Key result
Initial therapy with IVIG plus infliximab reduced the need for additional therapy compared to IVIG alone (11% vs 44%; OR 8.1 for IVIG alone, 95% CI 2.26-37.55, P=0.003) in children with KD and CALs.
Why the study?
Because 80% of Kawasaki disease patients who develop coronary artery lesions have them at diagnosis, they may benefit from more aggressive initial therapy. While adding infliximab to standard therapy decreases inflammation, outcomes comparing initial IVIG plus infliximab versus IVIG alone in patients presenting with coronary artery lesions needed evaluation.
Does adding infliximab to initial IVIG and aspirin therapy reduce the need for additional therapy and improve coronary artery outcomes compared to IVIG and aspirin alone in children with Kawasaki disease presenting with coronary artery lesions?
Cohort (n=69)
No
Does adding infliximab to initial IVIG and aspirin therapy reduce the need for additional therapy and improve coronary artery outcomes compared to IVIG and aspirin alone in children with Kawasaki disease presenting with coronary artery lesions?
Answers are grounded in this paper and cite their sources.
Adding a single dose of infliximab to initial IVIG and aspirin therapy in children with Kawasaki disease presenting with coronary artery lesions significantly lowers the rate of treatment resistance requiring second-line therapy from 44% to 11%.
BACKGROUND: We previously demonstrated that 80% of Kawasaki disease (KD) patients who develop coronary artery lesions (CALs) have them at diagnosis. We postulated that KD patients presenting with CALs represent a group that may benefit from more aggressive initial therapy. Infliximab has been shown to decrease inflammation in KD patients when added to standard therapy. We compared outcomes of KD patients with CALs initially treated with intravenous immunoglobulin (IVIG) alone versus IVIG plus infliximab. METHODS: Medical records of KD patients from January 2009 to July 2016 were retrospectively reviewed. CALs were defined as a left anterior descending or right coronary artery Z score ≥2.5. KD patients with CALs on initial echocardiogram treated with IVIG alone were compared with those treated with IVIG plus infliximab. Clinical characteristics were compared between groups using Wilcoxon rank-sum test, χ test and Fischer's exact tests; length of stay was analyzed using log-normal regression and need for additional therapy using logistic regression. Effect of treatment on CALs between groups was assessed using linear mixed models. RESULTS: Sixty-nine KD patients with CALs at presentation were included. Fifteen of 34 (44%) patients treated with IVIG alone required additional therapy compared with 4 of 35 (11%) patients treated with IVIG plus infliximab (P = 0.003). There were no significant differences between treatment groups for length of stay, CALs or C-reactive protein fall. CONCLUSIONS: IVIG plus infliximab as initial therapy reduces the need for additional therapy in KD patients presenting with CALs. Intensified initial therapy, consisting of infliximab plus IVIG, could be considered for this group of KD patients.
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Jone et al. (2018) conducted a cohort in Kawasaki disease presenting with coronary artery lesions (n=69). Infliximab plus intravenous immunoglobulin (IVIG) and high-dose aspirin vs. Intravenous immunoglobulin (IVIG 2 g/kg IV over 12 hours) and high-dose aspirin (80-100 mg/kg/day) alone was evaluated on Need for additional therapy (IVIG resistance / persistence or recrudescence of fever) (OR 8.1 (for IVIG alone vs IVIG plus infliximab), 95% CI 2.26-37.55, p=0.003). Initial therapy with IVIG plus infliximab reduced the need for additional therapy compared to IVIG alone (11% vs 44%; OR 8.1 for IVIG alone, 95% CI 2.26-37.55, P=0.003) in children with KD and CALs.
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