Cyclosporine treatment for Stevens-Johnson syndrome/toxic epidermal necrolysis: Retrospective analysis of a cohort treated in a specialized referral center

Lee, Haur Yueh; Fook‐Chong, Stephanie; Koh, Hong Yi; Thirumoorthy, T; Pang, Shiu Ming

doi:10.1016/j.jaad.2016.07.048

Cited by 75 publications

(56 citation statements)

References 34 publications

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“…In the case of intravenous immune globulin in particular this may relate to the lateness of presentation of most patients with drug-induced SJS/TEN and loss of an earlier window period where this treatment may have been effective. Other immunosuppressive drugs like cyclosporine, have been reported with mixed results or limited benefit that still need further studies in larger populations (116). Prevention of long-term eye complications is critical in the management of SJS/TEN.…”

Section: Managementmentioning

confidence: 99%

Severe Delayed Cutaneous and Systemic Reactions to Drugs: A Global Perspective on the Science and Art of Current Practice

Peter

Lehloenya

Dlamini

et al. 2017

The Journal of Allergy and Clinical Immunology: In Practice

121

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The majority of immune-mediated adverse drug reactions (IM-ADRs) involve the skin, and many have additional systemic features. Severe cutaneous adverse drug reactions (SCAR) are an uncommon, potentially life-threatening and challenging sub-group of IM-ADRs with diverse clinical phenotypes, mechanisms and offending drugs. T-cell mediated immunopathology is central to these severe delayed reactions, but effector cells and cytokines differ by clinical phenotype. Strong HLA-gene associations have been elucidated for specific drug-SCAR IM-ADRs such as Stevens-Johnson Syndrome/toxic epidermal necrolysis (SJS/TEN); although the mechanisms by which carriage of a specific HLA allele is necessary but not sufficient for the development of many IM-ADRs is still being defined. SCAR management is complicated by substantial short and long-term morbidity/ mortality and the potential need to treat ongoing co-morbid disease with related medications. Multidisciplinary specialist teams at experienced units should care for patients. In the setting of SCAR, patient outcomes as well as preventive,diagnostic, treatment and management approaches are often not generalizable, but rather context specific, driven by population HLA-genetics, the pharmacology and genetic risk factors of the implicated drug, severity of underlying co-morbid disease necessitating ongoing treatments, and cost considerations. In this review, we update the basic and clinical science of SCAR diagnosis and management.

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Section: Managementmentioning

confidence: 99%

Severe Delayed Cutaneous and Systemic Reactions to Drugs: A Global Perspective on the Science and Art of Current Practice

Peter

Lehloenya

Dlamini

et al. 2017

The Journal of Allergy and Clinical Immunology: In Practice

121

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“…In a retrospective cohort, 9 out of 24 patients that received cyclosporine stopped treatment early due adverse effects including worsening renal function, n = 6, suspected myotoxicity, n = 1, and patient's preference, n = 2 (Lee et al, 2017). The largest prospective study evaluating cyclosporine efficacy for SJS/TEN enrolled 29 patients.…”

Section: Safetymentioning

confidence: 99%

“…It should be noted that studies assessing the efficacy of cyclosporine in TEN excluded patients with a creatinine clearance <60 ml/ min, hypertension (systolic ≥160 mmHg and or diastolic ≥100 mmHg), a previous intolerance to cyclosporine, pregnancy, uncontrolled diabetes mellitus, severe infection, malignancy, or immunodeficiency (Lee et al, 2017;Nassif et al, 2002;Valeyrie-Allanore et al, 2010). Studies assessing cyclosporine efficacy and safety in rheumatoid and psoriatic arthritis also excluded patients with uncontrolled hypertension, significant renal disease at baseline and four patients were removed from the study because of serum creatinine increase (Karanikolas et al, 2011;Miranda, 2004;Tugwell et al, 1995).…”

Section: Safetymentioning

confidence: 99%

“…Studies assessing cyclosporine efficacy and safety in rheumatoid and psoriatic arthritis also excluded patients with uncontrolled hypertension, significant renal disease at baseline and four patients were removed from the study because of serum creatinine increase (Karanikolas et al, 2011;Miranda, 2004;Tugwell et al, 1995). Rates of nephrotoxicity in renal, cardiac and liver transplant patients have been reported to be 25%, 38%, and 37%, respectively (Lee et al, 2017;Singh et al, 2013). It is worth noting that initial oral cyclosporine dosing for transplant rejection prophylaxis is much higher than doses described for treatment of SJS/TEN Patients usually are not stabilized in psoriasis treatment until 12-16 weeks, but likely require 3-4 months of treatment before experiencing optimal control (Menter et al, 2009).…”

Section: Safetymentioning

confidence: 99%

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Efficacy and safety of cyclosporine in Stevens-Johnson syndrome and toxic epidermal necrolysis

Gilbert

Scherrer

2018

Dermatologic Therapy

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Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare but life threatening cutaneous reactions that are most commonly caused by exposure to medications. This review assesses the efficacy and safety of cyclosporine therapy for SJS, TEN, and SJS/TEN overlap. A literature review was conducted in PubMed using the MeSH terms TEN, SJS, and cyclosporine. Five case series and one meta-analysis were analyzed. From review of the existing literature, cyclosporine appears to not only have a mortality benefit in the treatment of SJS/TEN, but also a relatively safe side effect profile.

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“…Analysis of this cohort also suggested benefit; however, the small number of SJS/TEN patients treated precluded statistical significance [47–50]. Similarly, a 2017 analysis of a cohort of 44 patients (24 treated with cyclosporine) revealed a statistically insignificant survival benefit compared to supportive care [51]. …”

Section: Discussionmentioning

confidence: 99%

Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: A Concise Review with a Comprehensive Summary of Therapeutic Interventions Emphasizing Supportive Measures

2017

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IntroductionStevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are two of the most severe dermatologic conditions occurring in the inpatient setting. There is a lack of consensus regarding appropriate management of SJS and TEN.PurposeThe scientific literature pertaining to SJS and TEN (subsequently referred to as SJS/TEN) is summarized and assessed. In addition, an interventional approach for the clinician is provided.MethodsPubMed was searched with the key words: corticosteroids, cyclosporine, etanercept, intravenous immunoglobulin, Stevens-Johnson syndrome, and toxic epidermal necrolysis. The papers generated by the search, and their references, were reviewed.ResultsSupportive care is the most universally accepted intervention for SJS/TEN. Specific guidelines differ from the care required for patients with thermal burns. Adjuvant therapies are utilized in most severe cases, but the data are thus far underwhelming and underpowered. Using systemic corticosteroids as sole therapy is not supported. A consensus regarding combined corticosteroids and intravenous immunoglobulin (IVIG) has not been reached. Data regarding IVIG, currently the standard of care for most referral centers, is conflicting. Newer studies regarding cyclosporine and tumor necrosis factor inhibitors are promising, but not powered to provide definitive evidence of efficacy. Data regarding plasmapheresis is equivocal. Thalidomide increases mortality.ConclusionClinicians who manage SJS/TEN should seek to employ interventions with the greatest impact on their patients’ condition. While supportive care measures may seem an obvious aspect of SJS/TEN patient care, providers should understand that these interventions are imperative and that they differ from the care recommended for other critically ill or burn patients. While adjuvant therapies are frequently discussed and debated for hospitalized patients with SJS/TEN, a standardized management approach is not yet clear based on the current data. Therefore, until further data are available, decisions regarding such treatments should be made on a case-by-case basis.

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Cyclosporine treatment for Stevens-Johnson syndrome/toxic epidermal necrolysis: Retrospective analysis of a cohort treated in a specialized referral center

Cited by 75 publications

References 34 publications

Severe Delayed Cutaneous and Systemic Reactions to Drugs: A Global Perspective on the Science and Art of Current Practice

Severe Delayed Cutaneous and Systemic Reactions to Drugs: A Global Perspective on the Science and Art of Current Practice

Efficacy and safety of cyclosporine in Stevens-Johnson syndrome and toxic epidermal necrolysis

Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: A Concise Review with a Comprehensive Summary of Therapeutic Interventions Emphasizing Supportive Measures

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