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Questions & Answers
Side Effects & Adverse Reactions
Kidney, Liver and Heart Transplant
(See boxed WARNINGS.)
Cyclosporine capsules, (NON-MODIFIED), when used in high doses, can cause hepatotoxicity and nephrotoxicity.
It is not unusual for serum creatinine and BUN levels to be elevated during cyclosporine capsules therapy. These elevations in renal transplant patients do not necessarily indicate rejection, and each patient must be fully evaluated before dosage adjustment is initiated.
Nephrotoxicity has been noted in 25% of cases of renal transplantation, 38% of cases of cardiac transplantation, and 37% of cases of liver transplantation. Mild nephrotoxicity was generally noted 2 to 3 months after transplant and consisted of an arrest in the fall of the preoperative elevations of BUN and creatinine at a range of 35 to 45 mg/dl and 2.0 to 2.5 mg/dl, respectively. These elevations were often responsive to dosage reduction.
More overt nephrotoxicity was seen early after transplantation and was characterized by a rapidly rising BUN and creatinine. Since these events are similar to rejection episodes, care must be taken to differentiate between them. This form of nephrotoxicity is usually responsive to cyclosporine capsules dosage reduction.
Although specific diagnostic criteria which reliably differentiate renal graft rejection from drug toxicity have not been found, a number of parameters have been significantly associated to one or the other. It should be noted however, that up to 20% of patients may have simultaneous nephrotoxicity and rejection.
|a p < 0.05, b p < 0.01, c p < 0.001, d p < 0.0001|
Nephrotoxicity vs. Rejection
Donor > 50 years old or hypotensive
Antidonor immune response
Prolonged kidney preservation
Prolonged anastomosis time
Concomitant nephrotoxic drugs
Often > 6 weeks postopb
Often < 4 weeks postopb
Prolonged initial nonfunction
Fever > 37.5°C
(acute tubular necrosis)
Weight gain > 0.5 kg
Graft swelling and tenderness
Decrease in daily urine volume >
CyA serum trough level > 200 ng/mL
CyA serum trough level < 150 ng/mL
Gradual rise in Cr (< 0.15 mg/dl/day)a
Rapid rise in Cr ( > 0.3 mg/dl/day)a
Cr plateau < 25% above baseline
Cr > 25% above baseline
BUN/Cr ≥ 20
BUN/Cr < 20
Arteriolopathy (medial hypertrophya,
hyalinosis, nodular deposits, intimal
(proliferationa, intimal arteritisb,
thickening, endothelial vacuolization,
Tubular atrophy, isometric
vacuolization, isolated calcifications
Tubulitis with RBCb and WBCb casts, some irregular vacuolization
Mild focal infiltratesc
Interstitial edemac and hemorrhageb Diffuse moderate to severe
Diffuse interstitial fibrosis, often
CyA deposits in tubular and endothelial cells
Inflammatory infiltrate with mononuclear phagocytes,
Fine isometric vacuolization of tubular cells
macrophages, lymphoblastoid cells, and activated T-cells
These strongly express HLA-DR antigens
Tubular cells with vacuolization and granularization
Degenerative tubular cells, plasma cells, and lymphocyturia > 20% of sediment
Intracapsular pressure < 40 mm Hgb
Intracapsular pressure > 40 mm Hgb
Unchanged graft cross-sectional area
Increase in graft cross-sectional
AP diameter ≥ Transverse diameter
Magnetic Resonance Imagery
Loss of distinct corticomedullary junction, swelling, image intensity of parachyma approaching that of psoas, loss of hilar fat
Normal or generally decreased
Patchy arterial flow
Decrease in tubular function
Decrease in perfusion > decrease in tubular function
(131 I-hippuran) > decrease in perfusion (99m Tc DTPA)
Increased uptake of Indium 111
Responds to decreased cyclosporine capsules
Responds to increased steroids or antilymphocyte globulin
A form of chronic progressive cyclosporine-associated nephrotoxicity is characterized by serial deterioration in renal function and morphologic changes in the kidneys. From 5% to 15% of transplant recipients will fail to show a reduction in a rising serum creatinine despite a decrease or discontinuation of cyclosporine therapy. Renal biopsies from these patients will demonstrate an interstitial fibrosis with tubular atrophy. In addition, toxic tubulopathy, peritubular capillary congestion, arteriolopathy, and a striped form of interstitial fibrosis with tubular atrophy may be present. Though none of these morphologic changes is entirely specific, a histologic diagnosis of chronic progressive cyclosporine-associated nephrotoxicity requires evidence of these.
When considering the development of chronic nephrotoxicity it is noteworthy that several authors have reported an association between the appearance of interstitial fibrosis and higher cumulative doses or persistently high circulating trough concentrations of cyclosporine. This is particularly true during the first 6 posttransplant months when the dosage tends to be highest and when, in kidney recipients, the organ appears to be most vulnerable to the toxic effects of cyclosporine. Among other contributing factors to the development of interstitial fibrosis in these patients must be included, prolonged perfusion time, warm ischemia time, as well as episodes of acute toxicity, and acute and chronic rejection. The reversibility of interstitial fibrosis and its correlation to renal function have not yet been determined.
Impaired renal function at any time requires close monitoring, and frequent dosage adjustment may be indicated. In patients with persistent high elevations of BUN and creatinine who are unresponsive to dosage adjustments, consideration should be given to switching to other immunosuppressive therapy. In the event of severe and unremitting rejection, it is preferable to allow the kidney transplant to be rejected and removed rather than increase the cyclosporine capsules dosage to a very high level in an attempt to reverse the rejection.
Due to the potential for additive or synergistic impairment of renal function, caution should be exercised when co-administering cyclosporine capsules with other drugs that may impair renal function (see PRECAUTIONS, Drug Interactions).
Occasionally patients have developed a syndrome of thrombocytopenia and microangiopathic hemolytic anemia which may result in graft failure. The vasculopathy can occur in the absence of rejection and is accompanied by avid platelet consumption within the graft as demonstrated by Indium 111 labeled platelet studies. Neither the pathogenesis nor the management of this syndrome is clear. Though resolution has occurred after reduction or discontinuation of cyclosporine capsules and 1) administration of streptokinase and heparin or 2) plasmapheresis, this appears to depend upon early detection with Indium 111 labeled platelet scans (see ADVERSE REACTIONS).
Significant hyperkalemia (sometimes associated with hyperchloremic metabolic acidosis) and hyperuricemia have been seen occasionally in individual patients.
Cases of hepatotoxicity and liver injury including cholestasis, jaundice, hepatitis, and liver failure have been reported in patients treated with cyclosporine. Most reports included patients with significant comorbidities, underlying conditions and other confounding factors including infectious complications and comedications with hepatotoxic potential. In some cases, mainly in transplant patients, fatal outcomes have been reported (see ADVERSE REACTIONS, Postmarketing Experience).
Hepatotoxicity, usually manifested by elevations in hepatic enzymes and bilirubin, was reported in patients treated with cyclosporine in clinical trials: 4% in renal transplantation, 7% in cardiac transplantation, and 4% in liver transplantation. This was usually noted during the first month of therapy when high doses of cyclosporine capsules were used. The chemistry elevations usually decreased with a reduction in dosage.
As in patients receiving other immunosuppressants, those patients receiving cyclosporine capsules are at increased risk for development of lymphomas and other malignancies, particularly those of the skin. The increased risk appears related to the intensity and duration of immunosuppression rather than to the use of specific agents. Because of the danger of oversuppression of the immune system, which can also increase susceptibility to infection, cyclosporine capsules should not be administered with other immunosuppressive agents except adrenal corticosteroids. The efficacy and safety of cyclosporine in combination with other immunosuppressive agents have not been determined. Some malignancies may be fatal. Transplant patients receiving cyclosporine are at increased risk for serious infection with fatal outcome.
Patients receiving immunosuppressants, including cyclosporine capsules are at increased risk of developing bacterial, viral, fungal, and protozoal infections, including opportunistic infections. These infections may lead to serious, including fatal, outcomes (see BOXED WARNING, and ADVERSE REACTIONS).
Polyoma Virus Infections
Patients receiving immunosuppressants, including cyclosporine capsules, are at increased risk for opportunistic infections, including polyoma virus infections. Polyoma virus infections in transplant patients may have serious, and sometimes, fatal outcomes. These include cases of JC virus-associated progressive multifocal leukoencephalopathy (PML), and polyoma virus-associated nephropathy (PVAN), especially due to BK virus infection, which have been observed in patients receiving cyclosporine.
PVAN is associated with serious outcomes, including deteriorating renal function and renal graft loss, (see ADVERSE REACTIONS, Postmarketing Experience). Patient monitoring may help detect patients at risk for PVAN.
Cases of PML have been reported in patients treated with cyclosporine capsules. PML, which is sometimes fatal, commonly presents with hemiparesis, apathy, confusion, cognitive deficiencies and ataxia. Risk factors for PML include treatment with immunosuppressant therapies and impairment of immune function. In immunosuppressed patients, physicians should consider PML in the differential diagnosis in patients reporting neurological symptoms and consultation with a neurologist should be considered as clinically indicated.
Consideration should be given to reducing the total immunosuppression in transplant patients who develop PML or PVAN. However, reduced immunosuppression may place the graft at risk.
There have been reports of convulsions in adult and pediatric patients receiving cyclosporine, particularly in combination with high-dose methylprednisolone.
Encephalopathy, including Posterior Reversible Encephalopathy Syndrome (PRES), has been described both in postmarketing reports and in the literature. Manifestations include impaired consciousness, convulsions, visual disturbances (including blindness), loss of motor function, movement disorders and psychiatric disturbances. In many cases, changes in the white matter have been detected using imaging techniques and pathologic specimens. Predisposing factors such as hypertension, hypomagnesemia, hypocholesterolemia, high-dose corticosteroids, high cyclosporine blood concentrations, and graft-versus-host disease have been noted in many but not all of the reported cases. The changes in most cases have been reversible upon discontinuation of cyclosporine, and in some cases, improvement was noted after reduction of dose. It appears that patients receiving liver transplant are more susceptible to encephalopathy than those receiving kidney transplant. Another rare manifestation of cyclosporine-induced neurotoxicity is optic disc edema including papilloedema, with possible visual impairment, secondary to benign intracranial hypertension.
The alcohol content (see DESCRIPTION) of cyclosporine capsules should be taken into account when given to patients in whom alcohol intake should be avoided or minimized, e.g. pregnant or breast feeding women, in patients presenting with liver disease or epilepsy, in alcoholic patients, or pediatric patients. For an adult weighing 70 kg, the maximum daily oral dose would deliver about 1 gram of alcohol which is approximately 6% of the amount of alcohol contained in a standard drink. The daily intravenous dose would deliver approximately 15% of the amount of alcohol contained in a standard drink.
Care should be taken in using cyclosporine capsules with nephrotoxic drugs (see PRECAUTIONS).
Conversion from Neoral to Cyclosporine capsules
Because cyclosporine capsules (NON-MODIFIED), is not bioequivalent to Neoral®*, conversion from Neoral®* to cyclosporine capsules, (NON-MODIFIED) using a 1:1 ratio (mg/kg/day) may result in a lower cyclosporine blood concentration. Conversion from Neoral®* to cyclosporine capsules, (NON-MODIFIED) should be made with increased blood concentration monitoring to avoid the potential of underdosing.
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Cyclosporine capsules, USP (NON-MODIFIED) are indicated for the prophylaxis of organ rejection in kidney, liver, and heart allogeneic transplants. It is always to be used with adrenal corticosteroids. The drug may also be used in the treatment of chronic rejection in patients previously treated with other immunosuppressive agents.
There is currently no drug history available for this drug.
Cyclosporine, the active principle in cyclosporine capsules, USP (NON-MODIFIED) is a cyclic polypeptide immunosuppressant agent consisting of 11 amino acids. It is produced as a metabolite by the fungus species Tolypocladium inflatum Gams.
Chemically, cyclosporine is designated as [R-[R*,R*-(E)]]-cyclic(L-alanyl-D-alanyl-N-methyl-L-leucyl-N-methyl-L-leucyl-N-methyl-L-valyl-3-hydroxy-N,4-dimethyl-L-2-amino-6-octenoyl-L-α-amino-butyryl-N-methylglycyl-N-methyl-L-leucyl-L-valyl-N-methyl-L-leucyl).
Cyclosporine capsules, USP (NON-MODIFIED) are available in 25 mg and 100 mg strengths.
Each 25 mg capsule contains:
Cyclosporine, USP…………………………………………………………25 mg
Each 100 mg capsule contains:
Cyclosporine, USP……………………………………………………..…100 mg
Each capsule contains the following inactive ingredients: methanol, purified water, sodium lauryl sulfate and talc. The 25 mg and the 100 mg capsule shell contains gelatin, red iron oxide and titanium dioxide.
The 25 mg and 100 mg capsule black imprinting ink contains the following inactive ingredients: n-butyl alcohol, D&C yellow #10 aluminum lake, FD&C blue #1 aluminum lake, FD&C blue #2 aluminum lake, FD&C red #40 aluminum lake, pharmaceutical glaze, propylene glycol, SDA-3A alcohol and synthetic black iron oxide.
The chemical structure of cyclosporine (also known as cyclosporin A) is:
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- American Health Packaging
- Physicians Total Care, Inc.
- Physicians Total Care, Inc.
- Cardinal Health
- Watson Laboratories, Inc.
- Ivax Pharmaceuticals, Inc.
- Apotex Corp.
- Paddock Laboratories, Inc.
- Eon Labs, Inc.
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