March 28, 2012
Volume 7 - Issue 13   

DynaMed Weekly Update

For the week ending March 23, 2012 

Last week 696 articles were evaluated via DynaMed's Systematic Literature Surveillance and 248 were added to DynaMed content.   

 

Based on the editors' criteria of selecting "articles most likely to change clinical practice," one article of significant interest was selected for the DynaMed Weekly Update.
Feature Article

Addition of Prednisolone to IVIG Plus Aspirin May Reduce Coronary Artery Abnormalities and Need for Additional Therapy in Children with Severe Kawasaki Disease

 

Kawasaki disease is an acute, febrile systemic vasculitis occurring mostly in young children. It is a leading cause of acquired heart disease, and may lead to long term coronary artery damage, particularly aneurysm formation. First line treatment includes high-dose intravenous immunoglobulin (IVIG) and aspirin. Adjunctive corticosteroids are recommended for patients with fever and inflammation that is unresponsive to initial IVIG treatment (Pediatrics 2004 Dec;114(6):1708). However, evidence for the efficacy of steroids as part of primary treatment for Kawasaki disease has been inconsistent (J Pediatr 2006 Sep;149(3):336, N Engl J Med 2007 Feb 15;356(7):663). The recently published RAISE trial lends support to the use of primary corticosteroids for children with severe Kawasaki disease who are at high risk of non-response to IVIG.

 

A total of 248 Japanese children with severe Kawasaki disease diagnosed within 9 days of fever onset were randomized without blinding to prednisolone IV vs. placebo. All children had been assessed to have high risk for unresponsiveness to IVIG and for coronary artery abnormalities using the Kobayashi score (Circulation 2006 Jun 6;113(22):2606). Initial prednisolone dosing was 2 mg/kg/day to maximum of 60 mg/day in 3 divided doses by IV injection for 5 days. When C-reactive protein was ≤ 5 mg/L, prednisolone was tapered to 0.5 mg/kg/day over 15 days in 5-day steps. Children whose fever was resolved at 5 days had oral prednisolone. All children received IVIG 2 g/kg over 24 hours and aspirin 30 mg/kg/day until afebrile, followed by aspirin 3-5 mg/kg/day for ≥ 28 days after fever onset.

 

The addition of prednisolone was associated with a reduction in fever duration after enrollment (median 1 day vs. 2 days, p < 0.0001) and with reduced need for additional treatment due to lack of response to first treatment (5% vs. 30%, p < 0.0001, NNT 4) (level 2 [mid-level] evidence). The prednisolone group had lower rates of coronary abnormalities at 1, 2, or 4 weeks (3% vs. 23%, p < 0.0001, NNT 5). Serious adverse events occurred in about 2% of children in each group (not significant), and there were no significant differences in relapse rates (11% vs. 12%). (Lancet 2012 Mar 7 early online).

 

It should be noted that while Kobayashi score has been shown to accurately predict risk in Japanese children, it had low sensitivity when applied to a cohort of North American children with Kawasaki disease (J Pediatr 2011 May;158(5):831). More generally applicable risk prediction tools may be needed to determine when children will benefit from steroid treatment.

 

For more information, see the Kawasaki disease topic in DynaMed.

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DynaMed Events
American College of Physicians (ACP) Conference
Please stop by the DynaMed booth (#1517) at the ACP Conference April 19th through the 21st. Its a great opportunity to give feedback, offer content suggestions, and explore collaboration opportunities.

Learn more about EBM and scholarly activity at seminars and education sessions at the STFM Annual Spring Conference April 25th through the 29th.

Saturday, April 28

S41: 10:30-12:00; Engaging Scholarly Activity: Electronic Peer Review of Evidence William Cayley Jr, MD; Brian Alper, MD, MSPH; Michael Mendoza, MD, MPH; Susan Hadley, MD

S43: 1:45-3:15; Using Electronic Knowledge Resources at the Point of Precepting William Cayley Jr, MD; Michael Mendoza, MD, MPH; Ingrid Watkins, MD; Mathew Devine, DO; Alexander Chessman, MD 


 

New Topic added to DynaMed this Week
Call for Peer Reviewers

We are currently seeking reviewers for:

Acute rheumatic fever
Compartment syndrome
Mucopolysaccharidosis type I (MPS I)

 

Learn more about the DynaMed Contribution Opportunities:

DynaMed Peer Review 

Editorial Policies for Reviewers 

About DynaMed Weekly Update

Prepared by the clinician members of the DynaMed Editorial Team, DynaMed Weekly Update is a compilation of one to five articles selected from DynaMed's Systematic Literature Surveillance as articles most likely to change clinical practice.

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CME Information

CREDITS

Physicians:
0.25 AMA PRA Category I Credit(s)™
Family Physicians: 0.25 Prescribed credits
Nurse Practitioners: 0.25 Contact hours
 
Release Date: March 28, 2012 
Expiration Date: March 28, 2013
Estimated Completion Time:
15 minutes
 
There is no fee for this activity.

To Receive Credit 
In order to receive your certificate of participation, you should read the information about this activity, including the disclosure statements, review the entire activity, take the post-test, and complete the evaluation form. You may then follow the directions to print your certificate of participation. To begin, click the CME icon at the end of the article.

Program Overview

Learning Objectives

Upon successful completion of this educational program, the reader should be able to:
1. Discuss the significance of this article as it relates to your clinical practice.
2. Be able to apply this knowledge to your patient's diagnosis, treatment and management.
 
Faculty Information
 
Alan Ehrlich, MD - Assistant Clinical Professor in Family Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA; Deputy Editor, DynaMed, Ipswich, Massachusetts, USA

Michael Fleming, MD, FAAFP - Assistant Clinical Professor of Family Medicine and Comprehensive Care, LSU Health Science Center School of Medicine, Shreveport, Louisiana, USA; Assistant Clinical Professor of Family Medicine, Department of Family and Community Medicine, Tulane University Medical School, New Orleans, Louisiana, USA; Chief Medical Officer, Amedisys, Inc. & Antidote Education Company

Disclosures  
Dr. Ehrlich, Dr. Fleming, DynaMed Editorial Team members, and the staff of Antidote Education Company have disclosed that they have no relevant financial relationships or conflicts of interest with commercial interests related directly or indirectly to this educational activity.
 
No commercial support has been received for this activity.

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ACCME This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of Antidote Education Company and EBSCO Publishing. Antidote is accredited by the ACCME to provide continuing medical education for physicians.  Antidote Education Company designates this educational activity for a maximum of 0.25 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

AAFP: This activity, DynaMed Weekly Update 2011, has been reviewed and is acceptable for up to 13 Prescribed credits by the American Academy of Family Physicians. AAFP accreditation begins March 2, 2011. Term of approval is for one year from this date. Each Weekly Update is approved for 0.25 Prescribed credits. Credit may be claimed for one year from the date of each Weekly Update.

  

AANP: This program is approved for 0.25 contact hour of continuing education by the American Academy of Nurse Practitioners.  

Program ID 1102072D.

 
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