How to switch a patient from Cyclosporin (Cyclosporine) A to Methotrexate for the treatment of psoriasis?

From the Guidelines

To switch a patient from Cyclosporin A to Methotrexate for psoriasis, begin by gradually tapering the Cyclosporin A while introducing Methotrexate, starting with a dose of 7.5-15 mg once weekly, as recommended by the joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management of psoriasis with systemic nonbiologic therapies 1. When switching, it is essential to consider the patient's overall health and potential contraindications, such as pregnancy, nursing, alcoholism, or liver disease, as outlined in the guidelines of care for the management of psoriasis and psoriatic arthritis: section 4 1. The following steps should be taken:

• Gradually taper Cyclosporin A by 25-50% of the original dose every 1-2 weeks until discontinuation
• Start Methotrexate at 7.5-15 mg once weekly
• Obtain baseline labs, including complete blood count, liver and renal function tests, hepatitis B/C screening, and chest X-ray
• Initiate folic acid supplementation (1-5 mg daily, except on Methotrexate day) to reduce side effects, as recommended by the guidelines 1
• Monitor blood counts and liver enzymes every 2-4 weeks initially, then every 2-3 months once stable, and consider liver biopsy if significant persistent abnormality in liver chemistry develops, as suggested by the guidelines of care for the management of psoriasis and psoriatic arthritis: section 4 1 The overlap period typically lasts 4-8 weeks to prevent disease flare, allowing for continuous disease control while minimizing the risk of cumulative immunosuppression. Key considerations include:
• Methotrexate dosage, which can be increased gradually until an optimal response is achieved, but should not ordinarily exceed 30 mg/wk, as recommended by the guidelines of care for the management of psoriasis and psoriatic arthritis: section 4 1
• Potential side effects, such as elevated liver function tests, anemia, and interstitial pneumonitis, which should be monitored closely, as outlined in the guidelines 1
• Contraindications, such as pregnancy, nursing, and alcoholism, which should be carefully evaluated before initiating Methotrexate therapy, as recommended by the guidelines of care for the management of psoriasis and psoriatic arthritis: section 4 1

From the FDA Drug Label

Methotrexate is indicated in the symptomatic control of severe, recalcitrant, disabling psoriasis that is not adequately responsive to other forms of therapy, but only when the diagnosis has been established, as by a biopsy and/or after dermatologic consultation Cyclosporine capsules, USP [MODIFIED] and cyclosporine oral solution, USP [MODIFIED] are indicated for the treatment of adult, nonimmunocompromised patients with severe (i.e., extensive and/or disabling), recalcitrant, plaque psoriasis who have failed to respond to at least one systemic therapy (e.g., PUVA, retinoids, or methotrexate) or in patients for whom other systemic therapies are contraindicated, or cannot be tolerated.

The information provided does not include specific instructions on how to switch a patient from Cyclosporin A to Methotrexate for psoriasis. Key points to consider when switching therapies include:

• The diagnosis of psoriasis should be established, as by a biopsy and/or after dermatologic consultation.
• Methotrexate is indicated for severe, recalcitrant, disabling psoriasis that is not adequately responsive to other forms of therapy.
• Cyclosporin A is indicated for severe, recalcitrant, plaque psoriasis in patients who have failed to respond to at least one systemic therapy. However, the FDA drug labels for methotrexate 2 and cyclosporin A 3 do not provide direct guidance on switching from one medication to the other.

From the Research

Switching from Cyclosporin A to Methotrexate for Psoriasis

• The decision to switch from Cyclosporin A to Methotrexate should be based on the patient's disease severity, quality of life, and presence of comorbidities 4.
• When switching from Cyclosporin A to Methotrexate, the doses of Cyclosporin A can be tapered by reducing the maintenance dose or increasing the between-dose intervals, while Methotrexate can be introduced at its standard dose 4.
• There is no direct evidence on the specific protocol for switching from Cyclosporin A to Methotrexate, but studies suggest that combination therapy with Methotrexate and Cyclosporin can be effective for severe psoriasis 5.
• A study comparing Methotrexate and Cyclosporin for moderate-to-severe chronic plaque psoriasis found no significant differences in efficacy between the two treatments 6.
• When transitioning from one therapy to another, the clinician must assess the benefits and risks of the new therapeutic agent or combination, taking into account the long-term risks to the patient 7.

Considerations for Switching Therapies

• The patient's disease severity, quality of life, and presence of comorbidities should be considered when making decisions about switching therapies 4.
• The potential for increased hepatotoxicity when combining Methotrexate with other therapies, such as acitretin, should be considered 8.
• The decision to switch therapies should be individualized and based on the patient's specific needs and circumstances 4, 7.