Oral cyclosporin in psoriasis: a systematic review on treatment modalities, risk of kidney toxicity and evidence for use in non-plaque psoriasis
Oral cyclosporin in psoriasis: a systematic review on treatment modalities, risk of kidney toxicity and evidence for use in non-plaque psoriasis
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DOI：
10.1111/j.1468-3083.2011.03992.x
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发表时间：
2011-05-01
影响因子：
9.2
通讯作者：
Paul, C.
中科院分区：
文献类型：
--
作者：
Maza, A.;Montaudie, H.;Paul, C.
尽管环孢菌素(CyA)用于治疗银屑病已有20多年的历史，但在治疗策略、肾功能监测和对非斑块型银屑病的有效性方面仍存在争议。目的：为了更好地确定治疗策略、肾毒性风险以及用于非斑块型银屑病的证据，我们进行了系统的综述，检索了1980年至2010年6月期间的关键词：‘银屑病’、‘CyA’、‘肾毒性’。最终入选包括16篇关于治疗策略的随机对照试验(RCT)，25篇关于肾脏毒性风险的文章(组织学研究和RCT)，以及10篇用于非斑块型银屑病的文章(RCT、前瞻性研究和病例系列)。在50%到97%的患者中，较高剂量的环磷酰胺5毫克/公斤产生牛皮癣面积严重指数(PASI)75的反应，而较低剂量的环磷酰胺2.5毫克/公斤产生28到85%的PASI 75。CyA在每天至少3 mg/kg的剂量下可维持缓解。肥胖患者的低卡路里饮食可提高CyA疗效。如果延长治疗2年，接受环磷酰胺治疗的患者中，超过50%的患者可能会有超过30%的血肌酸值上升。环磷酰胺2.5 mg/kg/d对89%的掌跖脓疱病患者有效。超过50%的红皮病型银屑病患者在2-4个月内在3-5 mg/kg/天的剂量下有明显改善。结论口服环磷酰胺治疗斑块型银屑病、脓疱型银屑病或红皮病型银屑病具有较好的疗效。起始剂量为5毫克/公斤与较高的清除度有关。对于没有肾毒性危险因素的患者，好处-风险似乎更好：没有高血压且年龄在60岁以下的非肥胖患者。尽管CyA非常适合危机干预，但在一些患者中可以考虑使用CyA进行持续的维持治疗，前提是定期监测血清肌酐，并且累计治疗时间最好限制在2年或更短时间。
BackgroundAlthough cyclosporin (CyA) has been in use in psoriasis for more than 20 years, there is still controversy regarding treatment strategy, monitoring of kidney function and utility in non-plaque psoriasis.ObjectivesTo prepare for evidence-based recommendations concerning the practical use of CyA in psoriasis, we performed a systematic review to better define treatment strategy, risk of kidney toxicity and evidence for use in non-plaque psoriasis.MethodsA systematic search was performed on PubMed, Cochrane and Embase databases, using the key-words 'psoriasis', 'CyA', 'nephrotoxicity' during the period from 1980 to June 2010.ResultsThe initial literature search identified 428 articles. The final selection included 16 randomized controlled trials (RCT) for treatment strategy, 25 articles (histological studies and RCT) for risk of kidney toxicity and 10 articles (RCT, prospective studies and case series) for use in non-plaque psoriasis. Higher doses of CyA of 5 mg/kg produced Psoriasis Area Severity Index (PASI) 75 response in between 50 and 97% of patients, whereas lower doses of 2.5 mg/kg yielded PASI 75 in between 28 and 85%. CyA could maintain remission at doses of at least 3 mg/kg/day. Low calory diet in obese patients was shown to improve CyA efficacy. More than 50% of the patients treated with CyA may have an increase in serum creatinin value over 30% of baseline if treatment is prolonged for 2 years. CyA at a dose of 2.5 mg/kg/day was effective for 89% of patients with palmoplantar pustulosis. More than 50% of the patients with erythrodermic psoriasis obtained a significant improvement at doses between 3 and 5 mg/kg/day at 2-4 months. CyA was more effective than etretinate on nail psoriasis.ConclusionOral CyA is indicated for patients with plaque psoriasis, pustular psoriasis or erythrodermic psoriasis. The starting dose of 5 mg/kg is associated with a higher degree of clearance. The benefit-risk appears to be better for patients without risk factors for nephrotoxicity: non-obese patients without hypertension and aged below 60. Although CyA is ideally suited for crisis intervention, continuous maintenance treatment with CyA may be envisaged in some patients provided serum creatinin is regularly monitored and the cumulative treatment duration is preferably limited to 2 years or less.