I have read with interest the correspondence by Chhabra et al. on the issue of refractory recurrent pericarditis.1 A small but significant subset of patients (overall 5% or less in my experience) may develop several recurrences despite polypharmacy and may become corticosteroid-dependent, since each attempt to taper or withdraw corticosteroids is followed by a recurrence.

Alternative treatments could be immunosuppressive drugs (especially azatioprine) or human intravenous immunoglobulins (hIVIgs). Such drugs are used in 2 broad disease categories: immunodeficiency and autoimmunity. Case reports and small series of patients with idiopathic recurrent pericarditis support the use of hIVIgs at doses of 400 to 500mg/kg iv for 5 days and a possible repeated therapeutic cycle in cases of disease recurrence.

Anakinra, a recombinant human interleukin-1β receptor antagonist, is a promising new biologic agent for the treatment of autoinflammatory diseases such as cryopyrinopathies, tumor necrosis factor receptor-associated periodic syndrome, and hyperimmunoglobulinemia D with periodic fever syndrome, especially in the pediatric setting. The main issue is that this drug requires prolonged subcutaneous administration and the exact length of treatment is unknown. Moreover, withdrawal of these agents is frequently followed by a relapse.

Biological agents are considered a possible new therapeutic frontier in the care of idiopathic recurrent pericarditis but, as correctly pointed out, their usefulness needs to be demonstrated in new randomized studies. As a last resort, pericardiectomy has been proposed especially by US experts from the Mayo Clinic, but such an intervention is controversial and is not recommended by all pericardial experts. Moreover, as pointed out, some patients may still have recurrent chest pain and symptoms after the surgery. Last but not least, pericardiectomy is a long procedure and requires the involvement of a skilled cardiac surgery team.