糖皮质激素在川崎病治疗中作用的循证医学研究

目的 通过循证医学方法研究肾上腺皮质激素在川崎病治疗中的作用.方法 采用循证医学方法,检索国内外5种大型专业数据库,筛选出随机或半随机对照研究的文献,再人工筛查确定适宜文献.通过Meta分析,比较激素与丙种球蛋白治疗川崎病在退热时间和冠状动脉病变发生率方面的差异.结果 初筛得到443篇文献.经过人工检索,8篇文献符合要求而被纳入标准.其中,3篇文献共有49例川崎病患儿接受甲基强的松龙治疗,5篇文献共有406例患儿接受强的松治疗.对照组共有33例接受静脉丙种球蛋白治疗,435例接受阿司匹林治疗.各组间患儿性别、年龄、病程差异无显著意义.①甲基强的松龙组(3篇文献):24例发生冠状动脉病变,对照组18例发生,两组病变发生率差异无显著意义.在退热方面,1篇文献显示甲基强的松龙组发热时间明显较丙种球蛋白组缩短,差异有显著意义;2篇文献显示差异无显著意义.②强的松组(8篇文献):28例发生冠状动脉瘤,阿司匹林对照组11例发生,3篇文献提示强的松组冠状动脉瘤发生率明显高于对照组.强的松组76例发生冠状动脉扩张,对照组75例发生,3篇文献提示强的松组冠状动脉扩张发生率明显高于对照组,2篇文献提示强的松组冠状动脉扩张发生率略低于对照组,但差异无显著意义.结论 目前的研究资料显示,激素治疗与丙种球蛋白治疗川崎病在冠状动脉病变发生率方面尚无差异或增高.在缩短热程上两者差异也不显著.尚可进一步通过更大数量病例的随机对照研究来证实本结果.目前治疗川崎病不主张单独应用激素.

The evidence-based research of corticosteroids treatment of Kawasaki disease

Objective To investigate the efficacy of corticosteroids in Kawasaki disease through comparing it with intravenous immunoglobulin. Methods We included all randomized or quasi-randomized control trials related by searching the Controlled Trials Register, Medline, EMBASE, two databases in Japan, and CNKI (Chinese National Knowledge Infrastructure, Janl994-Jan 2003), checking the reference lists of articles, and contacting the experts in this field. Data collection and meta-analysis were done to evaluate the effect of corticosteroids. Results Eight trials were included (n = 913). Because of the methodological differences, the results were not pooled. Methodologically, the quality of the included studies was not high. Considering the occurrence of coronary aneurysms, three studies about methylprednisolone showed no significant difference between those receiving methylprednisolone and IVIG or aspirin (RR 0. 71-1. 33, 95%CI 0. 22-4. 97), four studies about prednisone showed increased morbidity compared with the IVIG or aspirin group (RR 1. 50-7. 00, 95%CI 0. 64-55. 87) and one has no data. In respect of the occurrence of coronary dilation, five trials showed an tendency of increased morbidity of coronary dilation in patients receiving steroid (RR 1. 24-9. 00, 95%CI 0. 64-69. 74) while one (Yuan;2000) showed no difference and two showed slightly reduced occurrence of coronary dilation compared with the control group (RR 0. 80-0. 89, 95%CI 0. 19-3. 37). One of the studies seemed to have low stringency because of the inadequacy of cases (Nakamura; 1985). For the course of febrile, one study showed significantly shortened course in those receiving methylprednisolone and aspirin compared with the control group (Hashino; 2001), two studies showed slight reduce of course in those receiving methylprednisolone and IVIG or aspirin (Yuan; 2000, Seto;1983). There were no data of febrile course among those receiving prednisone. Conclusions The selection of steroid therapy for Kwasaki disease should be more prudent in spite of its possible benefit in shortening the febrile duration, considering its intendancy in increasing the morbidity of coronary aneurysms and dilation.