Pharmacists Educate and Bridge Communication Gaps for Patients With Pericarditis

In an interview with Pharmacy Times®, Jessica Farrell, PharmD, clinical pharmacist in the Division of Rheumatology, Albany Medical Center, and faculty professor in the Department of Pharmacy Practice, Albany College of Pharmacy and Health Sciences, discussed pericarditis and highlighted its symptoms. Standard treatments consist of non-steroidal anti-inflammatory drugs, colchicine, and steroids, but considerations need to be made if patients have kidney or cardiovascular issues. Farrell also emphasized the importance of the pharmacist’s involvement in patient care—notably in hospitalized patients—because they serve as a guide and bridge when communicating with multiple parties.

Pharmacy Times®: Can you introduce yourself?

Jessica Farrell, PharmD: My name is Jessica Farrell. I'm a clinical pharmacist at Albany Medical Center, Division of Rheumatology, and [I'm] also a faculty professor in the Department of Pharmacy Practice at Albany College of Pharmacy and Health Sciences.

Pharmacy Times: Can you explain what pericarditis is and what its symptoms are?

Farrell: So, pericarditis can occur on its own as a primary condition, it can be inflammation around the sac of the heart. It can be triggered sometimes by a virus. In patients with rheumatic disease, it can be a symptom of ongoing systemic inflammation, it can happen in our lupus patient population and sometimes Sjögren syndrome.

Patients will experience pain in their chest, sometimes, some will describe it as a tightness. Generally, if they are laying back, the symptoms are worse—so, the pain will be worse—if they sit up, and/or lean forward, the pain goes away and can lessen. [Patients] can also have [electrocardiogram] changes, there can be fluid that builds up around the sac of the heart, which can be seen on imaging. Some patients will have more pain if they cough or if they take a deep breath...[but] those are some of the common symptoms that we have.

Pharmacy Times: How do you factor in patient comorbidities while treating this disease?

Farrell: Our current standard of care is really anti-inflammatory, so [non-steroidal anti-inflammatory drugs] (NSAIDs)—like ibuprofen (Advil; Pfizer), naproxen (Aleve; Bayer HealthCare), [celecoxib] (Celebrex; Pfizer), those kinds of drugs—which can be problematic if the patients have kidney disease, if they have cardiovascular disease, or if they have gastrointestinal issues. Those drugs, [we] usually need to use pretty big doses of those medications, so, if they are at risk for kidney injury [or] if they have any underlying kidney dysfunction, we try to avoid those therapies.

Oftentimes, if we have to have them on NSAIDs, we'll have to add on a medication to protect our stomach, like a proton pump inhibitor, [for example,] pantoprazole (Protonix; Pfizer) or omeprazole (Prilosec; Procter & Gamble). Other options we have are colchicine (Colcrys; Takeda Pharmaceuticals), [which] is primarily used in in gout as an anti-inflammatory. [It] works really well, it does have some issues, though: we have to be careful in kidney dysfunction, because it is cleared by the kidney, so we usually have to reduce the dose. There are a lot of drug interactions with colchicine, and tolerability can be a concern because a lot of patients will experience loose stools or diarrhea with it, and we do usually need to have them on a treatment dose, so twice a day dosing...but those are some of the limitations that we have with colchicine.

And then, prednisone or methylprednisolone, so steroids are another option. Steroids can be problematic in patients with cardiovascular disease, with diabetes, they can increase their risk for infections. So, in some patients, they just don't do well, or their symptoms don't resolve on any of those treatment options. Usually first-line therapy is just monotherapy, so one of those therapies—depending on what's the safest option for them—and then, sometimes we have to use 2 together, which can add to the safety profile.

And then interleukin-1 (IL1) inhibition, so with drugs like anakinra (Kineret; Sobi) or rilonacept (Arcalyst; Regeneron) are used in more refractory cases. Either [the patient] is not responding to one of those therapies, or they have a contraindication, or tolerability issue with all of those first-line options, or if we need to add on something else.

Pharmacy Times: What is the role of the pharmacist in pericarditis? How might they navigate treating patients?

Farrell: The one thing we didn't talk about yet is that rilonacept is a limited distribution drug, so it's not a medication, it's a specialty drug...meaning that we don't have access to it at our institution at our specialty pharmacy, and it has to come from very specific pharmacies that are registered with the company. In order for patients to get started on therapy, they have to have, they have to be enrolled. There's an enrollment form that has to be filled out, the company does coordinate and has...a patient care coordinator that will talk to the patient, make sure that they can afford the medication. The company [also] does offer what's called Quick Start so they can get started on the medication pretty quickly, once we make sure that the prior authorization is in process. I think that's one of the limitations to this medication, is that this is an acute condition—so you need therapy quickly—and that's why the company does offer the Quick Start option, but it does need to get shipped to the patient.

The other piece, having a pharmacist involved in that process to just navigate the logistics can speed things along. When we first started using the medication, there were certainly some delays in navigating that process and then making sure the patient understands...we're their care team, but then they're going to get called from the company that makes the medication to coordinate, to make sure they can afford the medication, and then they're going to get a call from their specialty pharmacy that's going to deliver it. So, that can be overwhelming and confusing to the patient, so my team makes sure the patient understands that. And we do try to do that if they're a hospitalized patient, and we do try to do that before they leave the hospital, so that...they [aren't receiving] phone calls from people that they haven't met.

The other issue is that it is a vial for reconstitution, so, the medication does need to be reconstituted by the patient. There's some dexterity [and] things that you know need to be kind of clarified. The company does have a nurse program where they'll send a nurse to the patient's home, so that's helpful. My team usually has the patient come to clinic and we use some saline vials and have them practice with us and/or bring a family member or someone that's maybe more savvy with using needles and syringes...but that part can be a little overwhelming for the patient too. So, having the pharmacy team involved adds another layer of support for them.

Pharmacy Times: Any final or closing thoughts?

Farrell: I think I touched on most of the things...I think there's still some clinical questions that we have following the patients long-term in terms of duration of treatment, and also that risk of infection. In the clinical trials for rilonacept in recurrent pericarditis, they did see some bumps in lipid panels...so, we were looking at lipid panels in the retrospective review that my team did, but we really haven't had patients on therapy long enough to see any differences, and I don't think it's going to be a major concern. Some of these patients are already on anti-hypercholesterolemia therapies anyway, so we might not notice anything there.