Contraindications to Cyclosporine Therapy
Cyclosporine is absolutely contraindicated in patients with abnormal renal function, uncontrolled hypertension, active malignancy (especially lymphoma or melanoma), and hypersensitivity to the drug; it should also be avoided in patients with severe hepatic dysfunction, serious active infections, unwillingness to undergo monitoring, or substance abuse that would compromise compliance. 1, 2
Absolute Contraindications
Renal Dysfunction
- Abnormal baseline renal function is a contraindication to initiating cyclosporine therapy, as the drug causes dose-dependent nephrotoxicity through afferent arteriole vasoconstriction. 1, 2
- Establish a reliable baseline creatinine (ideally mean of 2-3 measurements) before starting therapy; patients with elevated creatinine should not receive cyclosporine. 1
Uncontrolled Hypertension
- Patients with uncontrolled hypertension must not start cyclosporine, as the drug causes hypertension in approximately 20% of patients through renal vasoconstriction. 1, 2
- Blood pressure must be measured on at least two separate occasions before initiation; sustained readings ≥140/90 mm Hg preclude therapy. 3
Malignancy History
- Cyclosporine is contraindicated in patients with any history of lymphoma (including cutaneous T-cell lymphoma) or melanoma, as immunosuppression promotes tumor growth and progression. 1, 4, 2
- The British Association of Dermatologists emphasizes absolute avoidance in lymphoma patients due to 41% incidence of lymphoproliferative disorders appearing as early as 11 months. 4
- Patients with other malignancies should generally not receive cyclosporine; any consideration requires oncology consultation and careful risk-benefit analysis. 1, 4
Hypersensitivity
- Known hypersensitivity to cyclosporine or any formulation ingredient is an absolute contraindication. 2
Relative Contraindications Requiring Extreme Caution
Hepatic Dysfunction
- Severe hepatic dysfunction impairs cyclosporine metabolism and is considered a contraindication; if therapy is unavoidable, dose reduction and intensive monitoring are mandatory. 1, 5
- Obtain baseline hepatitis B and C serology, as active hepatitis increases risk. 1, 5
Active Infections
- Serious infections of any type are contraindications to cyclosporine initiation due to further immunosuppression risk. 1
- Consider tuberculosis screening (interferon-gamma release assay, chest X-ray) when risk factors exist. 1
Immunodeficiency States
- Pre-existing primary or secondary immunodeficiency makes cyclosporine use more hazardous. 1
- HIV-positive patients require consultation with their HIV specialist team before considering cyclosporine, as further immunosuppression may be dangerous. 1
Compliance Issues
- Substance abuse (drugs or alcohol) or any factor interfering with compliance is a contraindication, as irregular dosing and missed monitoring can lead to serious toxicity. 1
- Patients unwilling to undergo required monitoring must not receive cyclosporine. 1
Specific Contraindications for Psoriasis Patients
Concomitant Therapies
- Psoriasis patients must not receive concomitant PUVA or UVB phototherapy, methotrexate, other immunosuppressive agents, coal tar, or radiation therapy while on cyclosporine. 1, 2
- History of >200 PUVA treatments is a contraindication due to synergistic skin cancer risk. 1
Prior UV Exposure
- Patients with extensive prior UV exposure (phototherapy or radiation) have markedly increased risk of cutaneous squamous cell carcinoma and should generally avoid cyclosporine. 4
Critical Monitoring Requirements Before Initiation
Mandatory Baseline Testing
- Blood pressure (on ≥2 occasions) 3
- Serum creatinine and BUN (calculate reliable mean baseline) 1
- Liver function tests 1, 5
- Complete blood count 1
- Urinalysis, uric acid, lipid profile, electrolytes (magnesium, potassium) 1, 5
- Hepatitis B and C serology (when indicated) 1, 5
- HIV serology in high-risk groups 1
- Varicella zoster virus serology (unless previously vaccinated) 1
- Tuberculosis screening when risk factors present 1