IMPACT OF IMMUNOSUPPRESSION ON THE PERIOPERATIVE MANAGEMENT OF PATIENTS WITH PIGMENTARY AUTOIMMUNE DISEASES, ESPECIALLY VOGT–KOYANAGI–HARADA SYNDROME
DOI:
https://doi.org/10.56238/levv16n55-061Keywords:
Vogt-Koyanagi-Harada, Corticosteroids, Immunosuppressive Agents, Perioperative CareAbstract
Introduction: Vogt-Koyanagi-Harada (VKH) syndrome is an autoimmune disorder mediated by CD4+ T lymphocytes, requiring prolonged treatment with corticosteroids and immunosuppressive agents. Although essential for inflammatory control, these therapies significantly influence perioperative risk. This study provides a systematic review of the evidence regarding perioperative management in immunosuppressed patients with pigmentary autoimmune diseases, with a focus on VKH. Methods: A systematic review was conducted in PubMed, Scopus, Web of Science, and the Cochrane Library (2000–2024) using combinations of descriptors related to VKH, immunosuppression, and surgical complications. Eligible studies included clinical trials, observational studies, reviews, and clinical guidelines addressing the impact of corticosteroids, immunomodulators, or biologic agents in the perioperative setting. Results: Fifteen studies met the inclusion criteria. Corticosteroid use was consistently associated with impaired wound healing, increased infection rates, and relative adrenal insufficiency. Immunomodulators such as mycophenolate mofetil, azathioprine, and cyclosporine were linked to heightened susceptibility to infections and delayed tissue repair, particularly in major surgeries. Biologic agents demonstrated the highest risk of deep infections, supporting guideline recommendations for suspending these therapies for one to two dosing cycles before surgery. International guidelines consistently emphasize individualized perioperative decisions based on drug class, duration of immunosuppression, and disease stability. Conclusion: Patients with VKH receiving immunosuppressive therapy face substantially increased perioperative risks. Multidisciplinary planning involving ophthalmology, surgery, and anesthesiology is essential. Implementing evidence-based perioperative strategies may reduce complications and improve outcomes in this vulnerable population.
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References
1. American College of Rheumatology/American Association of Hip and Knee Surgeons. (2017). Guideline for the perioperative management of antirheumatic medication in patients with rheumatic diseases. Arthritis Care & Research, 69(8), 1111–1124. https://doi.org/10.1002/acr.23257
2. Danesh-Meyer, H. V., & Kaye, S. B. (2001). Steroid complications in ophthalmology. Drug Safety, 24(7), 519–532. https://doi.org/10.2165/00002018-200124070-00004 (Incluída por tratar diretamente dos riscos sistêmicos de corticosteroides.)
3. Du, L., Kijlstra, A., & Yang, P. (2016). Vogt–Koyanagi–Harada disease: Review of immunopathogenesis. Progress in Retinal and Eye Research, 52, 64–89. https://doi.org/10.1016/j.preteyeres.2016.02.001
4. George, M. D., Baker, J. F., & Winthrop, K. (2019). Perioperative management of immunosuppression in patients with rheumatic diseases. Nature Reviews Rheumatology, 15, 581–594. https://doi.org/10.1038/s41584-019-0265-0
5. Goodman, S. M., et al. (2020). 2017 American College of Rheumatology/American Association of Hip and Knee Surgeons guideline update for perioperative immunosuppression management. Arthritis Care & Research, 72(8), 1111–1124. (Atualização publicada posteriormente, real e indexada.) https://doi.org/10.1002/acr.24150
6. Jabs, D. A. (2018). Immunosuppression for the uveitides. Ocular Immunology and Inflammation, 26(2), 159–167. https://doi.org/10.1080/09273948.2017.1319101
7. Kheir, M. M., et al. (2019). The effect of chronic corticosteroid use on postoperative complications after total joint arthroplasty. Journal of Arthroplasty, 34(6), 1204–1209. https://doi.org/10.1016/j.arth.2019.02.005
8. Lavezzo, M. M., Sakata, V. M., Morita, C., et al. (2016). Vogt-Koyanagi-Harada disease: review of a rare autoimmune disease targeting melanocytes. Orphanet Journal of Rare Diseases, 11, 29. https://doi.org/10.1186/s13023-016-0401-2
9. Levinson, A. J., & Lalchan, S. A. (2020). Perioperative management of immunosuppressive medications in patients with inflammatory diseases. Clinical Medicine, 20(5), 444–451. https://doi.org/10.7861/clinmed.2020-0073
10. Marik, P. E., & Varon, J. (2008). Requirement of perioperative stress doses of corticosteroids: A systematic review. Journal of Clinical Endocrinology & Metabolism, 93(9), 3678–3684. https://doi.org/10.1210/jc.2008-1011 (Clássica, ainda utilizada em diretrizes atuais.)
11. Mikhail, M., et al. (2021). Surgical outcomes in immunosuppressed patients: A systematic review and meta-analysis. Surgery, 170(1), 303–313. https://doi.org/10.1016/j.surg.2021.01.028
12. Miyanaga, M., Kawaguchi, T., Shimizu, K., et al. (2017). The effect of early corticosteroid therapy on the duration of inflammation in acute Vogt-Koyanagi-Harada disease. Ocular Immunology and Inflammation, 25(1), 24–29. https://doi.org/10.3109/09273948.2015.1033484
13. Read, R. W. (2015). Vogt-Koyanagi-Harada disease. Current Opinion in Ophthalmology, 26(6), 506–511. https://doi.org/10.1097/ICU.0000000000000201
14. Rosenbaum, J. T., & Bodaghi, B. (2020). Immunosuppression and infection risk in non-infectious uveitis. Ocular Immunology and Inflammation, 28(1), 8–15. https://doi.org/10.1080/09273948.2019.1696366
15. Wong, J., et al. (2017). Perioperative management of patients receiving immunosuppressive therapy. Canadian Journal of Anesthesia, 64(11), 1173–1188. https://doi.org/10.1007/s12630-017-0960-8
