{"id":30664,"date":"2026-07-05T04:06:00","date_gmt":"2026-07-04T20:06:00","guid":{"rendered":"https:\/\/csccm.org.cn\/?p=30664"},"modified":"2026-07-05T06:27:37","modified_gmt":"2026-07-04T22:27:37","slug":"nejm%e5%8f%91%e8%a1%a8%e8%bf%b0%e8%af%84%ef%bc%9a%e7%b3%96%e7%9a%ae%e8%b4%a8%e6%bf%80%e7%b4%a0%e6%b2%bb%e7%96%97%e5%b7%9d%e5%b4%8e%e7%97%85%ef%bc%9a%e9%87%8d%e6%96%b0%e5%ae%9a%e4%b9%89%e9%80%82","status":"publish","type":"post","link":"https:\/\/csccm.org.cn\/?p=30664","title":{"rendered":"[NEJM\u53d1\u8868\u8ff0\u8bc4]\uff1a\u7cd6\u76ae\u8d28\u6fc0\u7d20\u6cbb\u7597\u5ddd\u5d0e\u75c5\uff1a\u91cd\u65b0\u5b9a\u4e49\u9002\u5e94\u8bc1"},"content":{"rendered":"\n

EDITORIAL<\/a><\/p>\n\n\n\n

Glucocorticoids in Kawasaki Disease \u2014 Refining Indications and the Science<\/h1>\n\n\n\n

Jane C.\u00a0Burns,\u00a0Jane W.\u00a0Newburger<\/h3>\n\n\n\n

N Engl J Med\u00a02026;394:1542-1543<\/h3>\n\n\n\n

DOI: 10.1056\/NEJMe2518759<\/h3>\n\n\n\n

Kawasaki disease is the most common cause of acquired heart disease in children in the developed world.1<\/a><\/sup> Although Kawasaki disease manifests with acute, transient systemic signs, its long-term morbidity derives from necrotizing vasculitis that predominantly affects the coronary arteries.2,3<\/a><\/sup> The primary goal of therapy during the acute illness is the prevention of coronary-artery aneurysms. Timely administration of high-dose intravenous immune globulin (IVIG) has reduced the incidence of such aneurysms from 20 to 25% to approximately 3 to 5%.4,5<\/a><\/sup> Yet, IVIG is not a panacea. Large or \u201cgiant\u201d aneurysms, defined by a diameter of 8 mm or a z score of 10 or higher, still occur in 0.5 to 1% of patients receiving IVIG and account for almost all long-term morbidity in Kawasaki disease. Efforts to further mitigate this risk through adjunctive antiinflammatory therapies have been hampered by the low baseline incidence of coronary-artery aneurysms, which necessitates large sample sizes to achieve adequate statistical power, and a limited mechanistic understanding of the biologic processes of inflammation in the arterial wall.<\/p>\n\n\n\n

Seeking to improve on IVIG monotherapy, researchers have investigated adjunctive glucocorticoids, a staple of vasculitis treatment. Although early trials in Japan showed mixed results, the landscape was changed by the Randomized Controlled Trial to Assess Immunoglobulin plus Steroid Efficacy for Kawasaki Disease (RAISE), which showed that adding a tapering course of prednisolone to initial IVIG lowered the incidence of coronary-artery aneurysms from 23% to 3% among high-risk Japanese children without such aneurysms at baseline.6<\/a><\/sup> These findings were bolstered by a Cochrane meta-analysis providing moderate-certainty evidence that adjunctive glucocorticoids reduce fever duration, accelerate the normalization of inflammatory markers, and lower the occurrence of coronary-artery aneurysms without increasing serious adverse events.7<\/a><\/sup> The real-world Post RAISE cohort study showed that high-risk patients with Kawasaki disease treated with primary prednisolone plus IVIG, including those with coronary-artery aneurysms at baseline, had outcomes similar to those in the prednisolone group of RAISE8<\/a><\/sup>; coronary outcomes were also similar to those of patients in the IVIG-alone group who did not have a response to IVIG and subsequently received rescue prednisolone or infliximab. Secondary analyses showed that a coronary z score of 2.5 or higher at presentation, an age of younger than 1 year, and initial nonresponsiveness to IVIG are powerful independent predictors of the development of coronary-artery aneurysms.9<\/a><\/sup> Few studies have focused on the efficacy of primary adjunctive glucocorticoids in unselected children with Kawasaki disease.<\/p>\n\n\n\n

In this issue of the Journal<\/em>, Lin and colleagues address this question in an open-label, multicenter, randomized, controlled trial evaluating adjunctive prednisolone in a large, unselected population of patients with Kawasaki disease in China.10<\/a><\/sup> The primary outcome \u2014 the occurrence of coronary-artery lesions, defined as a z score of 2 or more in any of five coronary segments, at 1 month after illness onset \u2014 did not differ significantly between the adjunctive prednisolone group and the IVIG-only group. Several secondary findings are noteworthy. The prednisolone group showed a significantly shorter fever duration, a more rapid normalization of C-reactive protein (CRP) levels, and a lower incidence of resistance to IVIG. However, among patients who had resistance to IVIG, those in the prednisolone group had a much higher incidence of coronary-artery lesions, which suggests that refractory fever in this context is a marker for exceptionally severe inflammation or that glucocorticoids impede coronary remodeling in this subgroup of patients. The incidence of adverse events did not differ significantly between the trial groups.<\/p>\n\n\n\n

Several issues in the trial design and analysis deserve comment. First, because the trial definition of a coronary-artery lesion (z score, \u22652.0) represents the 97.5th percentile in an afebrile population, a small proportion of healthy children will meet this threshold in any single coronary segment; in a study looking at five segments, the probability of a false positive result increases further. By using such a sensitive but nonspecific outcome, the trial may have inflated the number of outcome events involving clinically insignificant lesions that typically remodel without long-term sequelae. Furthermore, the trial had a paucity of prespecified subgroup analyses for the highest-risk patients: those with a coronary z score of 5.0 or higher at baseline and infants younger than 6 months of age. Future studies involving this invaluable dataset should explore the effect of glucocorticoids in the highest-risk groups who might or might not benefit.<\/p>\n\n\n\n

In summary, the work of Lin et al. aligns with medical-society recommendations in the United States and Japan: treatment with adjunctive glucocorticoids is not indicated in unselected patients with Kawasaki disease. The trial also suggests that although glucocorticoid therapy improves systemic inflammation, it remains imperfect at controlling inflammation in the coronary arterial wall. Because glucocorticoids can mask fever, which is often used as an indicator of disease activity, frequent echocardiographic surveillance is critical for patients receiving intensified regimens. Future research must move beyond systemic markers to identify the specific biologic factors driving tissue-level inflammation. Only a deeper understanding of mechanisms driving arterial inflammation in Kawasaki disease will allow for the development of targeted therapies for the children at highest risk for life-altering cardiovascular complications.<\/p>\n","protected":false},"excerpt":{"rendered":"

EDITORIAL Glucocorticoids in Kawasaki Disease \u2014 Refinin […]<\/p>\n","protected":false},"author":3,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":[],"categories":[24,23],"tags":[],"_links":{"self":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/30664"}],"collection":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=30664"}],"version-history":[{"count":1,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/30664\/revisions"}],"predecessor-version":[{"id":30671,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/30664\/revisions\/30671"}],"wp:attachment":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=30664"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=30664"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=30664"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}