Calcineurin Inhibitors as Steroid-Sparing Agents

In the Literature

Banovic F, Robson D, Linek M, Olivry T. Therapeutic effectiveness of calcineurin inhibitors in canine vesicular cutaneous lupus erythematosus. Vet Dermatol. 2017;28(5):493-e115.

The Research …

Vesicular cutaneous lupus erythematosus (VCLE) is a form of cutaneous lupus erythematosus that is seen mainly in collies and Shetland sheepdogs. VCLE has a distinctive clinical appearance, with lesions consisting of annular to serpiginous ulcerations primarily on the ventral abdomen, groin, and axillae, although mucocutaneous junctions and the concave aspect of the pinnae are commonly affected as well. As with many other autoimmune skin diseases, the treatment of choice has historically involved immunosuppressive doses of oral glucocorticoids. Although glucocorticoids are usually effective at inducing remission, side effects are common, and the long-term prognosis is guarded. As such, there is a need for safer long-term treatment options for VCLE. Calcineurin inhibitors (eg, cyclosporine, tacrolimus) are frequently used as steroid-sparing agents in dogs with autoimmune skin diseases, but there is a lack of published data examining the outcomes of these treatments.

In this study, the authors analyzed the outcomes of 11 dogs with VCLE that were treated with oral modified cyclosporine (5-10 mg/kg q24h). Initial therapies included systemic and topical antimicrobials (6 and 2 dogs, respectively) and oral corticosteroids (9 dogs); these treatments resulted in clinical improvement for several dogs, but none achieved clinical remission. After initiation of treatment with oral modified cyclosporine, complete remission was noted in 8 of the 11 dogs within 35 to 70 days. Complete remission was achieved in 2 additional dogs when the cyclosporine dosage was increased and topical tacrolimus was added. Relapse was often seen when cyclosporine doses were tapered. Three dogs were euthanized, but clinical remission was maintained in the remaining 8 dogs with oral cyclosporine and, occasionally, topical tacrolimus or pimecrolimus.

… The Takeaways

Key pearls to put into practice:

• Cyclosporine appears to be a safer long-term treatment option for VCLE than glucocorticoids alone.

• Once clinical remission has been achieved, clinicians should attempt to gradually taper medications to the lowest effective dose. Topical calcineurin inhibitors (eg, tacrolimus, pimecrolimus) can be used to further reduce the need for oral cyclosporine. Although these topical products are initially expensive, one tube usually lasts several months, as only a small amount is used for each dose.

• In dogs with immune-mediated skin disease, avoiding excess sun exposure is recommended. UV light has been known to exacerbate skin lesions in humans with CLE,¹ and anecdotal information supports this effect in dogs.