Cyclosporine-Induced neurotoxicity during treatment of Crohn's disease: lack of correlation with previously reported risk factors

Medication neurotoxicity in children

Medication neurotoxicity may have a variety of imaging manifestations in children. In this pictorial essay, we review the two most common brain injury patterns, posterior reversible encephalopathy syndrome (PRES) and acute toxic leukoencephalopathy (ATL). Proposed etiologies, salient features on neurological imaging, and methods for differentiating these entities and their implications will be discussed. Certain agents do not fall into these two broad patterns but instead characteristically involve central structures. We individually review several medications and their respective neurotoxic appearances including methotrexate, cyclosporine A, tacrolimus, metronidazole and vigabatrin. Diagnosis of medication neurotoxicity may be achieved by the combination of new-onset neurological deficits, recent initiation of a new therapy agent and distinctive findings on magnetic resonance imaging. Clinical and radiological improvement and/or resolution are frequently observed after the agent is discontinued.

Neurologic manifestations in inflammatory bowel diseases: current knowledge and novel insights

BACKGROUND

Crohn's disease (CD) and ulcerative colitis (UC), widely known as inflammatory bowel diseases (IBD), are thought to result from an inappropriate activation of the mucosal immune system driven by intestinal bacterial flora.

METHODS

Although the extraintestinal manifestations of IBD are well documented, the association of IBD with neurologic and neuromuscular involvement is rare and often controversial, with sporadic and conflicting data on its prevalence and spectrum. In addition, a serious number of the latter manifestations may become life-threatening, playing a very important role in disease morbidity. To define the pattern of neurologic involvement in IBD, the most important manifestations in these patients have been reviewed, exploring also their clinical significance.

RESULTS

There is evidence that UC and CD can manifest both in the PNS and CNS. Thrombotic complications are common in IBD patients, but cerebral vascular involvement is rare.

CONCLUSIONS

Neurologic manifestations in IBD patients are more common than previously estimated and may follow a different pattern of involvement in CD and UC. Small numbers of patients currently preclude a better characterization of the clinical spectrum and a better understanding of pathogenesis.

Cyclosporine A inhibits acetylcholinesterase activity in rats experimentally demyelinated with ethidium bromide

Cyclosporine A is the major immunosuppressive agent used for organ transplantation and for the treatment of a variety of autoimmune disorders such as multiple sclerosis. In this work, we investigated the effect of the cyclosporine A on the acetylcholinesterase activity in the cerebral cortex, striatum, hippocampus, hypothalamus, cerebellum and pons of the rats experimentally demyelinated by ethidium bromide. Rats were divided into four groups: I control (injected with saline), II (treated with cyclosporine A), III (injected with 0.1% ethidium bromide) and IV (injected with 0.1% the ethidium bromide and treated with cyclosporine A). The results showed a significant inhibition (p<0.05) of acetylcholinesterase activity in the groups II, III and IV in all brain structures analyzed. In the striatum, hippocampus, hypothalamus and pons the inhibition was greater (p<0.005) when ethidium bromide was associated with cyclosporine A. In conclusion, the present investigation demonstrated that cyclosporine A is an inhibitor of acetylcholinesterase activity and this effect is increased after an event of toxic demyelination of the central nervous system.

Update in the treatment of paediatric ulcerative colitis

Ulcerative colitis is an important disease in the paediatric population. Ulcerative colitis is one of the chronic inflammatory bowel diseases, and is medically incurable. However, the arsenal of medications has grown as knowledge of the pathogenesis of this disease advances. This review looks at the classical treatments for children with ulcerative colitis, including the 5-aminosalicylates, corticosteroids and imunomodulators, as well as biological therapy and other, newer modalities.

Postoperativ aufgetretene reversible posteriore Enzephalopathie bei einem Patientin mit Morbus Crohn

Posterior encephalopathy (PE) is a rare condition with different origins and unknown pathogenesis. We report on a case of a 16-year-old boy with Crohn's disease who developed PE after peridural anesthesia with ropivacain. A possible connection between PE, ropivacain and Crohn's disease is discussed on the basis of the current literature.

Review article: how and when to use ciclosporin in ulcerative colitis

Although colectomy for ulcerative colitis is curative, long-term quality of life is reduced. Intravenous ciclosporin 4 mg/kg/day has significant toxicity. There is now evidence that low-dose ciclosporin (2 mg/kg daily by intravenous infusion, or 5-6 mg/kg daily in a twice daily oral dosage) has an acceptable safety profile, even when used in combination with corticosteroids. Drug dosage should be adjusted to the levels of 150-250 ng/mL initially (random levels during intravenous infusion, or trough levels for oral use). Ciclosporin should be considered not only in those who have failed 7 days of corticosteroids, but also in fulminant colitis at day 3, if not responding to corticosteroids. The drug should be avoided in frail or elderly patients with significant comorbidity, and also where colectomy is likely to be necessary in the short to medium term. Ciclosporin should not be continued for more than 7 days, unless there is a definite response. A 70-80% initial response is likely, and responders are discharged on oral ciclosporin, adding thiopurines and tailing prednisolone rapidly. The drug should be continued for 3 months. The likelihood of avoiding colectomy over 2-3 years is 40-50%. More studies are needed to evaluate the use of oral ciclosporin in corticosteroid-refractory colitis in out-patients, and to assess whether monotherapy (without corticosteroids) is significantly safer, without loss of efficacy.

Cyclosporine, tacrolimus, and mycophenolate mofetil in the treatment of inflammatory bowel disease

In the past decade, immunosuppressive drugs have come to play an integral role in the treatment of patients with inflammatory bowel disease. Cyclosporine, microemulsion cyclosporine, tacrolimus, and mycophenolate mofetil can be considered for the treatment of patients with refractory inflammatory Crohn's disease, fistulizing Crohn's disease, and severe ulcerative colitis. This article reviews the use of cyclosporine, tacrolimus, and mycophenolate mofetil in patients with inflammatory bowel disease, with emphasis on pharmacology, results in controlled clinical trials, and safety, and issues related to dosing and toxicity monitoring.

Current therapy of ulcerative colitis in children

Ulcerative colitis presents in childhood in 10% of those affected, usually with pancolitis. Important features in management include growth, development and avoidance of treatment toxicity. This review addresses the current treatment options including both the paediatric evidence-based experience and areas where paediatric practice is informed by adult studies. Standard treatments include sulfasalazine or 5-aminosalicylates, corticosteroids, purine derivatives (azathioprine or 6-mercaptopurine) and surgery. Other immunosuppressant therapies and the emerging roles for biological therapies and probiotics are discussed.

[Posterior reversible encephalopathy syndrome: about 2 cases related to the cyclosporine]

Following a pulmonary transplantation for cystic fibrosis, 2 patients exhibited a syndrome associating arterial hypertension, headache, visual trouble and generalized seizures. Cerebral magnetic resonance imaging revealed diffuse cortical and subcortical lesions predominantly in posterior regions. The exclusion of alternate diagnoses and the disappearance of the symptoms when the cyclosporine treatment was stopped confirmed the diagnosis of cyclosporine-related reversible posterior encephalopathy syndrome (PRES). Immediate appropriate management resulted in symptom disappearance and regression of radiological images.

The use of ciclosporin in paediatric inflammatory bowel disease: an Italian experience

AIM

To asses the efficacy and safety of ciclosporin in a paediatric population with inflammatory bowel disease.

PATIENTS AND METHODS

Twenty-three Italian children treated with ciclosporin were studied retrospectively. The indications for treatment were severe unresponsive colitis, chronic active colitis or severe fistulizing Crohn's disease. The treatment duration, follow-up and causes of drug discontinuation were assessed.

RESULTS

Sixteen patients were treated intravenously for a mean time of 10 +/- 7 days (1-24 days) and 19 orally for a mean time of 133 days (17-660 days). The mean follow-up of all patients was 13.2 months. Ciclosporin was totally ineffective, being discontinued for surgery, in nine of 23 patients (39%); it was discontinued for partial response in three patients (13%). During treatment, clinical remission was achieved in eight children (35%) and maintained after drug withdrawal in four (17%). In severe unresponsive colitis, urgent colectomy was avoided in 12 (85%) of 14 patients who tolerated the drug. Side-effects appeared in six of 23 patients (26%), and three (13%) required ciclosporin to be discontinued due to neurotoxicity.

CONCLUSIONS

Ciclosporin shows disappointing long-term results in the treatment of refractory inflammatory bowel disease, but can play an important role in preventing urgent surgery in unresponsive severe colitis. Severe side-effects can occur.

Therapy of Crohn's disease in childhood

Crohn's disease in childhood is a chronic relapsing and remitting condition that can significantly impact on normal growth and development. This influences the choice of both initial and ongoing management. The goal of therapy is to induce and maintain remission with minimal side effects. Enteral nutrition as the sole therapy for active disease is effective in some children, thus avoiding the use of corticosteroids. In disease that is resistant to conventional treatment, immunosuppression or anti-tumour necrosis factor therapy is indicated. We review the use of these treatments and discuss the new therapies being developed, including antibodies, cytokines and probiotics.