The April 1, 2015 issue of Urology Times reports on an abstract by Chade and co-workers regarding long-term follow-up of patients with refractory interstitial cystitis/bladder pain syndrome (as defined by NIDDK criteria) showing excellent results in almost 80% of this difficult-to-treat cohort. Not only did quality of life improve, but Interstitial Cystitis Symptom and Problem Index scores and initial filling sensation showed dramatic positive changes. Perhaps most impressive, mean bladder capacity increased over 50% after 5 years of follow-up on the dose of 1.5 mg/kg of cyclosporine A twice daily.
Cyclosporine was first reported for this indication in 1996 by Forsell et al from Finland (J Urol 1996; 155:1591-3). One year follow-up showed no tachyphylaxis, but symptoms recurred on stopping the medication (J Urol 2004; 171:2138-41). A randomized study by the same researchers compared results in cyclosporine to pentosan polysulfate sodium (Elmiron) and found a 75% response versus 19% with pentosan polysulfate. A subsequent American study by Forrest et al reported a 68% response in patients with Hunner lesions and a 30% response in non-Hunner patients (J Urol 2012; 188:1186-91). Ehren and Swedish co-workers (Scand J Urol 2013; 47:503-8) showed that bladder nitric oxide (NO) levels could serve as a surrogate for bladder inflammation, and NO levels dropped in patients treated with cyclosporine A and increased when treatment was suspended.
This drug is not without potential major and minor side effects and complications, and the urologist who prescribes it would do well to study the drug thoroughly before using it. If you have a patient with rheumatologic co-disorders, it would be a good idea to consult with the rheumatologist who may have considerable experience in using the drug (Rheumatol Int 2012; 32:1215-8). I give all of my patients information from the following website: www.ncbi.nlm.nih.gov/pubmedhealth/PMH0049770/.
I discuss potential side effects and use an order template so that I don’t forget what chemistries to order when following them. It seems to be most effective in patients with active inflammation, whether that be discreet Hunner lesions or a bladder that has peeling, edematous, erythematous mucosa and looks like a bomb went off in it.
For the desperate patient with severe symptoms and a contracted, inflamed bladder who has failed standard therapies, cyclosporine A can be an effective treatment and prevent or delay the need for cystectomy and/or urinary diversion.
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