Maintenance Immunosuppression -- Cyclosporine

Post-Heart Transplant

Indications

 Maintenance immunosuppressive agent to prevent rejection

 Utilized when patients cannot tolerate or when patients experience adverse events
associated with tacrolimus

Plan/Management

 Educate patient & family about life long immunosuppressant therapy for the management
of patients after heart transplantation

Dosing Protocol

 Cyclosporine should be started at 2-4 mg/kg orally in two divided doses

 When utilizing induction therapy for patients with renal insufficiency or those that are at a
high immunological risk, cyclosporine is started on POD #3 or when improved renal
clearance is evident

Monitoring

 Repeat trough level daily or less than daily when patients are hospitalized

- Cyclosporine should be ordered for an administration time of 6 AM

and 6 PM (0600/1800) in ALL patients in the hospital, regardless of
their home administration times.

- Troughs should always be drawn as close to 5 AM OR 30-60

minutes prior to AM dose, to acquire an accurate 12 hour trough

 In the first 6 months post-transplant target cyclosporine dose to maintain a cyclosporine

trough blood level (FPIA) of 250-300 ng/ml.

 After first 6 months through 12 months target cyclosporine dose to maintain a

cyclosporine trough blood level (FPIA) of 200-250 ng/ml.

 Beyond 12 months target cyclosporine dose to maintain a cyclosporine trough blood level
(FPIA) of 100-150 ng/ml.
Special Considerations

 Multiple manufacturers make cyclosporine as different pharmacologic preparations.

Neoral, Gengraf, and Sandimmune are three common brands used in our program.
Different brands of cyclosporine are not interchangeable. Ensure that the patient
remains on the same preparation to make certain we achieve accurate and reliable
levels.

 When calling in a prescription to the patient's pharmacy, make sure to state specifically
which brand of cyclosporine the patient is receiving and is state "No Substitution".

 Patients with renal dysfunction (creatinine >2.0 mg/dl, or creatinine clearance < 50 ml
min), consider consultation with transplant physician for individual management.

 When making adjustments in dosing, nurses may increase or decrease a total of 50mg
total daily dose.

 AVOID split dosing of Cyclosporine (Ie Neoral 100mg AM, 75mg PM)

 When converting from oral to IV preparation for hospital use. IV dose is 1/3 of total
oral daily dose in divided doses every 12 hours as a continuous infusion. Any patient
getting IV cyclosporine, consult Transplant Pharmacist @ (615) 484-3129.

 When initiating any other drug that will interact with cyclosporine (-azole antifungal, non-
dihydropyridine CCB etc), consider a dose reduction due to elevation of cyclosporine
levels with these medications

Follow-Up

 In outpatients, check a trough 5-10 days following any dose adjustment or with the
addition of a drug that may potentially interact with cyclosporine. (Consult pharmacist with
any questions)
 If chronic renal insufficiency, check BMP in addition to trough
 Monitor Uric Acid and Magnesium per lab protocol and as needed

Physician Consult

 For goal adjustment in patients with CrCl <50, dose adjustments in increments larger
than 50mg/day, when converting to PO to IV form, or if patient requests to change to
different brand of cyclosporine.
References
Robbins RC, Barlow CW, Oyer PE, et al. Thirty years of cardiac transplantation at Stanford University. J Thoracic
and Cardiovascular Surg. 1999; 117(5):939-51

Neoral [package insert]. East Hanover, NJ: Novartis Pharmaceuticals Corp; 2001

REVISED 11/2010