COVID-19 Disease in Patients With Recurrent Pericarditis During Treatment With Anakinra: Comment on the Article by Navarro-Millán et al.

To the Editor:

We read with interest the article by Dr. Navarro‐Millán and colleagues about the use of anakinra to prevent mechanical ventilation in patients with COVID‐19 (1). However, it is also important to consider patients who develop COVID‐19 while being treated with anakinra for their underlying condition (2).

We describe 5 patients, median age 43 years, with recurrent pericarditis (post‐pericardiotomy in 1 case; idiopathic pericarditis in 4 cases) who developed COVID‐19 disease during treatment with anakinra. Median duration of recurrent pericarditis was 48 months. All patients were being treated with anakinra when COVID‐19 disease occurred, after having initially received treatment with glucocorticoids and/or nonsteroidal antiinflammatory drugs (including colchicine) (Table 1).

Table 1

Summary of main features of patients*

Patient/age/sex	Pericardial disease duration, months	Therapy when COVID‐19 occurred	COVID‐19 clinical features	Adjusted/additional therapies during COVID‐19	Hospitalization or ER visit	Duration of COVID‐19 symptoms, days
1/54/M	12	Anakinra (100 mg every 48 hours)	Fever; cough; infiltrate in right middle lobe on chest radiograph; CRP and d‐dimer elevation	Azithromycin	ER visit	5
2/15/M	21	Anakinra (100 mg every 3 days); colchicine (1 mg/day)	Low‐grade fever; asthenia	None	None	2
3/43/F	48	Anakinra (100 mg every 4 days); colchicine (1 mg/day)	Fever; cough for 4 days; ageusia; anosmia; diarrhea; headache	None	None	15
4/35/F	54	Anakinra (100 mg/day); colchicine (1.5 mg/day); nadolol	Dry cough; fever for 3 days; asthenia; diarrhea; chest pain; normal CRP	Prednisone (25 mg/day for 5 days) then 12.5 mg/day); indomethacin	ER visit	10
5/78/F	60	Anakinra (100 mg/day); colchicine (1 mg/day); prednisone (2.5 mg every 2 days)	Low‐grade fever for 2 days; dyspnea	Prednisone (2.5 mg/day); acetaminophen; amoxicillin–clavulanic acid	None	15

ER = emergency room; CRP = C‐reactive protein.

The patients developed COVID‐19 disease between March 2020 and October 2020. Symptoms, usually mild, included fever, cough, ageusia, anosmia, headache, diarrhea, dyspnea, and chest pain (Table 1). SARS–CoV‐2 was diagnosed by nasopharyngeal swab in 4 patients, and by serologic test in 1 patient, after symptoms began. Two patients went to the emergency room; in one case, chest radiograph showed a small lung infiltrate, but neither of the patients required hospitalization. Treatment with anakinra was continued unchanged, and 3 patients received additional therapies after the development of COVID‐19 disease (Table 1). All patients recovered completely within 15 days and had no recurrence of pericarditis.

Polytherapy is often necessary in patients with recurrent pericarditis and treatment with an interleukin‐1 receptor antagonist may lead to resolution of symptoms (3); however, a concern may be raised that biologic therapy could aggravate the clinical course of COVID‐19. Our small case series shows that anakinra therapy in patients with recurrent pericarditis may be associated with a benign clinical course. We propose that there is no reason to discontinue anakinra therapy if a patient with recurrent pericarditis develops COVID‐19 disease (4, 5, 6, 7). Our recommendation is consistent with the findings obtained in the study by Dr. Navarro‐Millán et al (1).

Dr. Brucato has received research support from Sobi and Acarpia. Dr. Imazio has received consulting fees or honoraria from Kiniksa and Sobi (less than $10,000 each).