Drug-Induced Pemphigus Medication
- Author: Diane M Scott, MD; Chief Editor: Dirk M Elston, MD more...
For patients in whom the disease does not resolve upon withdrawal of the offending agent, medical therapy is necessary. Generally, systemic corticosteroids or other immunosuppressants are required. Anecdotal reports support the use of alternate immunomodulating agents (eg, antimalarial drugs, rituximab, intravenous immunoglobulin, mycophenolate mofetil). Recent reports suggest targeting cholinergic drugs as antiacantholytic therapy for idiopathic pemphigus.
Systemic corticosteroids (eg, prednisone) should be initiated in patients with disease that persists after the implicated agent has been discontinued. Since most cases of drug-induced pemphigus involve an immune mechanism, the anti-inflammatory and immune modulating properties of corticosteroids are beneficial. In idiopathic pemphigus vulgaris and pemphigus foliaceus, high doses of systemic corticosteroids may be needed. This also may be necessary for cases of drug-induced pemphigus.
Prednisone is the initial drug of choice for severe or recalcitrant cases of drug-induced pemphigus. It is an immunosuppressant for the treatment of autoimmune disorders, and it may decrease inflammation by reversing increased capillary permeability and suppressing PMN activity. Prednisone stabilizes lysosomal membranes and suppresses lymphocytes and antibody production. It up-regulates keratinocyte adhesion molecules desmoglein 1 and 3.
Immunosuppressants are for patients who do not respond to moderate doses of systemic steroids or for patients in whom steroids are contraindicated. They also are used as steroid-sparing agents.
Azathioprine antagonizes purine metabolism and inhibits synthesis of DNA, RNA, and proteins. It may decrease the proliferation of immune cells, which results in lower autoimmune activity. Azathioprine is useful in steroid-resistant patients. It is less toxic than some other immunosuppressants. Generally, it is used in conjunction with low doses of systemic corticosteroids.
Prior measurement of thiopurine methyltransferase (TPMT) levels can be useful in guiding the initial dose.
Cyclophosphamide is chemically related to nitrogen mustards. As an alkylating agent, the mechanism of action of the active metabolites may involve cross-linking of DNA, which may interfere with growth of normal and neoplastic cells. Cyclophosphamide is effective in treating pemphigus; however, this drug also is very toxic.
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