The following are key points to remember about rilonacept in the treatment of recurrent pericarditis:

1. Rilonacept is an interleukin (IL)-1 antagonist, which was recently approved (March 18, 2021) by the US Food and Drug Administration (FDA) for treatment of recurrent pericarditis.
2. Rilonacept binds IL-1 alpha and IL-1 beta and prevents its interaction with pericardial cell surface receptors, thus reducing the inflammatory cascade. Steady state may be reached in about 6 weeks. Median time to improvement in pain was 5 days. Median time to C-reactive protein (CRP) normalization was 7 days. Rilonacept is primarily eliminated through the reticuloendothelial system.
3. In the phase III RHAPSODY trial of rilonacept, patients with symptomatic recurrent pericarditis and elevated CRP experienced a decreased risk of recurrent pericarditis (hazard ratio [HR], 0.04; 95% confidence interval [CI], 0.01-0.18; p < 0.001) compared with placebo. Patients on rilonacept experienced more days with no or minimal pericarditis symptoms (81% vs. 25%; p < 0.001) and more persistent clinical response at 16 weeks (81% vs. 20%; p < 0.001) compared with placebo.
4. The most frequent adverse reactions to rilonacept included injection-site reactions, upper respiratory tract infections, and hyperlipidemia.
5. In clinical practice, rilonacept should be used for patients with recurrent pericarditis of idiopathic etiology with elevated CRP, who have been unable to wean off of glucocorticoids. Its use should be reserved for patients whose pericarditis recurs repeatedly despite use of aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), colchicine, and/or glucocorticoids.
6. Cost of rilonacept is about $20,000 per month. Specialty, rather than community, pharmacies usually dispense the drug.
7. In adults, an initial 320 mg loading dose is followed by weekly doses of 160 mg. In adolescents, the dosage is based on weight. Rilonacept is administered by subcutaneous injection. The initial subcutaneous injection should be performed under the supervision of a qualified health care professional, to ensure correct technique.
8. Rilonacept has immunosuppressant effects. Therefore, patients who develop an infection or illness while on the drug should contact their prescriber. Patients receiving the drug should not receive live vaccines. Required immunizations should be administered prior to the initiation of rilonacept therapy.
9. Rilonacept should only be used in pregnant patients if the benefit justifies potential risk to the fetus, as the drug has been associated with teratogenicity in primates.
10. Periodic assessments of lipid panel are recommended in patients receiving rilonacept. Prescribers should also monitor patients for signs or symptoms of recurrent pericarditis.

Clinical Topics: Cardiovascular Care Team, Congenital Heart Disease and Pediatric Cardiology, Dyslipidemia, Pericardial Disease, Prevention, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Prevention, Lipid Metabolism

Keywords: Anti-Inflammatory Agents, Anti-Inflammatory Agents, Non-Steroidal, Aspirin, Colchicine, C-Reactive Protein, Fetus, Glucocorticoids, Health Personnel, Hyperlipidemias, Immunosuppressive Agents, Interleukin-1alpha, Interleukin-1beta, Lipids, Patient Care Team, Pericarditis, Pharmacies, Pregnancy, Primary Prevention, Respiratory Tract Infections

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