Ciclosporin

What is ciclosporin?

Ciclosporin (brand names Cyclosporin, Cicloral, Neoral and Sandimmun) is a medicine used to treat rheumatoid arthritis and other conditions such as systemic lupus erythematosus (lupus/SLE), polymyositis (muscle inflammation), nephrotic syndrome (kidney inflammation) and severe skin conditions like psoriasis, atopic dermatitis (eczema) and pyoderma gangrenosum.

Ciclosporin is used in rheumatoid arthritis when other treatments have been unsuccessful. It is also used to prevent the rejection of transplanted organs or bone marrow

Ciclosporin is an immunosuppressive medicine, which means that it works by reducing the activity of the immune system. In rheumatoid arthritis, this action helps to reduce pain, swelling and damage to the joints.

Because ciclosporin reduces the damage to the joints, rather than just relieving the pain, it belongs to the group of medicines called disease modifying antirheumatic drugs (DMARDS).

What benefit can you expect from your treatment?

Ciclosporin may be of benefit where other DMARDs have been unsuccessful or have caused side effects.

Improvement in joint pain, swelling and stiffness may be seen after 4 weeks, but may be delayed for up to 4 months. If you stop ciclosporin treatment for more than a few weeks there is a risk that your condition may worsen. Continue with your treatment unless advised by your doctor or unless side effects develop.

How is ciclosporin taken?

Ciclosporin is taken by mouth, either as a liquid or capsules.

Capsules are the most convenient way of taking the medicine. They are available in four different strengths – 10 mg, 25mg, 50mg and 100mg.

Treatment is started with a low dose and is then increased depending on how effective the treatment is and whether you have side effects. A usual maintenance dose is 75 mg or 100 mg taken twice daily.

Do not chew the capsules but swallow whole with water.

Ciclosporin may be used with other arthritis medicines including:

• other DMARDs such as methotrexate
• steroid medicines such as prednisolone or cortisone injections into the joint
• anti-inflammatory medicines (NSAIDs) such as naproxen (Naprosyn) or ibuprofen (Brufen, Nurofen).
• simple pain medicines such as paracetamol.

There are separate information sheets for the medicines mentioned above.

Are there any side effects?

You might experience side effects with your treatment. Tell your doctor if you are concerned about possible side effects.

A reduction in the dose may minimise side effects so that you can continue to take the treatment. Your doctor will advise on any dose changes that are necessary.

Most common possible side effects

• Ciclosporin can cause an increase and darkening of body hair especially on the face. This can be managed with bleaching or other cosmetic approaches.
• Bleeding, tender or enlarged gums may occur but good dental hygiene minimises this effect.
• At the beginning of treatment, a feeling of pins and needles or a burning feeling can occur in the hands and feet. There might also be a slight tremor of the hands. These effects tend to lessen after a few weeks and are not serious.
• Ciclosporin can affect your kidneys and may increase blood pressure. These problems are more common in older people. Kidney function and blood pressure will be monitored regularly. If problems occur, the dose will be reduced or the medicine may be stopped.

Less common or rare possible side effects

• Less common side effects include skin rash, nausea (feeling sick), vomiting, fever or chills.
• Ciclosporin can increase the risk of skin cancers (see Precautions) and lymphomas (cancer of lymph glands)
• Ciclosporin can increase the risk of infections. You should report any infections such as a sore throat or fever to your doctor.
• Rarely, ciclosporin has been found to cause mouth ulcers, diarrhoea, headaches, leg cramps, confusion, weight loss, difficulty breathing, tiredness and swelling of the hands or feet

What precautions are necessary?

Blood tests

• Since the kidneys, liver and blood pressure may be affected by ciclosporin you must have regular blood and urine tests and GP visits during your treatment. This is important as you may not get symptoms from blood pressure rising or kidney issues.
• As well as monitoring for side effects, blood tests help to monitor your condition to determine if the treatment is effective.
• Blood tests are recommended every two weeks to begin with. As treatment is stabilised the tests will be done less frequently.
• Your general practitioner (GP) will be informed about the monitoring schedule. It is important to see your GP if you have been asked to do so as they have an important role to play in monitoring your condition.

 Use with other medicines and food

• Ciclosporin can interact with other medicines. You should tell your doctor (including your general practitioner, rheumatologist and others) about all medicines you are taking or plan to take. This includes over the counter or herbal/ naturopathic medicines. You should also mention your treatment when you see other health professionals.
• If you are taking ciclosporin you should not take St John’s wort. This is an ingredient in some complementary medicines recommended for depression, which you can buy without a prescription.
• You should avoid eating grapefruit or drinking grapefruit juice while taking this medicine, as it can affect the level of ciclosporin in the body.
• Ciclosporin is often used together with other DMARDs to treat rheumatoid arthritis.

Vaccines

• If you are on ciclosporin it is recommended you should not be immunised with ‘live’ vaccines such as MMR (measles, mumps and rubella), OPV (oral polio virus), BCG (Bacillus Calmette Guerin), Herpes Zoster (Zostavax)  or yellow fever.
• Pneumococcal vaccines and the yearly seasonal flu vaccinations are safe and encouraged.
• More information on vaccination including the COVID-19 vaccination is available here.

Pregnancy, breastfeeding and fertility

• Ciclosporin can be used in pregnancy if the mother’s condition is serious and no other effective treatment is available. It must, therefore be used with caution.
• Ciclosporin has been used in pregnancy and breastfeeding but this should first be discussed with your paediatrician and rheumatologist.
• Men can take ciclosporin when trying to start a family but this should first be discussed with your rheumatologist.
• More detailed information is available here.

 Skin checks

• When taking ciclosporin, it is important to use a sunscreen and avoid prolonged sun exposure. A yearly skin check is recommended.

How to store ciclosporin

• Ciclosporin capsules and liquid should be stored at room temperature in a dry place, not in the fridge. If liquid ciclosporin is stored in too cool a place, it may become jelly-like. Returning the solution to room temperature can reverse this.
• Keep the capsules in the blister pack until just before you take them. For example, do not take them out of the blister package to put them into a ‘dossette’ or pill box.
• The solution should be used within two months of opening.
• Keep all medicines out of reach of children

Important things to remember

• While taking ciclosporin you should see your rheumatologist regularly to make sure the treatment is working and to minimise any possible side effects.
• You should have regular blood tests as directed by your rheumatologist.
• If you are concerned about any side effects you should contact your rheumatologist as soon as possible.

For more information see the Ciclosporin – printable information sheet.