Resposta ao dupilumabe na dermatite atópica grave sem uso prévio de imunossupressor sistêmico durante a pandemia de COVID-19
Response to dupilumab in severe atopic dermatitis without prior use of systemic immunosuppressive agents during the COVID-19 pandemic
Mara Morelo Rocha Felix; Laira Vidal da Cunha Moreira; Ana Carolina de Moura Rocha Teixeira Miranda; Nathalia Mota Gomes Almeida
Resumo
A dermatite atópica (DA) é uma doença inflamatória crônica da pele, caracterizada por intenso prurido e eczema recorrente. Acomete principalmente a infância, mas tem se tornado bastante prevalente em adolescentes e até em adultos. Apesar de ser geralmente não fatal, apresenta uma carga psicossocial importante para os pacientes e seus familiares. O tratamento da DA envolve a hidratação cutânea e medicações anti-inflamatórias. Em casos graves, pode haver necessidade de terapia sistêmica com imunossupressores como ciclosporina, metotrexato e azatioprina. Mais recentemente, alguns imunobiológicos estão em desenvolvimento para controle da DA. O dupilumabe é um anticorpo monoclonal com ação dupla anti-IL-4/IL-13, liberado para tratamento de crianças a partir de 6 anos com DA grave e adolescentes/adultos com DA moderada a grave. O objetivo deste artigo foi relatar uma série de casos de pacientes adolescentes e adultos com DA grave e sua resposta ao dupilumabe durante a pandemia do COVID-19. Trata-se de quatro pacientes (três do sexo feminino), com piora significativa da DA durante o ano de 2020. Todos tinham história de DA desde a infância, com exames complementares evidenciando sensibilização IgE-mediada para ácaros. Já haviam sido submetidos a diversos tratamentos tópicos e sistêmicos, inclusive a cursos de corticosteroides orais. Nenhum deles havia recebido imunossupressor sistêmico, porém estavam recusando este tipo de tratamento devido ao medo da pandemia. Todos apresentaram boa resposta ao dupilumabe, evidenciada pela redução do número de lesões cutâneas e prurido, com poucos efeitos colaterais. Dois pacientes apresentaram sintomas sugestivos de COVID-19 durante o tratamento com dupilumabe (um com confirmação por PCR), com boa evolução. Concluindo, os pacientes com DA grave possuem grande impacto na qualidade de vida e, durante a pandemia de COVID-19, muitos apresentaram piora significativa do seu quadro dermatológico. Nesse contexto, o dupilumabe se mostrou uma opção terapêutica eficaz e segura para tratamento destes pacientes.
Palavras-chave
Abstract
Atopic dermatitis (AD) is a chronic inflammatory skin disease characterized by intense itching and recurrent eczema. It mainly affects childhood but has become quite prevalent in adolescents and even adults. Despite being generally nonfatal, it has an important psychosocial burden for patients and their families. AD treatment involves skin hydration and antiinflammatory medications. In severe cases, systemic therapy with immunosuppressive agents such as cyclosporine, methotrexate, and azathioprine may be necessary. More recently, some biologicals are being developed to control AD. Dupilumab is a monoclonal antibody with anti-IL-4/IL-13 dual-action, approved for the treatment of children from 6 years of age with severe AD and adolescents/adults with moderate to severe AD. This article aimed to report a case series of adolescent and adult patients with severe AD and their response to dupilumab during the COVID-19 pandemic. These are four patients (three female), with a significant worsening of AD during the year 2020. All had a history of AD since childhood, with complementary exams showing IgE-mediated sensitization to mites. They had already undergone several topical and systemic treatments, including courses on oral corticosteroids. None of them had received systemic immunosuppressive agents, but they were refusing this type of treatment due to fear of the pandemic. All had a good response to dupilumab, evidenced by a reduction in the number of skin lesions and pruritus, with few side effects. Two patients had symptoms suggestive of COVID-19 during treatment with dupilumab (one confirmed by PCR) with a good outcome. In conclusion, patients with severe AD have a great impact on quality of life and, during the COVID-19 pandemic, many had a significant worsening of their dermatological condition. In this context, dupilumab proved to be an effective and safe therapeutic option for the treatment of these patients.
Keywords
Referências
1. Antunes AA, Solé D, Carvalho VO, Bau AEK, Kuschnir FC, Mallozi MC, et al. Guia prático de atualização em dermatite atópica – Parte I: etiopatogenia, clínica e diagnóstico. Posicionamento conjunto da Associação Brasileira de Alergia e Imunologia e da Sociedade Brasileira de Pediatria. Arq Asma Alerg Imunol. 2017;1(2):131‑56.
2. Weidinger S, Novak N. Atopic dermatitis. Lancet. 2016 Mar 12;387(10023):1109-22.
3. Kunz B, Oranje AP, Labrèze L, Stalder JF, Ring J, Taïeb A. Clinical validation and guidelines for the SCORAD index: consensus report of the European Task Force on Atopic Dermatitis. Dermatology. 1997;195(1):10-9.
4. Carvalho VO, Solé D, Antunes AA, Bau AEK, Kuschnir FC, Mallozi MC, et al. Guia prático de atualização em dermatite atópica – Parte II: abordagem terapêutica. Posicionamento conjunto da Associação Brasileira de Alergia e Imunologia e da Sociedade Brasileira de Pediatria. Arq Asma Alerg Imunol. 2017;1(2):157-82.
5. Ludwig MW, Oliveira Mda S, Muller MC, Moraes JF. Quality of life and site of the lesion in dermatological patients. An Bras Dermatol. 2009;84(2):143-50.
6. Alvarenga TM, Caldeira AP. Quality of life in pediatric patients with atopic dermatitis. J Pediatr (Rio J). 2009;85(5):415-20.
7. Amaral CSF, March MFBP, Sant’Anna CC. Quality of life in children and teenagers with atopic dermatitis. An Bras Dermatol. 2012;87(5):717-23.
8. Campos ALB, Araújo FM, Santos MAL, Santos AAS, Pires CAA. Impacto da dermatite atópica na qualidade de vida de pacientes pediátricos e seus responsáveis. Revista Paulista de Pediatria [online]. 2017;35(1):5-10.
9. Wollenberg A, Barbarot S, Bieber T, Christen-Zaech S, Deleuran M, Fink-Wagner A, et al; European Dermatology Forum (EDF), the European Academy of Dermatology and Venereology (EADV), the European Academy of Allergy and Clinical Immunology (EAACI), the European Task Force on Atopic Dermatitis (ETFAD), European Federation of Allergy and Airways Diseases Patients’ Associations (EFA), the European Society for Dermatology and Psychiatry (ESDaP), the European Society of Pediatric Dermatology (ESPD), Global Allergy and Asthma European Network (GA2LEN) and the European Union of Medical Specialists (UEMS). Consensusbased European guidelines for treatment of atopic eczema (atopic dermatitis) in adults and children: part II. J Eur Acad Dermatol Venereol. 2018 Jun;32(6):850-78.
10. Ni YN, Chen G, Sun J, Liang BM, Liang ZA. The effect of corticosteroids on mortality of patients with influenza pneumonia: a systematic review and meta-analysis. Crit Care. 2019;23(1):99.
11. Davila-Seijo P, Dauden E, Descalzo MA, Carretero G, Carrascosa JM, Vanaclocha F, et al. Infections in Moderate to Severe Psoriasis Patients Treated with Biological Drugs Compared to Classic Systemic Drugs: Findings from the BIOBADADERM Registry. J Invest Dermatol. 2017;137(2):313-21.
12. Goujon C, Viguier M, Staumont-Salle D, Bernier C, Guillet G, Lahfa M, et al. Methotrexate Versus Cyclosporine in Adults with Moderateto-Severe Atopic Dermatitis: A Phase III Randomized Noninferiority Trial. J Allergy Clin Immunol Pract. 2018;6(2):562-9 e3.
13. Seegräber M, Srour J, Walter A, Knop M, Wollenberg A. Dupilumab for treatment of atopic dermatitis. Expert Rev Clin Pharmacol. 2018 May;11(5):467-74.
14. Eichenfield LF, Bieber T, Beck LA, Simpson EL, Thaci D, de BruinWeller M, et al. Infections in Dupilumab Clinical Trials in Atopic Dermatitis: A Comprehensive Pooled Analysis. Am J Clin Dermatol. 2019;20(3):443-56.
15. Rossi M, Rovati C, Arisi M, Soglia S, Calzavara-Pinton P. Management of adult patients with severe atopic dermatitis treated with dupilumab during COVID -19 pandemic: a single-center real-life experience. Dermatol Ther. 2020;33:e13765.
16. Ferrucci S, Romagnuolo M, Angileri L, Berti E, Tavecchio S. Safety of dupilumab in severe atopic dermatitis and infection of Covid-19: two case reports. J Eur Acad Dermatol Venereol. 2020;34 e303- e304.
17. Georgakopoulos JR, Yeung J. Patient-driven discontinuation of dupilumab during the COVID-19 pandemic in two academic hospital clinics at the University of Toronto. J Cutan Med Surg. 2020;24:422-3.
Submetido em:
02/07/2021
Aceito em:
15/07/2021
Facebook
Google+
Twitter
LinkedIn
Mendeley
StumbleUpon
CiteULike
Reddit
Email