Voclosporin-induced gingival enlargement: A case report

Abstract

Background: Drug-influenced gingival enlargement (DIGE) is a recognized adverse effect of certain medications, particularly immunosuppressants like cyclosporin and tacrolimus. However, there have been no documented cases of DIGE associated with voclosporin, a newer calcineurin inhibitor used primarily to treat lupus nephritis.

Methods: This report describes the case of a 27-year-old female with systemic lupus erythematosus and lupus nephritis who developed significant gingival enlargement within 2 months of initiating voclosporin therapy. The patient presented with generalized gingival swelling, spontaneous bleeding, and difficulty eating, leading to her referral to a periodontics clinic. Nonsurgical periodontal therapy was initially attempted, followed by a biopsy to confirm the diagnosis.

Results: Despite nonsurgical interventions, the gingival enlargement persisted. Surgical therapy was offered but declined by the patient. Following interdisciplinary consultation, the voclosporin dosage was gradually reduced, and the drug was eventually discontinued. Marked clinical improvement was observed within 1 month after drug discontinuation, with reduced enlargement and diminished pain.

Conclusion: This case is the first to document gingival enlargement associated with voclosporin therapy. The findings emphasize the need for awareness of this potential adverse effect and highlight the importance of interdisciplinary care in managing such cases.

Key points: Voclosporin may cause gingival enlargement, similar to other calcineurin inhibitors, such as cyclosporin. With voclosporin emerging as a promising alternative for nephrologists in managing lupus nephritis, its prescription rates are likely to rise, which accentuates the importance of dental professionals being informed and vigilant about associated adverse effects on gingival tissues. Discontinuation of voclosporin should be considered, in consultation with the patient's medical team, if its oral adverse effects outweigh its therapeutic benefits, underscoring the significance of interdisciplinary cooperation and care.

Plain language summary: The gingiva (gums) is often a site in the mouth where changes or reactions can occur in response to certain systemic medications. Some drugs, particularly those used to treat autoimmune conditions or following organ transplants, can cause the gums to grow excessively, a condition known as drug-induced gingival enlargement (also known as gingival overgrowth). In this report, we document the case of a 27-year-old woman with lupus nephritis who developed gingival enlargement after starting a medication called voclosporin. This drug is a newer treatment option for lupus nephritis, but until now had not been linked to gingival enlargement. The patient experienced significant gum swelling, bleeding, and pain, making it difficult for her to eat. After trying nonsurgical treatments with limited success, and given her objection to surgical therapy, the medication was gradually stopped in consultation with her physician. The enlargement of the gums significantly improved once the drug was discontinued. This report highlights for the first time, to the authors' knowledge, the development of gingival enlargement in response to voclosporin therapy and the significant improvement of the condition upon cessation of drug usage.

Keywords: calcineurin inhibitors; gingival overgrowth; lupus nephritis; periodontal disease; systemic lupus erythematosus; voclosporin.