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Standard initial treatment for Kawasaki disease in the USA is a single dose of intravenous immunoglobulin (IVIG) 2 gm/kg plus aspirin 80–100 mg/kg/day. The role of steroid treatment is controversial. Steroids have been used either as initial therapy or as rescue therapy after failure of IVIG and aspirin. Most studies have documented clinical improvement with steroids but there has been a suggestion that the risk of coronary abnormalities might be increased. A small trial in Boston, Massachusetts of pulsed–dose intravenous methylprednisolone added to IVIG and aspirin as initial treatment has confirmed that clinical resolution is quicker with steroid therapy (
, see also editorial, ibid 601–3).
Thirty-nine children were randomised on day 4–10 (median, day 7) of illness to IVIG 2 gm/kg over 10 hours plus oral aspirin either with or without pulsed-dose intravenous methylprednisolone, 30 mg/kg prior to the IVIG. The methyl prednisolone group had a shorter duration of fever after starting treatment (1.0 vs 1.9 days), shorter hospital stay (1.9 vs 3.3 days), and lower ESR and C-reactive protein at 6 weeks. Coronary artery dimensions after treatment did not differ significantly between the two groups but numbers were small.
The authors of this paper call for a large, multicentre trial. An editorialist advises that in the meantime there is not enough evidence to justify the routine use of steroids in primary therapy. For rescue therapy he also considers the evidence to be inadequate but prefers to use a second, or even a third, dose of IVIG if necessary.