What medications are contraindicated in Kawasaki disease?

Medications Contraindicated in Kawasaki Disease

Ibuprofen is contraindicated in patients with Kawasaki disease who are taking aspirin for antiplatelet effects, as it antagonizes aspirin-induced platelet inhibition and may increase the risk of coronary artery thrombosis. 1

Key Contraindicated Medications

1. Ibuprofen and other NSAIDs

   • Antagonizes the irreversible platelet inhibition induced by aspirin
   • Should be avoided in children with coronary aneurysms who are taking aspirin for its antiplatelet effects
   • Alternative antipyretics such as acetaminophen should be used when needed

2. High-dose aspirin during viral illnesses

   • Aspirin should be temporarily discontinued during infections with influenza or varicella due to risk of Reye syndrome
   • During these periods, alternative antiplatelet therapy should be considered:
     • Clopidogrel (1 mg/kg/day, up to 75 mg) is the preferred alternative
     • Low-molecular-weight heparin may be used temporarily

Special Considerations for Aspirin Therapy

While aspirin is a cornerstone of Kawasaki disease treatment, there are important contraindications and precautions:

• Reye syndrome risk: Aspirin has been associated with Reye syndrome during viral illnesses, particularly influenza and varicella 1
• Vaccination considerations:
  • Annual inactivated influenza vaccine is recommended for all children on aspirin therapy 2
  • Only inactivated vaccines should be administered to children on aspirin therapy
  • Some physicians substitute another antiplatelet medication for aspirin during the 6-week period after varicella vaccination 1

Management Algorithm for Antiplatelet Therapy

1. During acute phase:

   • Standard therapy includes aspirin (80-100 mg/kg/day in 4 doses) with IVIG
   • Avoid ibuprofen completely

2. After fever resolution:

   • Transition to low-dose aspirin (3-5 mg/kg/day)
   • Continue to avoid ibuprofen

3. During viral illness (influenza/varicella):

   • Temporarily discontinue aspirin
   • Consider alternative antiplatelet therapy:
     • Clopidogrel (preferred)
     • Low-molecular-weight heparin

4. For patients with aspirin allergy:

   • Clopidogrel (1 mg/kg/day, up to 75 mg) is the preferred alternative 2

Corticosteroid Considerations

Early studies suggested corticosteroids might be contraindicated in Kawasaki disease, but more recent evidence shows they may be beneficial in certain scenarios:

• For patients with refractory disease (persistent fever after IVIG treatment)
• For high-risk Japanese patients (though identification criteria for high-risk non-Japanese patients remain unclear) 3
• Current guidelines recommend considering IV pulse methylprednisolone (30 mg/kg/day for 1-3 days) for patients with persistent fever after second IVIG dose 2

Important Caveats and Pitfalls

• The risk of untreated Kawasaki disease (15-25% risk of coronary artery abnormalities) far outweighs the risk of trying alternative antiplatelet agents 2
• While some recent studies question the necessity of aspirin in the acute phase 4, 5, current guidelines still recommend its use
• Ensure all family members of patients on aspirin therapy are vaccinated against influenza to reduce transmission risk 2
• Regular echocardiographic follow-up is essential for patients on aspirin therapy to monitor for coronary abnormalities 2