Ciclosporin

The same oral formulation must always be used:

CICLOSPORIN

• 2.5 mg/kg/day in two divided doses for 6 weeks, increasing in 2-4 week intervals  to a maximum of 4 mg/kg/day in gradual 25 mg increments if necessary.  
• 2.5mg -3.2 mg/kg/day often sufficient.  

TACROLIMUS- doseage as per Rheumatologist (varies with brand)

Patients should receive annual flu vaccination and the Pneumococcal vaccine and Shingrix.

• Pre-Treatment – ECG (for QT interval), Blood Pressure,  FBC, U+E, CRP, LFT inc Albumin, Lipids, HbA1c and glucose, Hepatitis , HIV and VZV serology

then   

• FBC U+E, CRP, LFT inc albumin, BP and glucose - fortnightly until dose stable for 6 weeks then monthly for 3 months then 3 monthly.  Magnesium 6 monthly (especially if co-prescribed PP1/K-Sparing Diuretics)
• Glucose (HbA1c) and BP – every monitoring visit and maintain <140/90

• Therapeutic drug trough level (aim 100-200ng/ml for CICLOSPORIN at 6 weeks and 4-10ng/ml for TACROLIMUS at 1 week then 3 weeks then periodically)       

Increase monitoring if NSAID changes or dose increases

Entering the results into a monitoring booklet will ensure that trends are not missed. Patients who do not attend for monitoring should be warned of the risk that serious adverse effects may go unnoticed. In the event of persistent failure to attend for monitoring please inform the Rheumatology department.

• Creatinine rise by > 30% of base line over 12 months or less        
• WC <3.5                                  
• Platelets <140 x 10⁹/l                                   
• AST or ALT >100 - withhold and inform rheumatology
• MCV >105
• Neutrophils <1.6
• Unexplained albumin <30mg/l
• Unexplained eosinophilia >0.5
• BP rise to abnormal range x 2, 2 weeks apart - discuss with rheumatologist
• Abnormal bruising - withhold until FBC available

• Treatment is continued indefinitely providing it remains effective and there are no significant side effects.  
• Cyclosporin takes up to 3 months to become effective.
• If no response at max tolerated dose at 3 months – withdraw.  
• During this period there are likely to be continued symptoms or signs of disease activity. 
• It is reasonable to use IM Depo Steroid (Kenalog 40 mg or Depo Medrone 80 mg) up to monthly, depending on the requirements of the individual patient. 
• The dose required is small (e.g., monthly Kenalog 40 mg = 1.6 mg Prednisolone daily). 

• Disease modifying drugs will not prevent all flares.
• These can be managed with IM Depo steroid as outlined above. 
• If flares become more frequent, or the disease fails to settle between flares, the dosage should be increased, or an alternative discussed with the rheumatologist.

• known hypersensitivity
• psoriatic and atopic dermatitis
• renal and liver failure
• severe electrolyte imbalance
• uncontrolled hypertension
• uncontrolled infections and
• any malignancy
• live vaccines are contraindicated

• pregnancy and lactation
• caution against a high K+ diet
• caution in hyperuricaemia
• avoid grapefruit juice
• avoid other immunosuppressants except steroids

Long list – please see BNF (including diclofenac, colchicine, simvastatin, nifedipine, digoxin, K-sparing diuretics, “Mycin “ antibiotics, antifungals, St Johns Wort).

Common effects are in bold type.

Mucocutaneous

• hypertrichosis
• gingival hypertrophy
• rashes

Haematological

• mild anaemia
• thrombocytopenia
• micro angiopathic haemolytic anaemia

Gastrointestinal

• nausea
• pancreatitis
• colitis

Other

• hyperkalaemia
• hyperuricaemia
• hypomagnesaemia
• impaired renal function
• hypertension
• tremor
• myopathy
• cramps
• headaches
• weight gain
• oedema
• paraesthesia

Secretaries 01387 241776

Helpline 01387 241095 (answering machine) - Rheumatology Nurse Specialists

Rheumatology doctors via Switchboard 01387 246246/RMS Advice Request