Infliximab may best intravenous immunoglobulin for retreatment of Kawasaki disease

A retrospective study in patients with intravenous immunoglobulin (IVIG)-resistant Kawasaki disease (KD) showed that, compared with retreatment with IVIG, retreatment with infliximab, a tumor necrosis factor-a blocker, results in faster resolution of fever and shorter hospitalization.

The study was conducted in 106 patients with KD at 2 centers. Eighty-six patients (81%) initially underwent retreatment with IVIG-41 patients at center 1 and 45 patients at center 2. The 20 patients (19%) who underwent retreatment with infliximab all were treated at center 2. At baseline, the 2 treatment groups were similar in demographics, days of fever at diagnosis, and baseline coronary artery dimensions.

Six weeks after diagnosis, the treatment groups did not differ in left anterior descending artery or right coronary artery outcomes. The similarity between the 2 groups held after adjustment for baseline factors known to be associated with increased risk of coronary artery abnormalities. In addition, the infliximab and IVIG retreatment groups did not differ significantly in the proportion of patients with aneurysms (35% vs 34%; P=.91).

Commentary

We will need more information on the use of infliximab in KD before it becomes part of standard therapy. This relatively small study showed some shortening of duration of fever as a measure of inflammation but no reduction in the real outcome of interest-coronary artery aneurysms. I wonder if a larger prospective study, perhaps one that compared IVIG, infliximab, and a combination of the 2 therapies for patients who fail to resolve after IVIG, would detect improvement in that measure.
-Michael Burke, MD