Inflammatory bowel disease cyclosporine

Therapeutic pyramid approach to inflammatory bowel diseases. Treatment choice is predicated on both the severity of the illness and the responsiveness to therapy. Agents at the bottom of the pyramid are less efficacious but carry a lower risk of serious adverse effects. Drugs may be used alone or in various combinations. Patients with mild disease may be treated with 5-aminosalicylates (with ulcerative colitis or Crohn s colitis), topical corticosteroids (ulcerative colitis), antibiotics (Crohn s colitis or Crohn s perianal disease), or budesonide (Crohn s ileitis). Patients with moderate disease or patients who fail initial therapy for mild disease may be treated with oral corticosteroids to promote disease remission immunomodulators (azathioprine, mercaptopurine, methotrexate) to promote or maintain disease remission or anti-TNF antibodies. Patients with moderate disease who fail other therapies or patients with severe disease may require intravenous corticosteroids, anti-TNF antibodies, or surgery. Natalizumab is reserved for patients with severe Crohn s disease who have failed immunomodulators and TNF antagonists. Cyclosporine is used primarily for patients with severe ulcerative colitis who have failed a course of intravenous corticosteroids. TNF, tumor necrosis factor. 

Cyclosporine is used to a somewhat lesser extent in treating autoimmune diseases, but it may be helpful in conditions such as psoriasis, rheumatoid arthritis, inflammatory bowel disease, and glomerulonephri-tiS.i5,32,63 as discussed in Chapter 32, cyclosporine has also been used in the early stages of type 1 diabetes mellitus to help control immune-mediated destruction of pancreatic beta cells, thus decreasing the severity of this disease in some patients.9... 

Sandborn WJ. A review of immune modifier therapy for inflammatory bowel disease azathioprine, 6-mercaptopurine, cyclosporine, and methotrexate. Am J Gastroenterol 1996 91(3) 423-33. 

Langford CA, Klippel JH, Balow JE, James SP, Sneller MC. Use of cytotoxic agents and cyclosporine in the treatment of autoimmune disease. Part 2 Inflammatory bowel disease, systemic vasculitis, and therapeutic toxicity. Ann Intern Med 1998 129 49-58. Ponticelli C. Calcineurin-inhibitors in renal transplantation. Too precious to be abandoned. Nephrol Dial Transplant 2000 15 1307-1309. 

Hermida-Rodriguez C, Cantero PJ, Garcia-Valriberas R, Pajares Garcia JM, Mate-Jimenez J. High-dose intravenous cyclosporine in steroid refractory attacks of inflammatory bowel disease. Hepatogastroenterology 1999 46 2265-2268. 

Sandborn WJ, Tremaine WJ. Cyclosporine treatment of inflammatory bowel disease. Mayo Clin Proc 1992 67 981-990. 

In rheumatoid arthritis, cyclosporine is used in severe cases that have not responded to methotrexate. Cyclosporine can be combined with methotrexate, but the levels of both drugs must be monitored closely. In psoriasis, cyclosporine is indicated for treatment of adult immunocompetent patients with severe and disabling disease for whom other systemic therapies have failed. Because of its mechanism of action, cyclosporine also has been used successfully in inflammatory bowel disease see Chapter 38). 

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