Reviewer: S. Randhawa, M.D., Allergist/Immunologist and Assistant Professor at LSU (Shreveport) Department of Allergy and Immunology
A 43-year-old Caucasian male with severe asthma and allergic rhinitis is seen for a follow-up at the allergy clinic. He had frequent emergency room visits and hospitalizations until he started omalizumab (Xolair) 2 years ago. He had an anaphylactic reaction to omalizumab which necessitated the discontinuation of the medication 2 months ago. Since then, he has had persistent symptoms requiring 3 ER visits and 1 hospitalization. He uses albuterol PRN 6-8 times per day.
Past medical history (PMH)
Asthma, allergic rhinitis.
Advair Diskus (fluticasone and salmeterol), Zyflo (zileutin), Combivent, prednisone 15 mg po daily alternating with 12.5 po daily, Singulair, fluticasone nasal spray
Weight 80 kg
HEENT: Pale boggy turbinates with 75% obstruction of the nasal cavity
Chest: CTA (B), decreased air entry (B)
CVS: Clear S1S2
Abdomen: Soft, NT, ND, +BS
Extremities: no c/c/e
PFTs: Obstructive defect with 15% response to bronchodilator. CXR: no infiltrates.
The patient wants to try some other medication to bring his asthma under control. He was treated with methotrexate in the past but stopped it due to side effects.
What would you recommend for this patient?
Cyclosporine can be considered.
What labwork should be ordered for this patient?
CMP baseline and after one month of therapy.
Cyclosporine blood level after one month of therapy.
What cyclosporine dose would you use?
Cyclosporine 5 mg/kg po. The dose is divided BID.
The patient was prescribed cyclosporine 200 mg po bid. Risks, benefits and alternatives were discussed in detail.
He was scheduled to have CMP, UA today and in one month. A cyclosporine blood level was ordered in one month from today.
A follow-up visit was schedulled in one month.
Cyclosporine Use in Severe Steroid-dependent Asthma.
What did we learn from this case?
Asthma is the most common chronic respiratory disease, affecting up to 10% of adults and 30% of children (JACI, 2011).
A Cochrane review of 98 patients with severe asthma treated with cyclosporine showed a small but significant treatment effect for cyclosporin in terms of steroid dose reduction. One study showed small, but significant improvements in lung spirometry.
In a RCT of cyclosporin A as a corticosteroid-sparing agent in corticosteroid-dependent asthma, predictable changes in renal function and blood pressure, and an increased incidence of hypertrichosis and paresthesia, were observed in the patients treated with CsA, but these did not necessitate withdrawal from the study, and were reversed during a 4-wk run-out period.
Given the side effects of cyclosporin, the evidence available does not recommend routine use of this drug in the treatment of oral corticosteroid dependent asthma. Cyclospotine can be used in selected patients not able to tolerate alternative medications.
Severe asthma - differential diagnosis and management (click to enlarge the image).
Cyclosporin as an oral corticosteroid sparing agent in stable asthma. Evans DJ, Cullinan P, Geddes DM, Walters EH, Milan SJ, Jones P. Cochrane Reviews, 2007.
Cyclosporin for steroid-dependent asthma. A. Szczeklik, E. Nizankowska, R. Dworski, B. Domagala, G. Pinis. Allergy, Volume 46 Issue 4, Pages 312 - 315.
Double-blind, placebo-controlled study of cyclosporin A as a corticosteroid-sparing agent in corticosteroid-dependent asthma. SH Lock, AB Kay and NC Barnes. Am. J. Respir. Crit. Care Med., Vol 153, No. 2, Feb 1996, 509-514.
Treatment of steroid-dependent bronchial asthma with cyclosporin. E Nizankowska, J Soja, G Pinis, G Bochenek, K Sladek, B Domagala, A Pajak, and A Szczeklik. Eur Respir J 1995; 8: 1091-1099.
Trial of cyclosporin in corticosteroid-dependent chronic severe asthma. Alexander AG; Barnes NC; Kay AB. Lancet 1992 Feb 8;339(8789):324-8.
An approach to recalcitrant, severe asthma - AAAAI Ask the Expert, 2011.