What is the recommended dose of cyclosporine (cyclosporin) for a patient with severe pustular psoriasis weighing 140 kg?

Cyclosporine Dosing for Severe Pustular Psoriasis in a 140 kg Patient

For a 140 kg patient with severe pustular psoriasis, the recommended starting dose of cyclosporine is 2.5 mg/kg/day, which equals 350 mg/day, administered as a divided dose (175 mg twice daily). 1

Dosing Algorithm

1. Initial dosing:

   • Start with 2.5 mg/kg/day (350 mg/day for a 140 kg patient)
   • Administer as divided doses (175 mg twice daily)
   • Take before meals for optimal absorption

2. Dose titration:

   • Maintain initial dose for at least 4 weeks
   • If insufficient response after 4 weeks, increase dose by approximately 0.5 mg/kg/day (70 mg/day) at 2-week intervals
   • Maximum dose should not exceed 4 mg/kg/day (560 mg/day for a 140 kg patient) 1

3. Dose reduction:

   • Reduce dose by 25-50% if adverse events occur (hypertension, serum creatinine elevation ≥25% above baseline, or significant laboratory abnormalities)
   • Discontinue if dose reduction doesn't control abnormalities or if adverse events are severe 1

Monitoring Requirements

• Blood pressure and renal function should be monitored closely, especially in the first 6-8 weeks
• Check blood pressure, creatinine, and blood urea nitrogen biweekly for the first 6-8 weeks, then monthly if stable 2
• Early morning resting blood pressure is a more sensitive indicator of early nephrotoxicity than elevated creatinine 2
• Regular monitoring of liver function tests, lipids, magnesium, potassium, and uric acid is also recommended 2

Special Considerations for Pustular Psoriasis

Pustular psoriasis often responds well to cyclosporine. The response can be quite rapid and remarkable, with studies showing improvement in 84% of patients with pustular psoriasis after treatment with systemic retinoids, and cyclosporine has shown similar efficacy 2.

Important Precautions

• Drug interactions: Avoid concomitant use of medications that interact with cyclosporine, including:

  • Aminoglycosides, amphotericin, trimethoprim, ketoconazole
  • Phenytoin, rifampicin, isoniazid
  • Non-steroidal anti-inflammatory drugs 2

• Hypertension management: If hypertension develops, calcium channel blockers (particularly isradipine) are preferred as they don't interact with cyclosporine metabolism. β-blockers can also be used. Avoid thiazide diuretics and potassium-sparing diuretics 2

• Duration of therapy: Long-term continuous treatment beyond one year is not recommended. Consider alternating with other treatments for long-term management 2

Common Pitfalls to Avoid

1. Improper formulation switching: Do not switch between different cyclosporine formulations as bioavailability may differ 2

2. Inappropriate diluent: When using oral solution, dilute with orange or apple juice at room temperature. Avoid grapefruit juice as it affects cyclosporine metabolism. Milk can make the solution unpalatable 1

3. Inadequate monitoring: Failing to monitor renal function and blood pressure can lead to irreversible nephrotoxicity and hypertension, especially in treatment extending beyond 2 years 3

4. Abrupt discontinuation: Abrupt termination leads to quicker relapse compared to gradual tapering 2