Infeções Associadas a Terapêuticas Sistémicas Não Biológicas em Dermatologia: Como Prevenir?
Resumo
O risco infecioso associado a terapêutica biológica é cada vez mais estudado e conhecido, existindo estratégias de rastreio e profilaxia bem estabelecidas. O mesmo não se verifica na utilização de corticoide sistémico nem dos tradicionais modificadores de doença autoimune, de que são exemplo o metotrexato e a ciclosporina, apesar de usados há largos anos. A dose e tempo de terapêutica com corticoide sistémico relacionam-se com a ocorrência de infeção oportunista. Doses superiores a 5 mg/dia associam-se a infeção bacteriana, superiores a 10 mg/dia a reativação de infeção por vírus herpes zoster (VHZ), e superiores a 15 mg/dia ou por mais de 2 a 4 semanas a reativação de tuberculose latente, o que implica rastreio e aplicação de quimioprofilaxia de forma adequada. O corticoide sistémico surge ainda como dos principais fatores de risco para o desenvolvimento de pneumocistose no doente não-VIH e doses prolongadas (por mais de 4 semanas) podem levar a reativação de infeção por vírus da hepatite B (VHB) e justificar a profilaxia com tenofovir disoproxil fumarato ou entecavir. Foram ainda descritos casos de estrongiloidíase complicada de síndrome de hiperinfeção em doentes sob corticoide. O grau de imunossupressão conferido pode contraindicar a realização de vacinas vivas atenuadas. O metotrexato e ciclosporina comportam baixo risco infecioso quando utilizados em monoterapia, sendo a vigilância de sintomas a principal estratégia preventiva. Não obstante, ambos são imunomoduladores, contraindicam a realização de vacinas vivas atenuadas e associam-se a risco de infeção bacteriana e reativação de infeção por VHZ, no caso da ciclosporina, ou reativação de infeção por VHZ e VHB no caso do metotrexato, sobretudo se administrado em dose >0,4 mg/kg/semana. Ambos se associam a evolução para tuberculose ativa quando em associação terapêutica com outros imunossupressores. Compreender e estudar o risco de infeção na utilização de terapêutica imunossupressora permite a sua aplicação de forma mais informada e segura.
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