Treatment of Graves' ophthalmopathy with cyclosporin A

Developing an in situ nanosuspension: a novel approach towards the efficient administration of poorly soluble drugs at the anterior eye

With about 50-60 million cases in the US alone, dry eye disease represents a severe health care problem. Cyclosporin A (CsA) would be a potent candidate for a causal therapy. However, CsA is not sufficiently water soluble to be administrated via simple eye drops. We developed an in situ nanosuspension (INS) as a novel approach towards the administration of CsA to the cornea. It precipitates upon contact with the tear fluid and creates CsA nanoparticles that enter the cornea and release the drug by dissolution. We selected two liquid poly(ethylene glycols) (PEG) that dissolve CsA and create nanoparticles by precipitation of CsA upon water contact. Aqueous solutions of PEG and Solutol, a non-ionic surfactant, were well tolerated by primary human epithelial cells in vitro. To determine the critical water content needed for a precipitation, the solubility of CsA was investigated in quaternary systems of drug, solvent, surfactant and water. The best INS formulation showed a particle size of 505 ± 5 nm, a polydispersity index (PdI) of 0.23 ± 0.03 and a neutral zeta potential of -0.07 ± 0.05 mV. After single administration to porcine eyes in vitro, 3165 ± 597 ng(CsA)/g(cornea) were detected in corneal tissue, while the levels of Restasis a commercial formulation were, with 545 ± 137 ng(CsA)/g(cornea), significantly lower (P<0.01). These results demonstrate that an INS is a promising, novel approach towards the causal treatment of inflammatory diseases at the anterior eye.

Prednisone and cyclosporine in the treatment of severe Graves' ophthalmopathy

It is uncertain what is the most appropriate medical therapy for patients with severe Graves' ophthalmopathy. Therefore, we carried out a single-blind, randomized clinical trial to compare the efficacy of prednisone with that of cyclosporine in 36 patients who had been euthyroid for at least two months. The two groups, each consisting of 18 patients, were similar in age, sex, and the duration and severity of ophthalmopathy. The initial dose of cyclosporine was 7.5 mg per kilogram of body weight per day, and that of prednisone was 60 mg per day, which was subsequently tapered to 20 mg per day. During the 12-week treatment period, 11 prednisone-treated and 4 cyclosporine-treated patients responded to therapy (61 percent vs. 22 percent; P = 0.018); response was manifested by decreases in eye-muscle enlargement and proptosis and improved visual acuity and total and subjective eye scores. There were no differences at base line between the patients who later responded and those who did not. Prednisone was tolerated less well than cyclosporine. After 12 weeks, patients who did not respond were treated for another 12 weeks with a combination of cyclosporine and a low dose of prednisone. Among the 9 patients who initially received prednisone, the addition of cyclosporine resulted in improvement in 5 (56 percent); among the 13 patients who received cyclosporine initially, 8 (62 percent) improved after the addition of prednisone. Combination therapy was better tolerated than prednisone treatment alone. We conclude that single-drug therapy with prednisone is more effective than cyclosporine in patients with severe Graves' ophthalmopathy. The combination can be effective in patients who do not respond to either drug alone.

Ciclosporin and thyroid-stimulating immunoglobulins in endocrine orbitopathy

The study investigated whether ciclosporin (C) affected the thyroid-stimulating immunoglobulins (TSI) in serum of patients with endocrine orbitopathy (EO). The effect of C was compared with that of prednisone (P). Fifteen patients with EO classes III-V received C (n = 7) or P (n = 8). In addition to the immunosuppressants, five patients with Graves' disease in each group received methimazole (MMI). The stimulation of the cAMP levels in the medium of thyrocyte cultures was determined as a parameter of TSI. The TSI levels were markedly lowered in both groups during and after therapy. C group: before therapy 6.2 pmol/ml +/- 1.63 (100%, mean +/- SEM), during treatment 4.6 pmol/ml +/- 2.28 (74%), after treatment 4.1 pmol/ml +/- 1.33 (66%). P group: before treatment 9.1 pmol/ml +/- 3.42 (100%), during treatment 5.9 pmol/ml +/- 2.90 (65%), after treatment 3.7 pmol/ml +/- 1.20 (41%). There is neither a significant difference between the two groups nor between the patients who received the combined therapy (MMI + immunosuppressants) or only received immunosuppressants (P more than 0.05). The mean cAMP value of the healthy reference group (n = 19) is 0.4 pmol/ml +/- 0.03. There is a significant difference between this value and the cAMP values of the patients both before and after therapy (P less than 0.01). Thus, both C and P markedly lower the TSI titers of patients with EO.

Immunosuppressant therapy of thyroid eye disease

Thyroid eye disease is attributed to an autoimmune process where both cellular and humoral immunity play a role. In this report, after a short introduction dealing with immunopathogenesis of the disease, immunosuppressant therapy is discussed. Treatment with glucocorticoids (as the standard substance), nonsteroid immunosuppressants (azathioprine, cyclophosphamide, lately cyclosporin) and with the immunomodulatory substance ciamexone is reviewed. Retroorbital irradiation as a "local" immunosuppressive method and plasmapheresis are also discussed. While systemic glucocorticoids and to a lesser extent orbital radiotherapy are routinely administered for severe Graves' ophthalmopathy, nonsteroid immunosuppressants and plasmapheresis are not yet part of the established treatment of thyroid eye disease. Their use should currently remain confined to controlled studies.

Ciclosporin and prednisone v. prednisone in treatment of Graves' ophthalmopathy: a controlled, randomized and prospective study

Forty patients with Graves' ophthalmopathy stages III-V were divided into two groups in a random manner according to their year of birth. Group I received prednisone in decreasing dosage. Group II received prednisone at a comparable dosage and ciclosporin. Steroids were discontinued after 10 weeks in the two groups. In the patients of group II, ciclosporin was continued over 12 months. The therapeutic effect was assessed by an activity score based on subjective and objective symptoms (computerized tomography and sonography of the orbit, Hertel values, clinical findings). All signs of endocrine ophthalmopathy improved significantly in both groups (P less than 0.01 in group I; P less than 0.001 in group II). The improvement was significantly greater in group II (P less than 0.05) according to the predefined score. After corticosteroids were discontinued, inflammatory signs recurred in nine patients in group I and in one of group II. During the observation period of 12 months, relapses occurred in eight out of twenty patients in group I and in only one out of twenty in group II. Muscle thickness decreased in nine patients in group II, 6 months after beginning therapy. At this time, the results were not influenced in any of the twenty patients in group I. Microsomal antibodies decreased significantly (P less than 0.001) in the ciclosporin group, whereas no change was seen in the other group. Renal values rose within the normal range in group II. In this group, an infection with Klebsiella pneumoniae occurred in one patient after 4 months of therapy.(ABSTRACT TRUNCATED AT 250 WORDS)