Cyclosporine
What is cyclosporine?
In 1995, Neoral (one brand name for cyclosporine) was FDA-approved to help prevent organ rejection in transplant patients. In 1997, the FDA approved Neoral as a treatment for psoriasis.
How does cyclosporine work?
Cyclosporine suppresses the immune system and prevents actions of certain immune cells, thereby slowing the growth of skin cells.
Who is a candidate for cyclosporine?
Adults with severe psoriasis and otherwise normal immune systems are candidates for cyclosporine.
Cyclosporine should only be used during pregnancy if the potential benefits outweigh the potential risks. For example, in the case of pustular psoriasis, which can be life threatening, cyclosporine may be the treatment of choice during pregnancy, compared to the pregnancy risks associated with treatments such as methotrexate or Soriatane.
In general, women are advised not to become pregnant while taking cyclosporine. Your doctor may recommend that if you do become pregnant while taking cyclosporine, you should stop the treatment.
Others who should avoid taking cyclosporine include:
- Individuals whose immune systems are compromised (for example, anyone with lymphoma or HIV infection, or patients receiving other immune-suppressing drugs)
- Women who are breastfeeding*
- Individuals with abnormal kidney function
- Anyone with high blood pressure
- Patients with malignancies, or a history of malignancies (other than basal or squamous cell skin cancers)
- People who are undergoing radiation treatment
*To learn about treatment options for pregnant and nursing women, see Conception, pregnancy and psoriasis.
How effective is cyclosporine?
Cyclosporine can provide fairly rapid relief from symptoms. Patients may see some improvement in symptoms after two weeks of treatment, particularly with stronger doses. However, it may take longer, from three to four months, to reach a more complete level of control.
If rapid improvement is not essential, your doctor initially may keep the dosage low.
If, after four weeks, improvement is not seen, dosage is gradually increased at one- or two-week intervals. Once the maximum recommended dosage (based on individual weight) is reached, satisfactory improvement should be seen within six weeks. If not, your doctor will most likely stop treatment with cyclosporine or add an additional treatment. For more severe psoriasis, including pustular or erythrodermic psoriasis, doctors often start with a high dose and gradually reduce it once patients have responded. When cyclosporine treatment is stopped, psoriasis usually reappears between six and 16 weeks later.
Extended use of cyclosporine by transplant patients is well-established. However, long-term use as a treatment for psoriasis is more limited. Therefore, use of the drug is not currently recommended by the FDA for longer than one year. However, there are no specific guidelines for how long a patient should stay off cyclosporine before resuming treatment with the drug. Some doctors may prescribe the drug for more than one year.
Rotational therapy
Your doctor may recommend alternating cyclosporine with other forms of treatment to better manage psoriasis.
Combination therapy
Dovonex (also known by its generic name calcipotriene) used with low-dose cyclosporine has been shown to be safe and effective for severe, chronic plaque psoriasis. The addition of Dovonex means a lower dosage of cyclosporine can be given, which minimizes the risk of potential side effects.
How is cyclosporine used?
Cyclosporine is taken daily by mouth and is available as either a capsule or a liquid. The liquid form must be diluted for use, preferably by mixing it with room-temperature orange or apple juice (not grapefruit juice; see Interactions, below). Patients should take cyclosporine on a consistent schedule. Your doctor will monitor your kidney function with blood tests before and during treatment with cyclosporine.
What are the possible side effects of cyclosporine?
Taking cyclosporine can cause the following potential side effects:
- Decreased kidney function
- Headache
- High blood pressure
- High cholesterol
- Excessive hair growth
- Tingling or burning sensations in the arms or legs
- Skin sensitivity
- Increased growth of gum tissues
- Flu-like symptoms
- Upset stomach
- Tiredness
- Musculoskeletal or joint pain
Generally, these side effects go away when the dose is lowered or the drug is stopped.
A risk of long-term cyclosporine treatment is kidney damage/toxicity. In some cases, the damage to the kidneys can be irreversible.
People taking cyclosporine can have an increased risk of developing skin malignancies, particularly if they previously have been treated with PUVA (the use of the light-sensitizing drug psoralen plus ultraviolet light A).
Interactions
The doctor prescribing cyclosporine should always be aware of any other medications, treatments or supplements you are using. Many medications interact with cyclosporine, including (but not limited to) some antibiotics, anti-inflammatories, antifungals, gastrointestinal agents, calcium channel blockers and anticonvulsants. Over-the-counter (OTC) medications such as aspirin and ibuprofen can also interact with cyclosporine. These interactions could affect the metabolism of the drug, causing you to have either too much or too little in your bloodstream.
Published reports have shown that St. John's wort, a popular herbal product used for treating depression, can reduce the blood levels of cyclosporine in transplant patients. It is not clear if the dose of cyclosporine used in psoriasis would be affected by St. John's wort. Still, psoriasis patients using cyclosporine should be cautious, because the herbal product could cause the drug to become less effective.
Grapefruit and grapefruit juice should be avoided when taking cyclosporine because they have been shown to increase levels of the drug in the blood.
Updated January 2007
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