How long should a patient with minimal change disease (MCD) who is steroid-resistant and on cyclosporine (CsA) continue taking the medication?

Duration of Cyclosporine Treatment in Steroid-Resistant Minimal Change Disease

For patients with steroid-resistant minimal change disease (MCD), cyclosporine should be continued for at least 12 months after achieving remission, followed by a slow taper. 1

Initial Treatment Duration

• Start cyclosporine at 3-5 mg/kg/day in divided doses
• Continue for at least 4-6 months initially to determine response 1
• Target cyclosporine trough levels: 80-120 ng/ml 1

Treatment Duration After Remission

Complete or Partial Remission Achieved:

• Continue cyclosporine for at least 12 months after achieving remission 1
• Following this period, implement a very slow taper:
  • Reduce by approximately 0.5 mg/kg per month 1
  • Target minimum effective dose that maintains remission (≤2 mg/kg/day) 1

No Remission After 6 Months:

• If no response after 6 months of therapy (defined as at least 50% reduction in proteinuria), consider discontinuing cyclosporine 1
• Perform repeat renal biopsy to confirm diagnosis 1
• Consider alternative therapies such as mycophenolate mofetil with high-dose dexamethasone 1

Monitoring During Long-Term Treatment

• Regular monitoring of renal function (GFR, serum creatinine)
• Monitor blood pressure and cyclosporine levels
• Consider repeat renal biopsy:
  • After 12-24 months of continuous therapy 1
  • Especially if serum creatinine increases >30% above baseline 1
  • Or if maintenance dose required is >3.5 mg/kg/day 1

Important Considerations

• Relapse rates are high (40-60%) after cyclosporine discontinuation 1, 2
• Many patients develop "cyclosporine dependence" similar to steroid dependence 2
• Long-term therapy carries risk of nephrotoxicity, which should be balanced against benefits 1, 2
• If proteinuria recurs during taper, increase dose temporarily for 1-2 months until remission is re-achieved 1

Special Situations

• For patients with both steroid resistance and toxicity, cyclosporine may be used as primary therapy 1
• In patients with long-term cyclosporine dependence who develop toxicity, consider transition to mycophenolate mofetil 3
• Patients with diabetes or cosmetic concerns may particularly benefit from minimizing steroid exposure through cyclosporine use 4

Pitfalls to Avoid

• Tapering too quickly, which often leads to relapse
• Failure to monitor for nephrotoxicity with long-term use
• Inadequate duration of therapy (less than 12 months after remission)
• Not considering alternative therapies when cyclosporine fails after 6 months

Remember that the goal of therapy is to maintain remission while minimizing medication toxicity, and that long-term treatment is often necessary in steroid-resistant MCD.