Vale a pena usar corticoide em altas doses na Leptospirose grave?
Também conhecida como Síndrome de Weil, é definida pela tríade: lesão renal aguda + icterícia rubínica + hemorragias. Apesar de ser doença rara na literatura em geral, é de grande incidência na nossa realidade. Ainda carecemos de informações para melhor tratar nossos pacientes com essa condição. Hoje trago uma revisão sistemática para discutir o tema.
Título:
“Corticoesteróides em alta dose na leptospirose grave: uma revisão sistemática” – High dose corticosteroids in severe leptospirosis: a systematic review – The Royal Society of Tropical Medicine and Hygiene – 2014
Cenário Clínico:
Paciente do sexo masculino de 30 anos com quadro clínico e epidemiologia positiva para leptospirose, apresentando lesão renal aguda e hemorragia alveolar.
Pergunta Clínica/PICO:
P: ADULTO JOVEM COM HEMORRAGIA ALVEOLAR POR SÍNDROME DE WEIL/LEPTOSPIROSE
I: PULSOTERAPIA COM CORTICOESTERÓIDES
C: SUPORTE CLÍNICO: MORTALIDADE, TEMPO DE ASSISTÊNCIA VENTILATÓRIA MECÂNICA (AVM) E INTERNAMENTO HOSPITALAR
T: INFECÇÕES NOSOCOMIAIS, PIORA DA HEMORRAGIA
S: REVISÃO SISTEMÁTICA DE ENSAIOS CLÍNICOS RANDOMIZADOS
Pergunta:
Em pacientes adultos jovens com quadro de hemorragia alveolar por Síndrome de Weil / Leptospirose o uso de pulsoterapia com corticoesteróides diminui mortalidade, tempo de AVM ou internamento hospitalar?
Estratégia de Busca:
Pubmed:
https://www.ncbi.nlm.nih.gov/pubmed
Termos: ((“Leptospirosis”[Mesh]) OR “Weil Disease”[Mesh]) AND “Steroids”[Mesh]
Resultados: 65 artigos (19/08/2019)
Cochrane Lybrary:
https://www.cochranelibrary.com/
Termo de pesquisa: leptospirosis
Resultados: 4 artigos (19/08/2019)
Cochrane Search Trials (central):
https://www.cochranelibrary.com/
Termos: leptospirosis + steroids
Resultados: 2 artigos (19/08/2019)
Resultado da Pesquisa:
Sumário da Evidência:
A análise da revisão sistemática estudada mostrou que a mesma tem alto risco de viés. Apresentou a pergunta objetivamente, porém de forma incompleta. Foi realizada por três avaliadores independentes, não houve restrição linguística e apresentou de forma detalhada a estratégia de busca, porém não apresentou de maneira adequada os critérios de exclusão e inclusão dos artigos e a análise do risco de vieses foi feita de forma inadequada. Não foram usados dados individuais de pacientes e não há conflitos de interesse.
Os estudos analisados na revisão foram de baixa qualidade e heterogêneos quanto a suas metodologias e protocolos, não sendo possível realizar uma meta-analise. No entanto, apesar dos problemas metodológicos, todos pareceram mostrar vantagem nos grupos que receberam a pulsoterapia. Não foram analisados potenciais efeitos colaterais no estudo em questão.
Aplicabilidade:
A intervenção proposta é acessível e viável, mas ainda carece de maiores evidências que mostrem de forma mais precisa seus benefícios e que analisem com maior rigor os riscos associados. Se trata de uma intervenção amplamente disponível e com custo acessível à maioria dos serviços de saúde.
Conclusão Clínica:
Baseado no estudo supracitado, ainda que tenhamos baixa qualidade de evidência para utilização da pulsoterapia com corticoesteroides para pacientes com hemorragia alveolar por Doença de Weil, eu recomendaria o uso da mesma. Há de se considerar que se trata de uma doença grave e a pulsoterapia com corticoesteroides, apesar de não ser um procedimento inócuo, parece diminuir mortalidade. Ainda são necessários melhores evidências, porém à luz do que está disponível na literatura, dados os potenciais benefícios e a plausibilidade biológica, considero a intervenção como recomendada.
Referências:
High dose corticosteroids in severe leptospirosis: a systematic review. Rodrigo C1, et al. Trans R Soc Trop Med Hyg. 2014 Dec;108(12):743-50. Epub 2014 Sep 28.
doi: 10.1093/trstmh/tru148
Avaliador:
Mário Petrônio Dowsley de Freitas Neto
MR1 de Clínica Médica – Hospital Miguel Arraes
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