Sıra | DOSYA ADI | Format | Bağlantı |
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01. | Initial Group Finding Condition | pptx | Sunumu İndir |
Transkript
Therapy with immune modulators (Cyclosporine A) in dermatology (focusing on psoriasis, atopic eczema, allergic vasculitis, and chronic urticaria)Hana Zelenková, M.D., Ph.D.Private Clinic of Dermatovenereology DOST Svidník, Slovakia
Cyclosporine A Cyclosporine A is an immunosuppressant cyclic polypeptide isolated from the Tolypocladium inflatum fungusIndications: organ transplantations (kidney, liver, heart, lungs, pancreas, skin), bone marrow transplantations, autoimmune disorders, and selected dermatoses such as psoriasis or atopic dermatitisHouston 20152
3Cyclosporine A - indicationsFirst choice drug to treat selected dermatoses like psoriasis, or ADAutoimmune disease like SLE, pemphigus, urticaria The indication range is constantly wideningImportant note – inform your patients and other physicians that CsA must not be combined with certain other drugs that might either increase or decrease its effect, and certain foodstuffs!Houston 2015
4Cyclosporine A Dosing and monitoringOral CsA is preferred in most indicationsOptimum dosing: two doses, one taken in the morning and one in the evening (suitable in patients with dermatoses)Transplanted patients require routine monitoring of CsA levels in blood In non-transplanted patients CsA monitoring is only of limited importance Houston 2015
5Cyclosporine A – laboratory screening, adverse effects creatinine levels, liver functions, and blood pressure must be monitoredmost often reported adverse effects include: hypertrichosis, tremor, weakness, disturbed kidney functions, loss of appetite, nausea, vomiting, and allergic skin reactionsconsidering the potential risk of skin malignancy, it is necessary to warn CsA patients about sun exposure!Houston 2015
6Cyclosporine A in dermatologyTherapeutic indications – 3 groups:Group I - dermatoses treated with maximum efficacy drugs, where CsA represents an extraordinarily effective first choice drug: pyoderma gangrenosum; generalised unmanagable scleroderma; morphaea, psoriasis generalisata et psoriasis arthropatica, acrodermatitis continua suppurativa, atopic dermatitis Houston 2015
7Cyclosporine A in dermatologyGroup II - dermatoses treatable with an alternative systemic drug based on the therapist’s choice, however, with CsA as the best choice: psoriasis vulgaris gravis, psoriasis pustulosa, neurodermitis gravis, Bechcet syndrome, actinic reticuloid, bullous dermatoses, dermatomyositisHouston 2015
8Cyclosporine A in dermatology Group III – other dermatosesIndividual therapy considering the expected prognosis and potential relapsesGroup III is still widening, and is expected to become the most numerous group in the future (chronic urticaria, vitiligo)Houston 2015
9Cyclosporine A in dermatology In clinical dermatology, CsA therapy must be used in a uniform manner Criteria must be set to identify those patients who might benefit from CsA therapyCsA therapy must be tailor made to the patient to fit their current condition Houston 2015
Cyclosporine A in dermatology - therapeutic schemesRapidly decreased high initial doses\Low dose CsA\ – slower onset of action, and prolonged optimum dosing Maintenance weekend therapy“In literature there are cases described of patients with various dermatoses using maintenance doses of CsA for months or even years Houston 201510
11CsA in dermatology- therapeutic schemesContinuous and intermittent therapy (cyclosporine consensus 2003)General consensus about the risk of rapid discontinuation of high CsA doses which may lead to severe complicationsUsage at 12-hour intervals 1 hour prior to administration grapefruit juice should be avoidedHouston 2015
12INTERMITTENT THERAPY SCHEMEHouston 2015
Houston 201513CsA and Psoriasis vulgaris in 18 years we treated more than 660 patients with initial doses of 3-5 mg /kg in form of continuous and intermittent therapy, with doses decreased according to condition and at the end we switched to weekend therapy with maximum dosing period of 3 years 6 patients had increased blood pressure 16 patients discontinued the therapy due to intolerance
Houston 201514Clinical effect - before therapy
Houston 201515Clinical effect after 14 months of therapy, with 8 years in remission
Houston 201516Local finding before and after therapy
Houston 201517Local finding after 8 months of therapy, 1 year of weekend therapy, with 6 years in remission
Houston 201518Local finding before and after 6 months of therapy, with 3 years in remission
Houston 201519Local finding before and after 7 months of therapy, with 5 years in remission
Houston 201520CsA and atopic dermatitis in 18 years we treated more than 480 patients with initial doses of 3-4 mg /kg in form of continuous therapy, and doses decreased according to condition at the end we switched to weekend therapy with a maximum dosing period of 2 years 11 patients had increased blood pressure 19 patients discontinued the therapy due to intolerance
Houston 201521CsA therapy of atopic dermatitis after 6 months
Houston 201522CsA therapy of atopic dermatitis after 8 months
23CsA therapy of urticaria Information in literature Autoimmune conceptPresence of systemic auto-antibodies Presence of anti FcRIConcomitant autoimmune disease (vitiligo, thyroiditis, collagenosis,...)1. Blinded placebo controlled study in 99 patients, with an initial dose of 5 mg/kg, gradually reduced+ Cetirizine or placebo, with significantly decreased urticaria severity score and DQLI in the CsA group, acute therapy was needed in much less patients in the CsA group2. KV Godse Indian J Dermatol 2008;53:101-2 - 5 patients with positive ASS test, 3 mg/kg for 12 weeks+ Cetirizine, CsA is suitable also in long-term maintenance therapy3. Grattan CE.: BJD 143, 2000, 365-72 - 30 patients with histamine resistant CIU, 20 patients with CsA and 10 patients with Pb for 4 weeks, monitored until week 204. Kessel A et al.: Allergy 65, 2010, 1478-82 - 120 patients treated due to severe CIU with CsA 3 mg/kg, 20 patients were excluded due to adverse effects, some patients were treated for 5 to 10 yearsHouston 2015
24Autologous serum test Mečiarová P., Urbanček S.: Kongres SDS-ČDS jún 2008Houston 2015
Houston 201525Our own experience with the therapy of urticaria In 11 years we treated 16 patients in form of continuous and intermittent therapy, with doses decreased according to conditiontowards the end we switched to weekend therapy with a maximum dosing period of 1 year 9 patients concluded the therapy, and have been without manifestations for 4 to 9 years 3 patients discontinued due to adverse effects 2 patients discontinued after 3 months due to non-provable effect
Houston 201526The data stated in literature was not proven in the monitored groupAntihistamine drugs were necessary In patients with chronic urticaria effects were better after biologic therapyCsA therapy of urticaria Our own experience
27SCLE therapy (Subacute Cutaneous Lupus Erythematosus) Recommended as 5th experimental line Cyclosporine A (proffered in SLE and lupus nephritides (Dubertret L et al.: Therapeutique dermatologique, Paris, Flammarion, 3-éme ed, 2002.) Houston 2015
28Pemphigus there are only limited cohorts and cases we have experience with a significantly efficient combined therapy in 8 patients Important especially in COMBINATION with CORTICOIDS, which is more comfortable forr the patient Barthelemy H et al.: JAAD 18, 1988, 1262-1266Houston 2015
29PEMPHIGUS VULGARISHouston 2015
301997 – Urbanček, Vojtáš from the SR „Were among the first...!“Houston 2015
31CasesSarcoidosis - Badgwell and Rose.: AAD, 56, 2007, 69-83, controversial indicationAlopecia areata - Gupta A K.: JAA 1990;22(2 Pt 1):242-50 ; Kim BJ, J Dermatolog Treat. 2008;19(4):216-20. - CsA is theoretically suitable to treat AA, in practice the results are ambiguousSevere lichen planusHouston 2015
32Pyoderma gangrenosum CsA is used usually in combination with corticoids in corticoid resistant or contraindicated cases corticoids spare the patient and are suitable in idiopathic forms we should rather use short term regimens (ca risk in chronic inflammatory bowel diseases after long term therapy)Miller J.: J Am Acad Dermatol 2010;62:646-54Houston 2015
33Pyoderma gangrenosum Our own experienceMale patient aged 49 years,without associated diseaseTherapy: CsA, corticoids, with complete healing (in 7 months) Houston 2015
34Pyoderma gangrenosum Our own experience Houston 2015
35Allergic vasculitis Diagnostic bottlenecks scars after healed minor ulcerations have a typical shape If you recognize it, you may determine the proper diagnosisHouston 2015
36Case I - condition before CsA therapyHouston 2015
37Case I – condition after 14 days of CsA and Prednisone therapy Houston 2015
38Case I – during CsA and Prednisone therapy (skipped month 12)Houston 2015
39Case I – total healing after 14 moths of CsA therapy Houston 2015
40Dermatomyositis there is only little data in literature a histological examination verified dermatomyositis and Raynaud's phenomenon in our male patient aged 28 years after unsuccessful therapy with Plaquenil, Methotrexate, Prednisone, Imuranwe started continuous CsA therapy with the initial dose of 4mg/kgwe concluded the treatment course with 6 months of weekend therapyHouston 2015
41First examinationHouston 2015
42After 14 months of CsA therapy, our patient has been without any problems for 4 yearsHouston 2015
43CONCLUSIONCsA therapy in 1st to 3rd line requires erudition and experience. In patients with severe dermatoses CsA therapy improves not only the local finding, but also the quality of lifeCsA therapy must be administered according to the principles of EVIDENCE BASED MEDICINE !!!Houston 2015
INVITATION 16th anniversary biggest Congress of the Slovak Society of Aesthetic and Cosmetic Dermatologywith international participation DERMAPARTY 2015December 3. - 5. 2015Holiday Inn Congress Centre ŽilinaSlovak Society of Aesthetic and Cosmetic Dermatology (SSACD)European Society for Cosmetic and Aesthetic Dermatology (ESCAD)International Academy of Cosmetic Dermatology (IACD)
45Thank you for your attention!Houston 2015