Most patients on ciclosporin for moderate-to severe psoriasis are discontinuing the drug within months due to lack of efficacy and moving onto biologics.

A review of ciclosporin use from 851 patients in the Australasian Psoriasis Registry found 62.8% of patients ceased using the drug due to lack of efficacy and 37.8% due to toxicity.

Those who stopped ciclosporin due to lack of efficacy did so earlier than those who stopped due to adverse events (median 12 v 14.9 weeks).

However there was no significant difference in the average dose of drug between the two groups of patients (2.59 v 2.48 mg/kg/d).

“The most common toxicities leading to cessation were hypertension (14.3%), renal impairment (8%), nausea (4.9%) and headache (3.1%),” the study said.

“Fatigue, gastrointestinal upset, headache and hepatic dysfunction occurred early in the treatment course (mean time to toxicity less than 12 weeks). By contrast, renal impairment occurred later (39.7weeks) and rarely occurred in the first 12 weeks of treatment.”

Hypertension had a similar incidence at any time point prompting the review to recommend patients on ciclosporin have regular blood pressure monitoring throughout treatment.

Renal function monitoring was also advised when patients were treated with prolonged courses of the drug.

The review, published in the Australasian Journal of Dermatology, found 93.7% of patients went on to use a biologic agent after ciclosporin.

“Many patients who experienced lack of efficacy did so after 6 weeks, which would make them eligible for a subsidised biologic agent on the Australian Pharmaceutical Benefits Scheme.”

“In combination with the mean dose for all patients on ciclosporin, it would appear that the availability of biologics may be driving more conservative dosing and duration of treatment with ciclosporin, given the potential for toxicity,” the authors said.

Co-author Associate Professor Chris Baker told the limbic that ciclosporin was still useful in some patients. 

“It’s a useful short-term treatment – efficacious in some but we wouldn’t consider it a long term option. And in most patients now it is part of the journey towards a biologic. It’s the longer term renal toxicity that limits its use.”

“You get the occasional patient who does extremely well on a low dose and stays on it for a longer period with their blood pressure and kidney function being monitored,” he said. 

He said the data showed that pushing the dose beyond 5mg/kg led to a better response but with greater toxicity.

“But we would feel that the biologics offer a safer, longer term option and if the patient qualifies, we do progress them to the biologics.”