Therapy should be commenced within 10 days of onset, and preferably within 7 days. Some patients require retreatment with IVIG for relapse [96]. There does not appear to be any additional benefit from using high-dose aspirin (80–120 mg/kg/day) plus IVIG compared with low dose of aspirin plus IVIG in terms of aneurysm formation [93]. Glucocorticoid therapy is generally Lumacaftor cost not used in the primary treatment of Kawasaki

disease but it may be of value in resistant cases [97]. In a small study intravenous methylprednisolone was effective, with more rapid initial resolution of fever in 77% (34 of 44) of cases compared to 63% (12 of 19) of controls [98]. Maintenance.  Kawasaki disease is a self-limiting and generally non-recurring vasculitis and long-term immunosuppressive therapy is not indicated. Children with learn more coronary artery abnormalities should be treated with low-dose aspirin, anti-coagulants and beta-blockers according to recommended guidelines [94]. The treatment of the ANCA-associated vasculitides, Wegener’s granulomatosis, Churg–Strauss syndrome and microscopic polyangiitis, are considered as one group. The presence of ANCA has been shown to be associated with more

severe forms of disease [99,100]. Collaborative trials conducted by EUVAS have demonstrated that patients with different levels of disease severity respond to different treatment protocols [19]. Treatment is based upon disease severity rather than ANCA status. Induction: cyclophosphamide.  Pulsed intravenous high-dose or low-dose oral continuous cyclophosphamide plus glucocorticoids are equally effective PAK6 for induction of remission in generalized ANCA-positive vasculitis [73]. However, pulsed cyclophosphamide is associated with reduced morbidity related to leucopenia and infection, due to a lower cumulative dose of cyclophosphamide than continuous daily oral therapy. Intravenous cyclophosphamide is given every 2 weeks for the first three pulses, and thereafter 3-weekly until remission is achieved, following which patients are switched to maintenance therapy after a median of 3 months. The usual dose is 15 mg/kg/pulse, but reductions

are made for impaired renal function and increasing age [89]. Continuous low-dose oral cyclophosphamide can be given at 2 mg/kg/day with dose reductions according to age (patients over the age of 60 and 75 years have a 25% and 50% dose reduction, respectively). The maximum daily dosage is 200 mg/day, given for 3 months, when 80% of patients would be expected to have achieved remission. Thereafter, the dose is reduced to 1·5 mg/kg/day. However, if remission has not been achieved, oral dosing can be continued at 2 mg/kg/day for a further 3 months, by which time 90% should have achieved remission. Use of cyclophosphamide should not usually exceed 6 months, and if patients still have active disease they should be considered for alternative immunomodulatory therapy [69].