pericarditis during pregnancy. The authors address a challenging and understudied setting, providing valuable insights.
In their cohort, corticosteroids were frequently used, with a median starting dose of 20 mg, reflecting current practice in pericarditis. However, this dosage is now considered too high in pregnancy. The 2020 American College of Rheumatology Guideline for the Management of Pregnancy in Rheumatic Diseases recommends continuing low-dose glucocorticoid treatment (≤10 mg daily of prednisone) during pregnancy and strongly recommends tapering higher doses of <20 mg daily of prednisone, adding pregnancy-compatible glucocorticoid-sparing agents if necessary.2 Similarly, the British Society Guidelines recommend that the dose of prednisolone should be <20 mg/day and tapered to the minimum effective dose, in conjunction with steroid-sparing drugs compatible with pregnancy.3 In fact, prolonged exposure to systemic corticosteroids is associated with well-recognized maternal and fetal risks, including gestational diabetes, hypertension, intrauterine growth restriction, and preterm delivery.
In this context, emerging evidence supports the role of interleukin-1 blockade with anakinra as a potential steroid-sparing strategy in selected patients with pericarditis during pregnancy.4 Notably, anakinra is a recombinant analog of the endogenous interleukin-1 receptor antagonist, which is physiologically present in human circulation and detectable in maternal milk.5 We reported favorable maternal and neonatal outcomes in 17 pregnancies in 14 women with recurrent pericarditis treated with anakinra throughout pregnancy and breastfeeding in a recent multinational case series.4 No congenital anomalies, neonatal infections, or drug-related adverse events were observed. Disease recurrences were effectively managed through anakinra dose adjustments, achieving sustained inflammatory control and minimizing prolonged corticosteroid exposure.3
Randomized trials are unlikely in this setting, and experiences such as those reported by Schmitz are very useful. Accumulating real-world evidence underscore 2 issues: 1) the dose of prednisone should be <20 mg/day and tapered to the minimum effective dose to control maternal disease during pregnancy, in conjunction with steroid sparing drugs compatible with pregnancy; and 2) in this context, anakinra may be very useful to reduce the dose of corticosteroids in women with recurrent pericarditis planning a pregnancy when previous therapies failed.
Footnotes
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Antonio Brucato reports institution received funding from Kiniksa Pharmaceuticals, Ltd as an investigative site; unrestricted research grant from SOBI, Kiniksa, Monterosa, and Acarpia; travel and accommodation for advisory committee from SOBI, Kiniksa, and Monterosa; and travel and accommodation from Accord. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.
References
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