From the Guidelines
Cyclosporin therapy for psoriasis should be discontinued after achieving a clinical response, typically within 1-2 years of continuous treatment, due to the increasing risks of nephrotoxicity and hypertension with prolonged use, as recommended by the joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care 1. The primary goal of using cyclosporin in psoriasis is to rapidly control severe symptoms, and then transition to safer long-term therapies. Key considerations for discontinuation include:
- Development of uncontrolled hypertension despite antihypertensive therapy
- Serious infections
- Malignancy
- Intolerable side effects like gingival hyperplasia or hypertrichosis
- Significant increase in serum creatinine levels, indicating renal impairment Regular monitoring is crucial during treatment, with:
- Blood pressure checks
- Renal function tests
- Electrolyte panels
- Monthly CBC, LFTs, lipid profile, magnesium, uric acid, and potassium tests If serum creatinine increases by more than 30% from baseline on two consecutive measurements, the dose should be reduced by 25-50%, and if this doesn't resolve the issue, discontinuation is necessary. After discontinuation, patients typically experience disease relapse within 8-16 weeks, so a transition plan to alternative therapies like methotrexate, biologics, or phototherapy should be established before stopping cyclosporin, as suggested by the guidelines 1. This approach balances the drug's effectiveness against its cumulative toxicity profile, which includes increased risk of skin cancers and lymphoproliferative disorders with extended use, highlighting the importance of careful monitoring and timely discontinuation 1.
From the Research
End Point of Using Cyclosporin in Psoriasis
- The end point of using cyclosporin in psoriasis is typically when the patient achieves a significant improvement in symptoms, such as a 75% reduction in Psoriasis Area Severity Index (PASI) score 2.
- The treatment duration with cyclosporin is usually limited to 2 years or less to minimize the risk of kidney toxicity and other adverse effects 2, 3.
- Intermittent short courses of cyclosporin, lasting an average of 12 weeks, are often preferred to continuous long-term treatment 3.
- The dose of cyclosporin used can vary, but higher doses of 5 mg/kg/day are often associated with a higher degree of clearance, while lower doses of 2.5 mg/kg/day may be effective for maintaining remission 2.
- Cyclosporin can be effective for various types of psoriasis, including plaque psoriasis, pustular psoriasis, and erythrodermic psoriasis 2, 4.
Factors Affecting Treatment Duration
- Patient factors, such as age, weight, and presence of comorbidities, can influence the treatment duration with cyclosporin 3.
- The risk of kidney toxicity and other adverse effects can also impact the treatment duration, with patients at higher risk requiring more frequent monitoring and potentially shorter treatment durations 2, 3.
- The response to treatment, as measured by PASI score and other clinical outcomes, can also guide the treatment duration, with patients achieving significant improvement potentially requiring shorter treatment durations 2, 5.
Comparison with Other Treatments
- Cyclosporin has been compared with other treatments for psoriasis, including methotrexate and acitretin, with varying results 5.
- Cyclosporin has been shown to be effective for palmoplantar psoriasis, with a faster response and higher efficacy compared to methotrexate and acitretin 5.
- However, the duration of remission and risk of adverse effects can vary between treatments, with cyclosporin potentially requiring more frequent monitoring and having a higher risk of kidney toxicity 2, 3, 5.