Guidelines for prescribing cyclosporine:

Reference: BerthJones J, Exton LS, Ladoyanni E, Mohd Mustapa MF, Tebbs V, Yesudian PD, Levell NJ. British Association of Dermatologists guidelines for the safe and effective prescribing of oral cyclosporine in dermatology 2018. British Journal of Dermatology. 2019 Jan 17.

Checklist for clinicians - prior to prescribing cyclosporine

  1. Take a full drug history keeping in mind possible interactions.
  2. Perform a physical examination.
  3. Ensure there are no contraindications to cyclosporine use
  4. Check results of baseline investigations
    1. a) Full blood count (FBC)
    2. b) Urea and electrolytes and calculate a reliable mean baseline creatinine
    3. c) Liver blood tests
    4. d) Urate, urinalysis and lipid levels
    5. e) Hepatitis B and C serology (by clinician judgement in children)
    6. f) HIV serology, especially in high-risk groups (by clinician judgement in children)
    7. g) Varicella zoster virus (VZV) serology (unless previously vaccinated)
    8. h) Interferon-γ release assay and, if indicated, chest X-Ray (CXR) when risk factors for tuberculosis exist
  5. Give special consideration to the following:
    1. a) Children
    2. b) Hepatic and renal impairment
    3. c) VZV non-immune: immunisation required
    4. d) Hepatitis B virus non-immune: consider immunisation in at-risk groups
  6. Formulate a plan for duration and eventual withdrawal of therapy.
  7. Complete checklist of what to tell patients prior to prescribing cyclosporine
  8. For unlicensed indications record provision of explanation of prescribing precedent in the patient’s notes.
  9. Supply with a PIL (if not previously) and record provision in case notes.

Checklist of what to tell patients and their carers prior to prescribing cyclosporine

  1. Explain that cyclosporine works by partially suppressing the immune system and the dose depends partly on body weight.
  2. Explain that the onset of therapeutic benefit of cyclosporine can be rapid and once improvement has been achieved the dose will be reduced gradually in steps of 0.5-1 mg/kg body weight, to the lowest effective dose.
  3. Advise that short courses of treatment lasting 2 to 4 months are recommended.
  4. Emphasize the need for monitoring for toxicity, with regular blood tests and blood pressure reading. Patients unable to comply should not be given the drug
  5. Advise patients and their carers of the most common side effects.
  6. Advise patient and their carers about good oral hygiene (to avoid gingival hyperplasia).
  7. Explain if usage is for a licensed or unlicensed indication. For unlicensed indications give a clear explanation of prescribing precedent.
  8. Advise patients and their carers to seek urgent medical attention if they develop signs or symptoms of renal impairment. Specifically warn patient about:
    1. a) Fever/flu-like illness
    2. b) Mouth ulceration
    3. c) Tiredness
    4. d) Unexplained bruising or bleeding of the gums
    5. e) Nausea, vomiting, abdominal pain or dark urine
    6. f) Breathlessness or cough
  9. Advise that grapefruit or grapefruit juice should be avoided while taking cyclosporine.
  10. Advise that live-attenuated vaccines should be avoided during treatment and other vaccinations may be less effective.
  11. Advise patients who have not had chickenpox and their carers to inform their doctor promptly if they come into contact with anyone with chicken pox or shingles.
  12. Advise female lactating patients that cyclosporine can pass into the milk and has the potential to cause adverse drug reactions in breastfed newborns/infants
  13. Caution regarding pregnancy and emphasize that if a patient does become pregnant they need to inform their doctor as soon as possible.
  14. Warn about potential drug interactions (also detailed in the PIL) and the need to warn other healthcare professionals prescribing concurrent medication that they are taking cyclosporine.
  15. Ask patients and their carers if they have any other concerns about cyclosporine.

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