Immunosuppressant, Disease-Modifying Antirheumatic Drug – DMARD
Issues for Surgery
For suppression of transplant rejection – risk of rejection if omitted (see Transplant Anti-Rejection Medication Monograph).
Risk of perioperative flare in disease activity if omitted.
Risk of post-operative infection if continued.
Advice in the Perioperative period
Monitoring of renal and hepatic function, blood pressure, and serum electrolytes (especially potassium and magnesium) is recommended perioperatively1, 2.
Individualised decisions should be made for procedures considered to have a high risk of infection1 and should be balanced against the risk of disease flare (see Further Information). The Surgical Team and the patient’s Rheumatologist should be involved in the planning.
Steroid exposure should be minimised prior to surgical procedures, and increases in steroid dose to prevent adrenal insufficiency are not routinely required1.
Other Indications (e.g. Dermatology, Ulcerative Colitis)
If the decision is made to stop ciclosporin prior to surgery, it should be stopped 2 weeks pre-operatively1.
The patient should be closely monitored for signs of infection following emergency surgery.
For high-risk surgical procedures or where there are patient factors that may increase surgical infection risk i.e. age and / or co-morbidity, consider withholding ciclosporin dose in the immediate post-operative period EXCEPT where used for prevention of transplant rejection (see Transplant Anti-Rejection Monograph).
If discontinued, restart once wound healing is satisfactory1.
NB: if the patient cannot take their oral ciclosporin post-operatively, consideration should be given to using intravenous (IV) ciclosporin. It is important to note that the oral and IV doses of ciclosporin are NOT equivalent. IV ciclosporin should only be prescribed by, or in close collaboration with, a Physician with experience of immunosuppressive therapy and / or organ transplantation.
Where ciclosporin is continued, close monitoring of renal function is important so that inadvertent drug accumulation does not occur1.
Interaction(s) with Common Anaesthetic Agents
Neuromuscular Blocking Drugs (NMBDs)
There is evidence that the neuromuscular blocking effects of atracurium, pancuronium and vecuronium may be increased in some patients treated with ciclosporin2, 3. The general importance is unclear but be alert for an increase in the effects of neuromuscular blockade in any patient receiving ciclosporin3.
Interaction(s) with other Common Medicines used in the Perioperative Period
CYP3A4 / P-glycoprotein Inhibition / Induction
Ciclosporin is an inhibitor of CYP3A4, the multidrug efflux transporter P-glycoprotein (P-gp) and organic anion transporter proteins (OATP) hence, there will be interactions with medicines that are also substrates of these enzymes and / or transporters4. There is potential for serious interactions resulting in decreased or increased ciclosporin levels. Care should be taken when prescribing any new medicine that may affect CYP3A4 and / or P-gp regulation. Consult current product literature.
Concomitant use of octreotide with ciclosporin decreases oral absorption of ciclosporin. It is recommended that a 50% increase in the ciclosporin dose or a switch to intravenous administration could be necessary2, 3, 4, 5.
Non-Steroidal Anti-inflammatory Drugs (NSAIDs)
Ciclosporin and NSAIDs can increase the risk of nephrotoxicity and hyperkalaemia2, 3, 4, 5.
Monitor renal and hepatic function if concomitant treatment with a NSAID is inititated2, 4.
Care should be taken when using ciclosporin together with other active substrates that exhibit nephrotoxic synergy3, 4, 5: -
Close monitoring of renal function is advised – if significant impairment of renal function occurs, the dosage of the co-administered medical product should be reduced or alternative treatment considered3, 4.
Antimicrobials (also see Nephrotoxicity above)
Reports of increased ciclosporin concentrations, and potential toxicity, has been reported with the following2, 3, 4, 5: -
Bear the interaction in mind with concomitant use of other antimicrobials if there is an unexplained change in ciclosporin concentrations or nephrotoxicity occurs3.
Whilst single surgical prophylactic doses should not pose a problem, continued post-operative treatment may require close monitoring of ciclosporin concentrations and / or effects (e.g. renal function)3. Consult current product literature.
Both ciclosporin and low molecular weight heparin (LMWH) / unfractionated heparin (UFH) can increase the risk of hyperkalaemia5.
MHRA/CHM Advice: Ciclosporin must be prescribed and dispensed by brand name (December 2009)
With systemic use, patients should be stabilised on a particular brand of oral ciclosporin because switching between formulations without close monitoring may lead to clinically important changes in blood-ciclosporin concentration5.
Rheumatoid Arthritis (RA) Flare
RA flares develop in 10-20% of patients undergoing surgery and have a potential to impact adversely on post-operative recovery. In addition, active RA increases infection risk, further complicating decisions regarding DMARD interruption1.