Early Steroids Are Effective Adjunct in Kawasaki Disease Treatment

Summary and Comment |
October 21, 2016

Early Steroids Are Effective Adjunct in Kawasaki Disease Treatment

  1. John D. Cowden, MD, MPH

Steroids added to intravenous immunoglobulin treatment of Kawasaki disease reduced likelihood of coronary artery abnormalities, particularly when added early.

  1. John D. Cowden, MD, MPH

Steroids have long been a mainstay of vasculitis treatment, but their role in Kawasaki disease has been unclear due to mixed results from controlled trials. These authors performed a meta-analysis of 16 studies that compared treatment with intravenous immunoglobulin (IVIG) plus steroids versus IVIG alone in 2746 patients with Kawasaki disease. Steroid use was defined as initial (started at the same time as IVIG) or rescue (started after failure of IVIG to reduce fever).

In the pooled analysis, adding steroids to IVIG was associated with a lower risk for coronary artery abnormalities compared with IVIG alone (odds ratio, 0.42). Initial steroids (OR, 0.32) were more effective than rescue steroids (OR, 0.85). The benefit of initial steroids was greatest in the subgroup of patients at high risk for IVIG resistance (OR, 0.24). A negative correlation was found between duration of illness before starting steroids and the effect of steroid treatment on coronary artery abnormalities. Fever duration was shorter with IVIG plus steroids than with IVIG alone (0.66 vs. 2.18 days), whereas the rate of adverse events was similar between the two groups (about 8.0%).

Comment

Even though steroids have been the first-line therapy for vasculitis for years, Kawasaki disease continues to be treated with IVIG and aspirin alone. Growing evidence shows that steroids can protect against coronary artery abnormalities when used as initial therapy (as opposed to rescue therapy), particularly in children at high risk for IVIG resistance. Identifying such high-risk children is a challenge, as multiple proposed scoring systems include a variety of different laboratory and clinical findings (e.g., neutrophilia, elevated C-reactive protein, hypoalbuminemia, elevated liver enzymes, lymphadenopathy, illness duration; J Formos Med Assoc 2016; 115:350). Consultation with a Kawasaki disease expert can help clinicians determine risk for IVIG resistance and utility of initial steroid treatment.

Editor Disclosures at Time of Publication

  • Disclosures for John D. Cowden, MD, MPH at time of publication Leadership positions in professional societies Co-Chair, Culture, Ethnicity, and Health Care Special Interest Group, Academic Pediatric Association

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