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xx/xxx. Duration of Treatment Long term Dermatology patients: 6 moths to 1 year in majority of patients Responsibilities of the specialist initiating treatment General: • To assess the suitability of the patient for treatment. • To ensure that the patient/carer has received counselling and understands the therapy, its benefits, limitations, continued monitoring (where applicable), adverse effects. • Inform the GP of the information provided to the patient. • To review the patient as agreed intervals and copy all relevant results to the GP • Carry out disease and drug monitoring as listed below • Formally hand over to GP by letter and patient informed Prescribing: • Initiate treatment with ciclosporin. The GPs will be typically asked to take up the monitoring and prescribing of ciclosporin approximately 2 months after it. has been initiated. Disease & drug monitoring: • Monitor bloods according to schedule: • Discuss shared care arrangement with patient. • Support and advise GPs as required. • Assess response to treatment and initiate any dose changes as clinically appropriate including discontinuation of treatment. Responsibilities of the General General and Prescribing: • Monitor and prescribe as recommended by the specialist. The Blood pressure Baseline In Rheumatic and connective tissue disease Serum creatinine needs to be measured at least twice before commencing treatment. In cutaneous disease A dermatological and physical examination including blood pressure and renal function required before starting. Urinalysis FBC U+Es LFTS Urate and lipids 24 hour urine creatinine clearance Blood pressure Then every 2 weeks until stable dose reached for more than 6 weeks and no change in NSAID therapy (RA patients). U+Es FBC LFTS Lipids After the first month of treatment. Practitioner GPs will be typically asked to take up the monitoring and prescribing of ciclosporin approximately 2 months after it has been initiated or when the patient is on a stable dose. • Vaccinations – note annual influenza vaccine and single dose pneumococcal vaccine should be offered unless otherwise advised by the specialist. • If patients are exposed to chickenpox or shingles, passive immunisation should be carried out using varicella zoster immunoglobulin. Please contact consultant microbiologist for further advice or refer to the green book (chapter 34). • Notify specialist if treatment with ciclosporin is discontinued or if unable to take on shared care.. • Ensure there are no drug interacti...
xx/xxx. If you disagree with my findings you may request a hearing to appeal the decision by contacting me using the details provided.
xx/xxx. Teacher web pages have links to their email addresses. Parents must communicate by email for official communication including sending absence excuse notes. Staff may only discuss a student and student progress with the legal parents or guardians.
xx/xxx. Adverse drug reactions Many side effects associated with ciclosporin therapy are dose- dependent and responsive to dose reduction. Common Nausea, vomiting, abdominal pain, diarrhoea, gingival hyperplasia, tremor, headache, paraesthesia. • Hypertension Hypertension (BP >130/>80mmHg) is a commonly encountered adverse effect which the GP will be best placed to monitor and treat. Standard antihypertensives can be used but avoid diltiazem, nicardipine, felodipine and verapamil as they may increase plasma ciclosporin levels. • Benign gingival hyperplasia This is relatively common with ciclosporin especially when nifedipine is co-prescribed. Patients should be advised to brush their teeth twice daily. • Hirsutism Hirsutism may be a problem, particularly to dark skinned females. Facial hair bleaches and depilatory creams are safe and often effective but electrolysis should be avoided because of infection risk. • Headache, tremor, and paraesthesiae These adverse effects are frequently seen. If persistent or severe, they may reflect toxic levels of ciclosporin. In this case, the patient should be referred back to the specialist. • Hepatic dysfunction and hyperlipidaemia Hepatic dysfunction and hyperlipidaemia should be routinely monitored for. In the event of increased lipids being found, restriction of dietary fat and, if appropriate, a dose reduction, should be considered. Some statins are contra-indicated with ciclosporin or must be used at a lower dose (see under interactions) .Ciclosporin may enhance statin myopathy. • Nephrotoxicity An acute nephrotoxicity may occur with ciclosporin which is usually identified by serum creatinine monitoring and is reversible by dose reduction. If serum creatinine consistently >30% above patients baseline, decrease ciclosporin dose by 25-50%. A chronic nephrotoxicity may also occur requiring withdrawal of this drug. • Cancer risk Like all immunosuppressant’s, ciclosporin increases the risk of developing lymphomas and other malignancies, particularly those of the skin. Patients should be advised to avoid excessive exposure to the sun and use high factor sunscreens. For full list see BNF or SPC at xxx.xxxxxxxxx.xxx.
xx/xxx. 4. By entering into this Agreement you are agreeing to the terms and conditions detailed in this agreement and the PTB guidance and information. The terms and conditions may be amended from time to time in line with legislation and changes to Council policy but the Council will let you know about any such changes as soon as possible.
xx/xxx. Drug Interactions Ciclosporin is metabolised by cytochrome P450 and therefore interacts with many drugs that are also metabolised by this group of liver enzymes. The following drugs /foods increase or reduce ciclosporin levels – Interacting drugs Effects on ciclosporin blood levels Antibiotics - Erythromycin, Increased clarithromycin, azithromycin Calcium channel blockers - Increased Diltiazem, nicardipine verapamil. Lercanidipine(BNF advises to avoid) Antifungals - Fluconazole, Increased itraconazole, ketoconazole Grapefruit juice or fruit Increased Others - metoclopramide, oral Increased contraceptives, danazol, allopurinol, amiodarone, colchicine Rifampicin Decreased Antiepileptics – Carbamazepine, Decreased phenobarbital, phenytoin Anti-obesity - Orlistat Decreased St John’s Wort Decreased Other interacting agents: • Tacrolimus – contraindicated • Statins – ⮚ Simvastatin and rosuvastatin are contra-indicated with ciclosporin ⮚ Atorvastatin should be used at a maximum dose of 10mg daily in combination with ciclosporin ⮚ Pravastatin can be used to a maximum dose of 40mg daily in combination with ciclosporin • NSAIDs and other nephrotoxic drugs (e.g. aminoglycosides,amphotericin B, ciprofloxacin, trimethoprim, methotrexate (unless initiated by consultant team) • Diclofenac – see above under NSAIDS. In addition always half the dose of diclofenac when ciclosporin is co-prescribed. • Potassium-sparing medicines may exacerbate ciclosporin- induced hyperkalaemia and should only be initiated with regular monitoring of U&E’s. • Live vaccines – avoid • Digoxin, colchicine – ciclosporin may increases levels of these drugs • Grapefruit and grapefruit juice: avoid an hour before and after taking ciclosporin. For full list see BNF or SPC at xxx.xxxxxxxxx.xxx.
xx/xxx. Although you are using the online platform for reporting your dispute or your complaint with Brite, the matter will be sent to the National Board for Consumer Disputes for a decision. Further information about online dispute resolution is available at xxx.xxxxxxxxxxxxxxx.xx.
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