PMID- 31425625 OWN - NLM STAT- MEDLINE DCOM- 20190924 LR - 20220907 IS - 1469-493X (Electronic) IS - 1361-6137 (Linking) VI - 8 IP - 8 DP - 2019 Aug 16 TI - TNF-alpha blockers for the treatment of Kawasaki disease in children. PG - CD012448 LID - 10.1002/14651858.CD012448.pub2 [doi] LID - CD012448 AB - BACKGROUND: Kawasaki disease (KD) is an acute inflammatory vasculitis (inflammation of the blood vessels) that mainly affects children between six months and five years of age. The vasculitis primarily impacts medium-sized blood vessels, especially in the coronary arteries. In most children, intravenous immunoglobulin (IVIG) and aspirin therapy rapidly reduce inflammatory markers, fever, and other clinical symptoms. However, approximately 15% to 20% of children receiving the initial IVIG infusion show persistent or recurrent fever and are classified as IVIG-resistant. Tumor necrosis factor-alpha (TNF-alpha) is an inflammatory cytokine that plays an important role in host defence against infections and in immune responses. Several studies have established that blocking TNF-alpha is critical for obtaining anti-inflammatory effects in children with KD, thus, there is a need to identify benefits and risks of TNF-alpha blockers for the treatment of KD. OBJECTIVES: To evaluate the efficacy and safety of using TNF-alpha blockers (i.e. infliximab and etanercept) to treat children with Kawasaki disease. SEARCH METHODS: The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL databases, the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials register to 19 September 2018. We also undertook reference checking of grey literature. SELECTION CRITERIA: We included randomised controlled trials (RCTs) that compared TNF-alpha blockers (i.e. infliximab and etanercept) to placebo or other drugs (including retreatment with IVIG) in children with KD, reported in abstract or full-text. DATA COLLECTION AND ANALYSIS: Two review authors independently applied the study selection criteria, assessed risk of bias and extracted data. When necessary, we contacted study authors for additional information. We used GRADE to assess the certainty of the evidence. MAIN RESULTS: We included five trials from 14 reports, with a total of 494 participants. All included trials were individual RCTs that examined the effect of TNF-alpha blockers for KD.Five trials (with 494 participants) reported the incidence of treatment resistance. TNF-alpha blockers reduced the incidence of treatment resistance (TNF-alpha blocker intervention group 30/237, control group 58/257; risk ratio (RR) 0.57, 95% confidence interval (CI) 0.38 to 0.86; low-certainty evidence).Four trials reported the incidence of coronary artery abnormalities (CAAs). Three trials (with 270 participants) contributed data to the meta-analysis, since we could not get the data needed for the analysis from the fourth trial. There was no clear difference between groups in the incidence of CAAs (TNF-alpha blocker intervention group 8/125, control group 9/145; RR 1.18, 95% CI 0.45 to 3.12; low-certainty evidence).Three trials with 250 participants reported the adverse effect 'infusion reactions' after treatment initiation. The TNF-alpha blocker intervention decreased infusion reactions (TNF-alpha blocker intervention group 0/126, control group 15/124; RR 0.06, 95% CI 0.01 to 0.45; low-certainty evidence).Two trials with 227 participants reported the adverse effect 'infections' after treatment initiation. There was no clear difference between groups (TNF-alpha blocker intervention group 7/114, control group 10/113; RR 0.68, 95% CI 0.33 to 1.37; low-certainty evidence).One trial (with 31 participants) reported the adverse effect 'cutaneous reactions' (rash and contact dermatitis). There was no clear difference between the groups for incidence of rash (TNF-alpha blocker intervention group 2/16, control group 0/15; RR 4.71, 95% CI 0.24 to 90.69; very low-certainty evidence) or for incidence of contact dermatitis (TNF-alpha blocker intervention group 1/16, control group 3/15; RR 0.31, 95% CI 0.04 to 2.68; very low-certainty evidence).No trials reported other adverse effects such as injection site reactions, neutropenia, infections, demyelinating disease, heart failure, malignancy, and induction of autoimmunity. AUTHORS' CONCLUSIONS: We found a limited number of RCTs examining the effect of TNF-alpha blockers for KD. In summary, low-certainty evidence indicates that TNF-alpha blockers have beneficial effects on treatment resistance and the adverse effect 'infusion reaction' after treatment initiation for KD when compared with no treatment or additional treatment with IVIG. Further research will add to the evidence base. Due to the small number of underpowered trials contributing to the analyses, the results presented should be treated with caution. Further large high quality trials with timing and type of TNF-alpha blockers used are needed to determine the effects of TNF-alpha blockers for KD. FAU - Yamaji, Noyuri AU - Yamaji N AD - Global Health Nursing, Graduate School of Nursing Sciences, St. Luke's International University, 10-1 Akashi-cho, Chuo-Ku, Tokyo, MS, Japan, 104-0044. FAU - da Silva Lopes, Katharina AU - da Silva Lopes K FAU - Shoda, Tetsuo AU - Shoda T FAU - Ishitsuka, Kazue AU - Ishitsuka K FAU - Kobayashi, Tohru AU - Kobayashi T FAU - Ota, Erika AU - Ota E FAU - Mori, Rintaro AU - Mori R LA - eng GR - ETM/442/CSO_/Chief Scientist Office/United Kingdom PT - Journal Article PT - Research Support, Non-U.S. Gov't PT - Systematic Review DEP - 20190816 PL - England TA - Cochrane Database Syst Rev JT - The Cochrane database of systematic reviews JID - 100909747 RN - 0 (Antibodies, Monoclonal, Humanized) RN - 0 (Immunologic Factors) RN - 0 (Tumor Necrosis Factor-alpha) SB - IM UOF - doi: 10.1002/14651858.CD012448 MH - Antibodies, Monoclonal, Humanized/*therapeutic use MH - Child, Preschool MH - Humans MH - Immunologic Factors MH - Infant MH - Mucocutaneous Lymph Node Syndrome/*drug therapy MH - Randomized Controlled Trials as Topic MH - Tumor Necrosis Factor-alpha/*antagonists & inhibitors MH - Vasculitis/drug therapy PMC - PMC6953355 COIS- NY: none known KL: none known TS: none known KI: none known TK: none known EO: none known RM: none known EDAT- 2019/08/20 06:00 MHDA- 2019/09/26 06:00 PMCR- 2020/08/16 CRDT- 2019/08/20 06:00 PHST- 2019/08/20 06:00 [pubmed] PHST- 2019/09/26 06:00 [medline] PHST- 2019/08/20 06:00 [entrez] PHST- 2020/08/16 00:00 [pmc-release] AID - CD012448.pub2 [pii] AID - 10.1002/14651858.CD012448.pub2 [doi] PST - epublish SO - Cochrane Database Syst Rev. 2019 Aug 16;8(8):CD012448. doi: 10.1002/14651858.CD012448.pub2.