Blood Cyclosporine Concentrations Research Articles

Effects of Miconazole Oral Gel on Blood Concentrations of Tacrolimus and Cyclosporine: A Retrospective Observational Study.

Although azole antifungal agents have been shown to affect the pharmacokinetics of calcineurin inhibitors such as tacrolimus (TAC) and cyclosporine (CyA) by inhibiting drug metabolism, there are few clinical reports on drug interactions between miconazole (MCZ) oral gel and calcineurin inhibitors. In this study, the effects of MCZ oral gel on the blood concentrations of TAC and CyA were investigated. In this retrospective study, 18 patients concomitantly administered MCZ oral gel and TAC (9 for dermatomyositis, 3 for myasthenia gravis, 2 for systemic lupus erythematosus, 2 for rheumatoid arthritis, 1 for polymyositis, 1 for prevention of graft-versus-host disease after bone marrow transplantation), and 15 patients concomitantly administered MCZ oral gel and CyA (11 for interstitial pneumonia, 2 for pemphigus, 1 for eosinophilic granulomatosis with polyangiitis, 1 for systemic lupus erythematosus) were evaluated. The dose-adjusted blood concentrations of TAC or CyA were compared before and after the initiation of MCZ oral gel. The trough blood concentration/dose (C/D) ratios of TAC and CyA increased significantly with the administration of MCZ oral gel. The median C/D ratios of TAC and CyA increased by 108% (range: -44% to 216%) and 44% (range: -34% to 195%), respectively. These results suggest that MCZ oral gel affects the pharmacokinetics of TAC and CyA. Detailed monitoring of the blood concentrations of these drugs, followed by dose adjustments, is needed for each patient because of the difficulties associated with accurately predicting the degree of the effects of MCZ oral gel.

CD4 T-HELPER CELL COUNT IS AN ALTERNATIVE PROMISING MARKER FOR DOSING CYCLOSPORINE IN KIDNEY TRANSPLANT PATIENT

CD4 T-HELPER CELL COUNT IS AN ALTERNATIVE PROMISING MARKER FOR DOSING CYCLOSPORINE IN KIDNEY TRANSPLANT PATIENT

Blood concentration of cyclosporine during early post-transplant period may have influence on the occurrence of chronic graft versus host disease in patients who received allogeneic hematopoietic stem cell transplantation.

IntroductionIt has rarely been studied that how the blood level of CsA affect the incidence of chronic GVHD after allogeneic hematopoietic stem cell transplantation (allo-HSCT).MethodsA total of 183 patients who underwent allo-HSCT from an HLA-matched or haplo matched family donors between 2006 and 2014 were reviewed.ResultsThe average monthly CsA blood concentration (CsAavr, ng/ml) was calculated in each patient: 0-1, 1-2, and 2-3 months after allo-HSCT. CsAavr at the first month showed significant association with the occurrence of moderate to severe cGVHD in multivariate analysis adjusted for gender, age, total body irradiation, anti-thymocyte globulin, acute GVHD ≥ grade 2 and CsAavr levels of other periods. The risk of cGVHD development was lowest in patients with CsAavr of 200-250 ng/ml when compared to those with CsAavr of ≥ 250 or < 200 ng/ml (p=0.003).ConclusionsCsA level between 200 and 250 mg/ml during the first month after transplantation was significantly associated with the decreased risk of moderate to severe cGVHD.

Comparison of the efficacy of prednisone and cyclosporine for treatment of dogs with primary immune-mediated polyarthritis.

To compare efficacy between cyclosporine and prednisone for treatment of primary immune-mediated polyarthritis (IMPA) in dogs. Randomized controlled clinical trial. 20 client-owned dogs with primary IMPA. Dogs were randomly assigned to receive prednisone (starting at 1 mg/kg [0.45 mg/lb], PO, q 12 h; n = 10) or cyclosporine (5 mg/kg [2.3 mg/lb], PO, q 12 h; 10) for 90 days. Cyclosporine-treated dogs also received carprofen, tramadol, or both for the first 7 days for analgesia. Data collection, physical examination, and cytologic analysis of synovial fluid samples were performed on days 0, 14, 45, and 90. Trough whole blood cyclosporine concentrations were determined on days 7 to 17 for cyclosporine-treated dogs. Treatment failure was defined as lack of clinical improvement by day 14, lack of cytologic improvement by day 45, or need to change treatment because of adverse effects. Treatment was successful for 7 prednisone-treated dogs and 7 cyclosporine-treated dogs. Absence of synovial fluid cytologic abnormalities on day 45 was identified for 5 prednisone-treated dogs and 8 cyclosporine-treated dogs. Prednisone-treated dogs were more likely to develop polyuria, polydipsia, and polyphagia than were cyclosporine-treated dogs. Opportunistic infections (ie, demodicosis or Erysipelothrix bacteremia) were identified in 2 cyclosporine-treated dogs and 0 prednisone-treated dogs, and diarrhea developed in 1 cyclosporine-treated dog, requiring treatment discontinuation. Although the number of dogs evaluated was small, limiting generalizability, results of this study suggested that cyclosporine offers promise as a suitable alternative to prednisone for treatment of IMPA in dogs.

Rhubarb decreased the systemic exposure of cyclosporine, a probe substrate of P-glycoprotein and CYP 3A

1. Rhubarb, rhizome of Rheum palmatum L. (RP), is an important herb in clinical Chinese medicine.2. Cyclosporine (CSP) is an immunosuppressant with narrow therapeutic window. The oral bioavailability of CSP was associated with P-glycoprotein (P-gp) and CYP 3A4. CSP was used as a probe substrate to investigate the in vivo modulation effects of RP on P-gp and CYP 3A.3. Rats were orally administered 2.5 mg/kg of CSP with and without 0.25 and 1.0 g/kg of RP. The blood CSP concentration was determined by a specific monoclonal fluorescence polarization immunoassay.4. Both dosages of RP significantly decreased the Cmax and AUC0–t of CSP in rats. Mechanism studies indicated that RP activated the functions of P-gp and CYP 3A.5. RP ingestion reduced the systemic exposure of CSP through activating P-gp and CYP 3A.

Association of SNPs with the efficacy and safety of immunosuppressant therapy after heart transplantation.

Studying the possible influence of SNPs on efficacy and safety of calcineurin inhibitors upon heart transplantation. In 60 heart transplant patients treated with tacrolimus or cyclosporine, we studied a panel of 36 SNPs correlated with a series of clinical parameters during the first post-transplantation year. The presence of serious infections was correlated to ABCB1 rs1128503 (p = 0.012), CC genotype reduced the probability of infections being also associated with lower blood cyclosporine concentrations. Lower renal function levels were found in patients with rs9282564 AG (p = 0.003), related to higher blood cyclosporine blood levels. A tendency toward increased graft rejection (p = 0.05) was correlated to rs2066844 CC in NOD2/CARD15, a gene related to lymphocyte activation. Pharmacogenetics can help identify patients at increased risk of clinical complications. Original submitted 30 January 2015; revision submitted 27 March 2015.

Model-Based Determination of Effective Blood Concentrations of Cyclosporine for Neutrophil Response in the Treatment of Severe Aplastic Anemia in Children.

Optimal immunosuppressive therapy in acquired severe aplastic anemia (SAA) remains to be refined, especially cyclosporine (CsA) use. Current recommendations state that CsA trough blood concentrations (TBC) should be maintained between 200 and 400 ng/mL despite the lack of supporting data. This study aimed at quantifying relationships between CsA exposure and neutrophil response and determining an effective range for CsA TBC. Twenty-three SAA patients treated with CsA were retrospectively analyzed. Nonlinear mixed effect modeling approaches were used to develop a pharmacokinetic-pharmacodynamic model. The pharmacokinetic model described the relationships between CsA doses and TBC. The pharmacodynamic model allowed to estimate boundaries for optimal CsA effects, neutrophils being used as biomarker of response. A time-to-event model linked effective concentration to time-to-therapeutic success. CsA TBC were adequately described by a two-compartment model with first-order absorption, a lag time, and a linear elimination. The efficient range of CsA TBC was estimated between 87 and 120 ng/mL. Model-based simulations and external validation in three additional patients confirmed these results. This original modeling approach was successful in describing the relationship between CsA TBC and neutrophil response in SAA patients. Although further evaluation of the model is necessary, this work suggests that an optimal CsA TBC target of 100 ng/mL would be associated with a better neutrophil response in children with SAA.

CYP3A4∗18B and CYP3A5∗3 polymorphisms contribute to pharmacokinetic variability of cyclosporine among healthy Chinese subjects

AimCyclosporine is an immunosuppressant drug used to prevent allograft rejection. It is metabolized by CYP3A4 and CYP3A5, has a narrow therapeutic index, and variable pharmacokinetics. Here, we investigated whether CYP3A5∗3 and CYP3A4∗18B polymorphisms contribute to inter-individual pharmacokinetic variability in healthy subjects. Patients and methodsFifty-six healthy Chinese subjects were enrolled in the study after signing a written consent. The subjects received 5mgkg−1 of cyclosporine orally and were genotyped for CYP3A5∗3 and CYP3A4∗18B using polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP). Blood concentrations of cyclosporine were measured by high-performance liquid chromatography for up to 30h post-dose. ResultsThe mean cyclosporine AUC0→30 and AUC0→∞ in the male group was significantly higher than that in the female group (P=0.037 and 0.035); the CL/F in the male group was significantly lower than that in the female group (P=0.033). The Cmax of cyclosporine in CYP3A4∗1/∗1 was significantly greater than that in CYP3A4∗1/∗18B in the male group (P=0.023), but not the female group. In addition, the Cmax in CYP3A5∗1/∗3 was significantly lower than that in CYP3A5∗3/∗3 in the male group (P=0.01). ConclusionsThe results indicate that gender and polymorphism in CYP3A4∗18B and CYP3A5∗3 significantly affect cyclosporine pharmacokinetics in healthy subjects.

Effect of oral administration of cyclosporine on Toxoplasma gondii infection status of cats.

To evaluate whether anti-inflammatory doses of cyclosporine activate Toxoplasma gondii in chronically infected cats or potentiate infection in cats exposed for the first time. 30 T gondii-negative cats. Cats were assigned to 1 of 3 groups (10 cats/group). Group 1 (control) cats were administered a placebo for 126 days; group 2 cats were administered a placebo for 84 days, followed by cyclosporine at 7.5 mg/kg/d, PO, for 42 days; and group 3 cats were administered cyclosporine at 7.5 mg/kg/d, PO, for 126 days. Cats were orally inoculated with T gondii on day 42. Results for fecal flotations, PCR assays, and histologic examinations and IgM and IgG titers were analyzed. Cyclosporine concentrations were measured on selected days. All cats were infected by T gondii and developed signs of self-limiting gastrointestinal tract infection. Group 3 had the highest incidence and severity of CNS and pulmonary histopathologic findings typical of toxoplasmosis. One cat in group 3 died of systemic toxoplasmosis; that cat had a cyclosporine concentration of 1,690 ng/mL. Group 2 cats infected with T gondii before cyclosporine administration did not have repeated oocyst shedding. Group 3 cats shed fewer oocysts for a shorter time than did control cats of group 1. Oral administration of cyclosporine in accordance with the protocol for this study did not potentiate the enteroepithelial phase of T gondii infection. Cats with high cyclosporine blood concentrations at the time of primary T gondii infection may be at risk of developing systemic toxoplasmosis.

CASE REPORT: LOW DOSE CYCLOSPORINE COMBINED KETOCONAZOLE CURES A DOG OF STERILE NODULAR PANNICULITIS

An eight-year-old neutered male Cocker Spaniel with multiple subcutaneous masses on the right flank was presented to National Taiwan University Veterinary Hospital. The masses were excised and submitted for histopathologic evaluation and bacterial culture. A diagnosis of severe panniculitis was made and no microorganism was identified with bacterial culture. The patient did not respond well and showed significant side effects from prednisolone therapy. Later, low-dose cyclosporine was used instead and the lesions resolved. Complete remission was observed when ketoconazole was added in order to increase the blood concentration of cyclosporine in the patient. There were no adverse side effects noted during this combination therapy. The patient has remained free of the disease at the time this report was written. In conclusion, low-dose cyclosporine combined with ketoconazole therapy is safe and effective for treating sterile nodular panniculitis, when glucocorticoid does not provide an adequate clinical result.

PRES Induced by Cyclosporin with Normal Blood Concentrations in a Bone Marrow Recipient

Introduction: Posterior reversible encephalopathy syndrome (PRES) is a clinic neuroradiological entity. This syndrome occurs in complex conditions as allogenic bone marrow transplantation, organ transplantation and immunosuppressant therapy such as cyclosporin (CsA). The occurrence of PRES is favored by a high concentration of CsA. Therefore, therapeutic monitoring of CsA is necessary to effects due to overdose. The therapeutic range of CsA is between 150-300 ng/mL. We aimed to present a case PRES induced by CsA in bone marrow transplantation with normal cyclosporine blood concentrations. Case: A 26 years old man received an allogenic bone marrow for bone marrow aplasia in January 2013. He was treated by CsA. Mean CsA dose was 2.57 mg/kg/day. CsA mean blood concentration was 295 ng/mL. After 20 days, our patient presented a complex partial seizure and cortical abnormal. He had no history of head injury, epilepsy or hypertension and there was no family history of neurological or psychiatric disorders. Patient’s blood pressure wasn’t measured. CsA was stopped. He received mycophenolate acid and clonazepam. Seizure and abnormal vision vanished 10 days later. Whereas, the patient developed graft-versus-host disease (GVHD). Then, mycophenolate acid was stopped 1.5 month later and CsA taken back. CsA mean dose was 1.1 mg/kg/day. Mean CsA blood concentration was 167.71 ng/mL. After two months, the patient developed general seizures and in Magnetic Resonance Imaging (MRI) there was a low-density in the subcortical white matter areas. So, CsA was stopped once and for all and the seizures vanished few days later. Conclusion: PRES is responsible for various and no specific neurological symptoms. These symptoms are usually reversible but sometimes fatal. Therapeutic monitoring of CsA was necessary to avoid neurotoxicity depending of concentration but we must remain cautious even if patients have CsA blood concentrations in the therapeutic range.

Effect of Blood Concentration of Cyclosporine A on Cyclosporine A Combined with Male Hormone and Compound Ferrous Sulfate in Treatment of Aplastic Anemia

Objective To study effect of blood concentration of cyclosporine A on cyclosporine A combined with male hormone and compound ferrous sulfate in treatment of aplastic anemia (AA),providing reference for rational use of cyclosporine A.Methods From January 2010 to December 2013,a total of 126 cases with AA were selected into this study,all of whom were given cyclosporine A combined with male hormone and compound ferrous sulfate therapy.Treatment effect was observed at two months,three months and six months of treatment.And blood concentration of cyclosporine A was compared between effective and ineffective group.Influences of different blood concentration of cyclosporine A on treatment outcome were compared.The study protocol was approved by the Ethical Review Board of Investigation in Human Being of Canglang Hospital of Suzhou.Informed consent was obtained from all participants.There were no signifcant differences of patients' general clinical features between severe AA patients and nonsevere AA patients (P＞0.05).Results At six months of immunotherapy with cyclosporine A combined with male hormone and compound ferrous sulfate,the effective rate (78.86 ％) was significantly higher than those at 2 months and 3 months (P＜0.05).The effective rate of non-severe AA patients at two months,three months and six months of treatment were 83.10％,88.72％ and 95.71％,respectively,and all of them were significantly higher than that of severe AA patients (P＜0.05).At 3 months of treatment,blood trough concentration and blood peak concentration of cyclosporine A in effective group were (198.87 ±68.45) μg/L and (742.15±188.95) μg/L,respectively,and both of them were significantly higher than those in ineffective group (P＜0.05).The effective rate of blood trough concentration ≥200 μg/L group (94.83 ％) was significantly higher than that of blood trough concentration ＜200 μg/L group (P＜0.05).The effective rate of blood peak concentration ≥700 μg/L group (92.31％) was significantly higher than that of blood peak concentration ＜700 μg/L group.Conclusions Blood concentration of cyclosporine A is associated with the treatment outcome of cyclosporine A combined with male hormone and compound ferrous sulfate in AA patients.Blood trough concentration ≥200 μg/L and blood peak concentration ≥700 μg/L can be a good therapeutic window. Key words: Anemia, aplastic; Cyclosporine; Compound ferrous sulfate; Plasma concentration; Therapeutic window

Efficacité et tolérance de la lacidipine dans le traitement de l’hypertension artérielle en onco-hématologie pédiatrique

In adults, lacidipine seems to have no CYP3A4-inhibiting action. This particular characteristic makes it advantageous when combined with drugs metabolized by CYP3A4, such as cyclosporine. Until now, no data on the efficacy or safety of this calcium antagonist have been available in children. Thirty-nine hypertensive children (age: 0.13-14years) receiving lacidipine in oncohematology for a mean of 75days were included in this retrospective study. The causes of high blood pressure were renal tumor (n=7), catecholamine-secreting tumor (n=4), corticoid treatment (n=5), and cyclosporine treatment (n=23). An initial dosage of 0.05mg/kg/day was sufficient for 41% of the patients. The remaining patients needed to increase the dosage, by steps of 0.03mg/kg/day, until reaching an average effective dosage of 0.1mg/kg/day. Lacidipine significantly decreased blood pressure by 30 (±14)mmHg for systolic blood pressure and by 26 (±13)mmHg for diastolic blood pressure. A medication plan with twice-daily administration was not significantly more effective than a single administration per day. Lacidipine was well tolerated, and no toxicity-related withdrawal of treatment occurred. For 22patients treated with both cyclosporine and lacidipine, renal function was not disturbed over time, suggesting its preservation by lacidipine. No significant increase in cyclosporine blood concentration was detected. Lacidipine seems to be an effective calcium antagonist in pediatric oncohematology, is well tolerated, has a kidney-protector effect and no drug interaction when combined with cyclosporine.

Pharmacokinetic interaction study of ticagrelor and cyclosporine in healthy volunteers.

Patients with acute coronary syndrome and certain co-morbidities may receive ticagrelor, a reversibly binding P2Y(12) receptor antagonist, and cyclosporine, a commonly used immunosuppressant drug. This study assessed the potential pharmacokinetic drug-drug interaction between ticagrelor and cyclosporine. In this single-centre, open-label, three-treatment, three-period crossover study (NCT01504906), healthy volunteers (n = 26) randomly received each of three treatments: cyclosporine (600 mg single oral dose) plus ticagrelor (180 mg single oral dose); cyclosporine alone; ticagrelor alone. Treatments were separated by a washout period of ≥14 days. Plasma concentrations of ticagrelor and its active metabolite (AR-C124910XX) and blood concentrations of cyclosporine were analyzed, and pharmacokinetic parameters were calculated. Safety and tolerability were assessed. Compared with ticagrelor alone, the geometric least squares mean (LSM) ratio (90 % confidence interval [CI]) for the ticagrelor area under the plasma concentration-time curve from time zero to infinity (AUC(∞)) was 2.83 (2.63-3.06), and the maximum plasma concentration (C(max)) was 2.30 (2.06-2.58), in the presence of cyclosporine. Co-administration of cyclosporine with ticagrelor significantly increased AR-C124910XX AUC(∞) (1.33 [1.23-1.42]) and decreased C(max) (0.85 [0.76-0.94]). Ticagrelor had no effect on cyclosporine pharmacokinetic parameters, as the 90 % CIs of the LSM ratios were all within the 0.80-1.25 no-effect range. Co-administration of ticagrelor and cyclosporine was generally well tolerated. Co-administration of cyclosporine with ticagrelor increased exposure to ticagrelor and its active metabolite and had no effect on cyclosporine pharmacokinetic parameters. The magnitude of cyclosporine's effect on ticagrelor pharmacokinetics does not warrant dose adjustment of ticagrelor.

Tu1232 Expressions of CYP3A and P-Glycoprotein Were Decreased in the Secondary Inflammatory Response of Dextran Sodium Sulfate-Induced Mice Colitis and Its Contribution to the Blood Concentration of Cyclosporine A

Background: Small intestinal lesions induced by NSAIDs are of great concern in clinical settings. Various hypotheses, mainly of which related to the inhibition of prostaglandin synthesis, have been proposed for the origin of these inflammatory responses, however, the precise mechanism is yet to be known. The cellular process of the lesions must involve upand down-regulations of a large number of proteins and complex interactions between them. To elucidate it, global and systematic identification of the proteins in intestinal cells affected by non-steroidal anti-inflammatory drugs (NSAIDs) is essential. Two-dimensional polyacrylamide gel electrophoresis allows the analysis of total proteins from both cells and tissues, so it can help to elucidate the complex interactions and mechanisms inside cells. Aims: To identify the proteins that play a critical role in NSAIDs toxicity in intestinal cells and to clarify the mechanism of intestinal mucosal injuries induced by NSAIDs. Materials and Methods: We performed 2-DE on IEC-6 rat normal intestinal cells that were treated with indomethacin (200 μΜ, 24 h) or a vehicle control. The differentially displayed proteins were identified through matrix-assisted laser desorption/ionization-time of flight mass spectrometry. Results: We found 18 up-regulated and 8 down-regulated proteins that showed a statistically significant difference of p < 0.05 and a ≥1.5 average fold difference in spot volume as a result of indomethacin treatment. Among these, we found that collagen I and the proteins involved in collagen I synthesis and maturation were all down-regulated. Consistent with this, immunohistochemical analysis showed that the indomethacin-treated rat intestinal mucosal cells exhibits decreased collagen I expression on its apical surface. Furthermore, the cell-protective effect of collagen I on intestinal mucosal cells was demonstrated by the use of a collagen-synthesis inhibitor and cell cultivation on collagen-coated plates versus uncoated plates. Conclusions: For the first time in the literature, a proteomic approach was employed to identify the global proteome alterations of the intestinal mucosa using indomethacin-treated and untreated IEC-6 cells. These results show that collagen I may play an important role in cytoprotection against indomethacin-induced intestinal mucosal injury. Insights gained from the current study may facilitate the development of new therapeutic strategies against NSAID-induced intestinal injury.

Once-daily oral administration of cyclosporine in a lung transplant patient with a history of renal toxicity of calcineurin inhibitors: Figure 1:

Cyclosporine is usually administered orally in two divided doses every 12 h in transplant patients. However, some patients have difficulty in achieving therapeutic levels after transplantation. In fact, cyclosporine is reportedly administered once daily in renal and liver transplantation cases, but not in lung transplantation cases. We report a patient with a history of calcineurin inhibitor-induced renal toxicity who successfully underwent living-donor lobar lung transplantation (LDLLT) with the novel immunosuppressive strategy of once-daily administration of cyclosporine. An 18-year old man with progressive respiratory insufficiency after bone marrow transplantation was referred to our hospital for lung transplantation. He had a history of renal toxicity due to calcineurin inhibitors. Based on his history of tacrolimus- and cyclosporine-induced renal toxicity, we decided to initiate basiliximab as induction therapy, followed by once-daily cyclosporine administration to obtain high enough blood cyclosporine concentrations at 2 h post-dose (C2) and lowered trough blood concentrations (C0) for protection of renal function as maintenance therapy. LDLLT was successfully performed, and the postoperative course was uneventful and free of rejection episodes. Cyclosporine dosing was adjusted with intensive therapeutic drug monitoring of blood cyclosporine levels. One year after LDLLT, the patient is alive and well with no problems with daily life activities.

Absorption of Transdermal and Oral Cyclosporine in Six Healthy Cats

Cyclosporine is commonly used orally to treat feline dermatoses. Due to difficulties administering oral medications, veterinarians sometimes prescribe compounded transdermal cyclosporine, despite studies showing limited absorption. The study objective was to compare cyclosporine blood concentrations after oral administration to concentrations after transdermal application of cyclosporine (prepared in pluronic lecithin organogel [PLO]) in six cats using a controlled, cross-over design with a 2 wk washout period. Cats were dosed at 5.1-7.4 mg/kg of cyclosporine q 24 hr either per os for 7 days or transdermally for 21 days. Cyclosporine blood concentrations were measured q 7 days and after the washout period. A monoclonal-based immunoassay (lower limit of quantitation was 25 ng/mL) was used. Median concentrations on the seventh day were 2,208 ng/mL (range, 1,357-3,419 ng/mL) 2 hr after orally administered cyclosporine and 37 ng/mL (range, 25-290 ng/mL) 2 hr after transdermally applied cyclosporine. Median concentration on day 21 was 58 ng/mL (range, 51-878 ng/mL) 2 hr after transdermally applied cyclosporine. Concentrations were quantifiable for transdermally applied cyclosporine, but considered therapeutic in only one of six cats. Based on those results, transdermally applied cyclosporine was not recommended in cats because of inconsistent absorption.

Successful Telaprevir Treatment in Combination of Cyclosporine against Recurrence of Hepatitis C in the Japanese Liver Transplant Patients

Telaprevir (TVR) is a protease inhibitor used in combination with pegylated interferon alfa-2b and ribavirin for hepatitis C, and TVR strongly inhibits CYP3A4 and CYP3A5. We reported successful TVR treatment of liver transplant patients with recurrence of hepatitis C during receiving immunosuppressive therapy. Before initiation of triple therapy, all patients switched from tacrolimus to cyclosporine, which has a lower inhibitory effect on CYP3A4 and CYP3A5 than tacrolimus. To avoid graft failure, we measured the cyclosporine blood concentrations at 0, 2, and 6 h after administration to maintain the target level (150-200 ng/mL) within 1 week after initiation of TVR and adjusted the dose of cyclosporine. The dose of cyclosporine was decreased 0.24-0.40 fold in all patients after initiation of TVR treatment. In 3 patients, the dose of TVR was decreased two-thirds of starting dose because of adverse effects, including anorexia and skin rash. However, the HCV RNA level rapidly decreased to undetectable levels within 1 month. Furthermore, all patients completed the TVR therapy in 12 weeks and did not experience liver graft rejection. In addition, we found the rapid elimination of inhibitory effect of TVR on the disposition of cyclospirne in the all four cases and therefore, rapid increase in the dosage of cyclosporine would be required immediately after the end of TVR administration. These results suggest that frequent measurement of cyclosporine levels was important for successful TVR triple therapy and prevention of rejection.

Significance of combined cyclosporine−prednisolone therapy and cyclosporine blood concentration monitoring for idiopathic membranous nephropathy with steroid-resistant nephrotic syndrome: a randomized controlled multicenter trial

BackgroundCombined treatment with cyclosporine microemulsion preconcentrate (CyA MEPC) and steroids has been widely used for idiopathic membranous nephropathy (IMN) associated with steroid-resistant nephrotic syndrome (SRNS). Recent studies have shown that once-a-day and preprandial administration of CyA MEPC is more advantageous than the conventional twice-a-day administration in achieving the target blood CyA concentration at 2 h post dose (C2). We designed a randomized trial to compare these administrations.MethodsIMN patients with SRNS (age 16–75 years) were divided prospectively and randomly into 2 groups. In group 1 (n = 23), 2–3 mg/kg body weight (BW) CyA MEPC was given orally once a day before breakfast. In group 2 (n = 25), 1.5 mg/kg BW CyA MEPC was given twice a day before meals. CyA + prednisolone was continued for 48 weeks.ResultsGroup 1 showed a significantly higher cumulative complete remission (CR) rate (p = 0.0282), but not when incomplete remission 1 (ICR1; urine protein 0.3–1.0 g/day) was added (p = 0.314). Because a C2 of 600 ng/mL was determined as the best cut-off point, groups 1 and 2 were further divided into subgroups A (C2 ≥600 ng/mL) and B (C2 <600 ng/mL). Groups 1A and 2A revealed significantly higher cumulative remission (CR + ICR1) (p = 0.0069) and CR-alone (p = 0.0028) rates. On the other hand, 3 patients with high CyA levels (C2 >900 ng/mL) in Group 1A were withdrawn from the study because of complications.ConclusionCyA + prednisolone treatment is effective for IMN with associated SRNS at a C2 of ≥600 ng/mL. To achieve remission, preprandial once-a-day administration of CyA at 2–3 mg/kg BW may be the most appropriate option. However, we should adjust the dosage of CyA by therapeutic drug monitoring to avoid complications.

Oral Cyclosporine Treatment in Dogs: A Review of the Literature

Cyclosporine is an immunomodulatory drug used to treat an increasing spectrum of diseases in dogs. Cyclosporine is a calcineurin inhibitor, ultimately exerting its inhibitory effects on T‐lymphocytes by decreasing production of cytokines, such as interleukin‐2. Although, in the United States, oral cyclosporine is approved in dogs only for treatment of atopic dermatitis, there are many other indications for its use. Cyclosporine is available in 2 oral formulations: the original oil‐based formulation and the more commonly used ultramicronized emulsion that facilitates oral absorption. Ultramicronized cyclosporine is available as an approved animal product, and human proprietary and generic preparations are also available. Bioavailability of the different formulations in dogs is likely to vary among the preparations. Cyclosporine is associated with a large number of drug interactions that can also influence blood cyclosporine concentrations. Therapeutic drug monitoring (TDM) can be used to assist in attaining consistent plasma cyclosporine concentrations despite the effects of varying bioavailability and drug interactions. TDM can facilitate therapeutic success by guiding dose adjustments on an individualized basis, and is recommended in cases that do not respond to initial oral dosing, or during treatment of severe, life‐threatening diseases for which a trial‐and‐error approach to dose adjustment is too risky. Pharmacodynamic assays that evaluate individual patient immune responses to cyclosporine can be used to augment information provided by TDM.