A Novel Risk Stratification-Based Immunomodulatory Treatment Strategy for Vogt-Koyanagi-Harada Disease

Abstract

PurposeTo develop a more tailored immunomodulatory treatment (IMT) strategy based on a novel two-arm risk stratification system in Vogt-Koyanagi-Harada (VKH) patients. DesignA retrospective clinical cohort study. Methods79 VKH patients in the acute stage were stratified into low (n = 58) and high-risk (n = 21) groups based on their exposure to risk factors. They were treated with oral glucocorticoids (GCs) plus pro re nata (PRN) or first-line IMT. Best corrected visual acuity (BCVA), sunset glow fundus (SGF) occurrence, relapse rate, and systemic adverse events were evaluated during follow-up. ResultsCompared with the low-risk group, the high-risk showed poorer BCVA at baseline (estimated difference, 0.51; 95% CI, 0.30-0.78; p < 0.001) and 6-month follow-up (estimated difference, 0.08; 95% CI, 0.00-0.08; p = 0.006), higher incidence of SGF at 12 months (52% vs 28%; RR, 1.9; 95% CI, 1.1-3.4; p = 0.040), and higher relapse rate at 6 months (24% vs 5%; RR, 4.6; 95% CI, 1.2-17.5; p = 0.028) and 12 months (52% vs 12%; RR, 4.4; 95% CI, 1.9-9.7; p < 0.001). In the low-risk cohort, no significant difference between the two IMT strategies was observed in primary outcomes. In the high-risk cohort, patients with the immediate IMT showed better BCVA (estimated difference, -0.20; 95% CI, -0.3 to -0.08; p = 0.007), lower incidence of SGF (27% vs 80%; RR, 0.3; 95% CI, 0.1-0.9; p = 0.030), and lower relapse rate (27% vs 80%; RR, 0.3; 95% CI, 0.1-0.9; p = 0.030) compared with the PRN regimen. Moreover, the immediate IMT regimen had a higher frequency of systemic adverse events than the PRN regimen (47% vs 7%; RR, 7.1; 95% CI, 2.5-20.4; p < 0.001). ConclusionsHigh-risk stratification at baseline was associated with poor prognosis. The immediate IMT regimen was only beneficial for high-risk VKH patients regarding visual outcome, SGF, and relapse rate. This study suggests a potential need for a customized IMT strategy for VKH patients.