{
  "abstract": "Kawasaki disease is an acute vasculitis affecting predominantly medium and small vessels, most prevalent in children under 5 years old. 1 A diagnosis is made on presentation of 4 of the 5 following characteristic features: bilateral conjunctival injection, oral cavity changes, extremity changes, cervical lymphadenopathy, and a rash, alongside a fever which has lasted for more than 5 days.1 Rapid diagnosis and then treatment is crucial to reduce the risk of cardiac side effects associated with Kawasaki disease. When left untreated around 25% of patients develop coronary artery aneurysms.1 Due to the systemic inflammation of the disease, we treat patients with 2g/kg intravenous immunoglobulin (IVIG).1 This should be given within 10 days of the first signs of illness, to reduce the risk of coronary artery aneurysm from 25% to 10%.2 A course of steroids is also given to reduce coronary artery complications.1 These are given alongside aspirin for its antiplatelet and anti-inflammatory effects.1 In refractory cases of Kawasaki disease, infliximab can be used, which prevents inflammation by inhibiting tumour necrosis factor alpha (TNF-alpha).1 Our patient is a 3-month-old male, presenting with a 5 day history of fever, alongside red and cracked lips, widespread maculopapular rash, prominent left lymph node and red sclera. IVIG was administered on day 7 following a delay due to difficult intravenous (IV) access requiring a midline insertion. Aspirin 10mg/kg 4 times a day was also started at this time alongside methylprednisolone.The patient remained afebrile, however bradycardic and hypertensive (deemed to be because of methylprednisolone). An echocardiogram on day 9 showed coronary artery aneurysms. The patient was then started on prophylactic enoxaparin 0.5mg/kg twice a day (dose as per British National Formulary for Children [BNFc]) and given two doses of IV infliximab 6mg/kg (dose as per health board guideline) one week apart.Due to extreme difficulty in obtaining and maintaining IV access, we looked at adalimumab, another biologic medication which inhibits TNF-alpha, however can be given subcutaneously. It is licensed in children over 2 years old with polyarticular juvenile idiopathic arthritis, with studies utilising a 24mg/m2 dose.3 Following a multi-disciplinary team discussion, involving dosage discussions with Scottish Paediatric and Adolescent Rheumatology Network (SPARN) and colleagues from other areas, adalimumab was started for our patient 6 weeks after first presentation for a 3-to-6-month course. The dose prescribed was 24mg/m2, which equated to 9mg. For ease of administration, 10mg every 2 weeks was prescribed, and dispensed as the 20mg in 0.4ml pre-filled syringe of which 0.2ml was decanted and given. The course of treatment was stopped after 5 months due to low adalimumab levels (<0.4microgram/ml) and high adalimumab antibodies (>200AU/ml). Follow up echocardiograms have shown the aneurysms have reduced in size.While it is impossible to tell if our patient benefitted from the adalimumab due to the low levels and high antibodies. This trial shows problem solving by practitioners using a multi-disciplinary approach which opens the possibility for other practitioners to utilise this drug in this context.References Jone P-N, Tremoulet A, Choueiter N, et al. Update on diagnosis and management of kawasaki disease: a scientific statement from the american heart association. Circulation 2024;150:e481–e500Van Stijn D, Korbee JM, Netea SA, et al. Treatment and coronary artery aneurysm formation in kawasaki disease: a per-day risk analysis. The Journal of Pediatrics 2022;243:167–172Kingsbury D, Quartier P, Arora V et al. SAT0436 safety and effectiveness of adalimumab in children with polyarticular juvenile idiopathic arthritis aged 2 To <4 years or ≥4 years weighing <15 KG. Annals of the Rheumatic Diseases 2013;72:A729",
  "authors": [
    {
      "affiliations": [
        "NHS Lothian, UK"
      ],
      "name": "Claire Morrison"
    }
  ],
  "title": "P40 Subcutaneous adalimumab in the treatment of kawasaki disease",
  "uid": "0cec238e-f8bb-51ef-b3bc-dc534eaac438"
}