Expanding the Therapeutic Landscape of Pericarditis: A Systematic Review of the Use of Conventional Immunosuppressants

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Background and Objectives: While interleukin-1 inhibitors represent the standard of care for refractory idiopathic recurrent acute pericarditis, current guidelines also endorse conventional immunosuppressive (IS) agents as potential alternatives. The use of conventional IS agents is particularly relevant in specific clinical scenarios, such as systemic immune-mediated disease (SID)-associated pericarditis. However, existing evidence regarding their efficacy and safety for pericarditis treatment remains fragmented, deriving exclusively from case reports, case series, and small monocentric observational studies. Our aims are: To characterize the clinical and diagnostic profiles of patients with pericarditis treated with conventional IS agents and to evaluate the therapeutic efficacy and safety of such agents. Materials and Methods: A systematic review was conducted in accordance with PRISMA guidelines. Major electronic databases were searched from January 1970 to March 2026 for case reports, case series, and observational studies detailing the use of conventional IS therapies for pericarditis. Clinical and therapeutic data, including specific IS indications and dosing regimens, were systematically extracted. Results: The final analysis included 39 reports comprising 75 patients (60% female; median age 36.0 years). The underlying pericarditis aetiology was predominantly SID-related (53%, n = 40) or idiopathic/presumed viral recurrent disease (40%, n = 30). The most frequently prescribed first-line IS agents were azathioprine (44%) and methotrexate (25%). Across published reports, IS therapy was described as achieving pericarditis clinical resolution in all cases and facilitated corticosteroid withdrawal in 72% of patients. Overall, pericarditis recurrence while on IS therapy occurred in only 10% of the cohort. Adverse events requiring IS withdrawal were rare (n = 2, 3%). Conclusions: Conventional IS agents appear effective and generally well tolerated in the published literature on SID-associated and isolated recurrent pericarditis. These findings reinforce the clinical utility of conventional IS therapies as a viable, steroid-sparing strategy when targeted biologic therapies lack sufficient investigation.

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