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Last updated: Acute Kidney Injury…
on 10 Apr 2017

Ciclosporin

  • Prophylaxis of graft rejection in liver, kidney, heart, combined heart-lung, lung or pancreas transplants
  • Treatment of allograft rejection and nephrotic syndrome

  • Calcineurin inhibitor
  • Brands available: Neoral®, Sandimmun®, Capimune®, Deximune®, Capsorin®
  • Neoral®, Capimune®, Deximune®, Capsorin® - available in capsules
  • Neoral® - oral liquid is available
  • IV Ciclosporin is available. Only IV preparation available is Sandimmun® brand
  • Prescribe by brand, do NOT switch between brands

  • Hypersensitivity to ciclosporin or any of the excipients
  • Uncontrolled BP or malignancy
  • Concomitant use of tacrolimus or rosuvastatin

  • Monitor creatinine. Nephrotoxic, use with caution with other nephrotoxic agents
  • Monitor ciclosporin levels (trough): initially 150-300 ng/ml, maintenance 75-150 ng/ml. Second dose conventionally given at 6pm to allow to dose adjustment after levels are known. The two daily doses should ideally be given 12 hours apart, exact timings vary between renal units
  • Monitor LFTs
  • Monitor Hb and platelets; microangiopathic haemolytic anaemia (MAHA)/haemolytic uraemic syndrome (HUS)
  • Use of live vaccines should be avoided

  • Nephrotoxicity, hyperkalaemia
  • Increased risk of infection and malignancies (esp lymphoma, skin and cervical cancer)
  • Bone marrow suppression. Hyperlipidaemia, tremor, neuro-psychiatric syndromes, hepatic dysfunction, headache, hypertension, diabetes mellitus (less common than tacrolimus), hirsutism, gum hyperplasia
  • Some of the side effects are dose-dependent and responsive to dose reduction

Note: microangiopathic haemolytic anaemia (MAHA)/haemolytic uraemic syndrome (HUS) is well recognised; this can be atypical, eg thrombocytopenia or anaemia mild or absent

  • Kidney transplantation: 10-15 mg/kg/day in 2 divided doses. Nephrotic syndrome: 5 mg/kg/day in 2 divided doses. Take the two daily doses 12 hours apart with the bigger dose in the morning
  • Intravenous = one third of the daily oral dose in 2 divided doses, each over 2-6 hrs peripherally or 1hr centrally. Dilute 50mg in 20-100ml with sodium chloride 0.9% or glucose 5% 
  • Prescribe by brand

  • As in normal renal function. Not dialysed by PD, HD, CVVH

  • Levels ↑ by macrolides, theophylline, diltiazem/verapamil, amiodarone, allopurinol and fluconazole/caspofungin
  • Levels ↓ by carbamazepine/phenytoin, rifampicin, metoclopramide, St Johns Wort
  • Care with other nephrotoxic drugs. Can increase digoxin levels

CICLOSPORIN (Brand)#75mg#see prescribing section#PO#8 18

  • Always take the same brand, do NOT swap brands without your doctor asking you to
  • Take ciclosporin consistently either on an empty stomach (one hour before or two hours after food), or with meals
  • Avoid grapefruit juice
  • When coming to clinic do not take your morning dose until after you have had your bloods taken – bring a dose to clinic with you
  • If you suffer from an episode of diarrhoea it is advisable to get your creatinine and ciclosporin levels checked
  • There is an increased risk of infection and certain cancers (including skin and cervical)
  • Avoid sunbathing, use high factor sun cream and women should attend for yearly cervical smears
  • Avoid live vaccines – ask your pharmacist

    Note: warn women re hirsutism