Ciclosporin Side Effects — SCE Dermatology MCQ
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Correct answer: C — Calcium channel blockers (Amlodipine/Nifedipine)
The correct answer is C, calcium channel blockers (amlodipine or nifedipine). Gingival hyperplasia is a recognised class effect of the dihydropyridine calcium channel blockers, with nifedipine the most frequently implicated agent and amlodipine also well documented; the mechanism relates to reduced calcium influx into gingival fibroblasts, altering collagen turnover and causing connective tissue overgrowth. This is clinically important because calcium channel blockers are commonly co-prescribed for ciclosporin-induced hypertension, and when combined with ciclosporin (itself a leading cause of drug-induced gingival hyperplasia) the effect on the gums is additive. The stem specifically asks for a drug she might reasonably be taking concurrently, and antihypertensives for ciclosporin-associated hypertension is the classic clinical scenario tested. Amlodipine is generally preferred over nifedipine or diltiazem in ciclosporin-treated patients because it has less impact on ciclosporin trough levels via CYP3A4. Why the other options are wrong: D. Oral antihistamines: these have no recognised association with gingival overgrowth and act on histamine receptors rather than fibroblast collagen metabolism. A. Methotrexate: this is an antimetabolite causing mucositis and oral ulceration, not gingival hyperplasia. E. Statins: HMG-CoA reductase inhibitors are not linked to gingival tissue overgrowth; their adverse effects relate to myopathy and hepatotoxicity. B. Paracetamol: a simple analgesic with hepatotoxicity in overdose as its main concern, with no effect on gingival tissue. Key point: alongside ciclosporin and phenytoin, calcium channel blockers (especially nifedipine, and amlodipine to a lesser extent) form the classic triad of drugs causing gingival hyperplasia, and their combined use in ciclosporin-treated hypertensive patients produces an additive risk.
Reference: NICE BNF, Nifedipine and Amlodipine, Side-effects sections: https://bnf.nice.org.uk/drugs/nifedipine/ and https://bnf.nice.org.uk/drugs/amlodipine/