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CYCLOSPORINE-A
1970 – Borel (Sandoz lab) at Basel, Switzerland, from common soil fungus Tolypocladium inflatum gams (erst. Beauveria nivea) ; Antifungal / Immunosuppressant
02 formulations : SANDIMMUNE for Px of Organ-Transplant-
Rejection (1983) NEORAL for Psoriasis / RA (FDA approved in
1997)
Cyclic Non-Ribosomal Peptide - 11 Amino Acids
Neoral has 10-54% Bioavailability than Sandimmune (‘Pre-digested, Modified’ form by ME)
Metab by CY P450 3A4 enzyme system in liver
Excreted by the way of bile through faeces (90%), with only 6 % excreted in urine
Hepatic dysfunction / CYP3A4 Inhibitors may prolong the half life and requires dose adjustment
Renal Disease does not alter Clearance
Peak Levels in 02 – 04 hrs
t1/2 = 05-18 hrs
Clearance Rate : 05-07 mL/min/kg
Inhibits production of Pro-inflammatory IL-2 by inhibiting calcineurin thus decreases T cell proliferation
Calcineurin inhibition leads to reduced activity of the transcription factor NFAT-1 (Nuclear Factor Activated T cells)
Inhibits INF-gamma production by T lymphocytes and thus reduces keratinocyte proliferation by downregulating ICAMs-1
US FDA approved :1.Psoriasis2.Severe psoriasis3.Recalcitrant, treatment resistant psoriasis
IN EU / AUSTRALIA :1. Atopic dermatitis2. Psoriasis
1. Papulosquamous dermatoses : Lichen Planus
2. Bullous dermatoses : Pemphigus, Pemphigoid, Epidermolysis Bullosa Acquisita, Linear IgA Bullous dermatoses
3. Autoimmune connective tissue disorders : Dermatomyositis, SLE, Scleroderma
4. Neutrohilic dermatoses : Behcet’s Syndrome, PG
5. Atopic dermatitis6. Alopecia (AA / LPP)
Granulomatous dermatoses : Granuloma Annularae, Sarcoidosis
Keratinization Disorders (PRP)
Chronic Actinic Dermatoses
Urticaria (CIU / Cold / Solar)
Others : Morphea, Prurigo Nodularis, Reactive Arthritis, Dyshidrotic Eczema, Eosinophilic Folliculitis
RA (Unresponsive to MTX)
ORGAN-DONOR-TRANSPLANT-REJECTION Prophylaxis in Renal / Liver / Heart
Prevention of GVHD in Bone Marrow Transplant
KERATOCONJUNCTIVITIS SICCA (Topical prep)
Brain Trauma (Orphan Indication)
1.Renal Dysfunction
2.Uncontrolled HTN
3.Hypersensitivity to CsA or its ingredients
4.Cutaneous T cell Lymphoma
5.Cured / Persistent Malignancies
1. Age < 18 or > 64 (CsA has been used in AD in Children > 01 year @ 5mg/kg/day with high efficacy, less side effects (Dec BA, better Clearance) but RCTs not performed)
2. Controlled HT
1. On medications that interfere with CsA metabolism
2. On medications that potentiate renal dysfunction
3. Pregnancy, lactation – Cat C
DOSE RELATED :
•Renal Dysfunction – dose related toxicity. To avoid it, the dose of CsA < 5 mg/kd/day
•HTN – mean diastolic BP > 90 mmHg – direct vasoconstrictor effect of CsA on vascular smooth muscles in kidneys but it could also be secondary to renal dysfunction. (Reversible)
DOSE INDEPENDENT :
Neurological effects :
CsA < 02 months
Tremors ParesthesiaheadacheHyperaesthesia
• Malignancy : Non-Melanoma Skin Cancers
• Dyselectrolytemia: HyperkalemiaHyperuricemia Hypomagnesemia Hyperlipidemia (esp TRIGs)
• Mucocutaneous : hypertrichosis (60%), gingival hyperplasia (30%), Acne (16%), Folliculitis (12%)
• Gastrointestinal : nausea, abdominal discomfort, diarrhea
• Musculoskeletal : myalgia, lethargy, arthralgia
Capsule form
•25 / 100 mg Strength (Neoral) 50 mg (Gengraf)•Inactive Ingredients - SLS / Talc / Purified Water•In 10 % v/w Absolute Alcohol as Vehicle•In a Soft, Gelatin Capsule as a Micro-Emulsion
•MRP - Rs 380 for 05 Capsules Marketed as NEORAL (NOVARTIS) / ARPIMUNE ME-100 (RPG LS) / CYCLOPHIL ME-25 (STRIDES)
• Oral solution contains 100 mg/ml and should be diluted with apple juice or orange juice
before it is administered to make it palatable.
OPHTHALMIC EMULSION 0.05%
INJECTABLE preparation
50 mg / mL (Sandimmune)
CYP3A4-inhibitors (Inc B/A) Macrolides (Erythromycin > Clarithromycin > Azith)◦Antifungals (Keto >Itraconazole > Flucanozole)◦Protease Inhibitors (Saquinavir / Nelfinavir / Darun.)◦H2 blockers (Cimetdine > Ranitidine)◦Grapefruit Juice (by >50%)◦Antiarrythmic Agents (Verapamil / Diltiazem)
Drugs that Decrease B/A of CsA AEDs (Phenobarbitol / Phenytoin )RifampicinTerbinafine
Potentiate / Inc Risk of ADRs :K+ Sparing Diuretics (Hyperkalemia)HMGCoA Reductase Inhibitor (Rhabdomyolysis)Colchicine (Myopathy)
Potentiate Renal DysfunctionAminoglycosides, TMP-SMX, Amphotericin-B, NSAIDs
• For patients with Severe, inflammatory flares of Psoriasis or Recalcitrant psoriasis :-Start with max dermatological dose of 5mg/kg/day administered over 2 doses (Rapid Onset of Action)
• As soon as the patient is no longer in distress, the dose of CsA can be decreased in decrements of 1mg/kg daily every 02 weeks until the minimum effective dosage for maintenance therapy.
• For patient with Chronic Plaque type Psoriasis :-Start with 2.5 to 3 mg/kg/dayIf improvement has not occurred by 1 month increase the CsA dose by 0.5 to 1 mg/kg daily every 2 weeks as necessary but not to exceed maximum dose of 5 mg/kg
• If there is insufficient response to 5mg/kg for 3 continuous months, CsA should be discontinued.
• While stopping CsA, it should be gradually tapered as Rebound is possible after sudden discontinuation.
• US FDA : CsA can be used continuously for 01 year
• Worldwide Consensus Guidelines : upto 02 years can be used.
• Recommended is short term use of CsA for 3 to 6 months ideally, especially for Psoriasis (Intermittent, Short Term, RESCUE therapy)
Open-label trials in PsA with 6mg/kg/day X 08 weeks with significant efficacy noted; Relapse in 02 weeks.
Rotational therapy (06 months CsA followed by MTX upto 15mg/wk) caused significant (>50%) reduction in Joint tenderness and Swelling)
Non-Bioequivalence between Sandimmune / Gengraf-Neoral
Before Meals / After Meals due to fatty food interaction
Dose-calculation based on IBW > ABW due to lean body fat
BASELINE :
Clinical :1.Complete history and physical examination (to rule out active infection, tumours)2.Baseline BP
Lab inv :1.Baseline Serum Urea / Creatinine levels2.Other baseline renal evaluation : Urine RE/ME3.CBC / LFT with Enzymes4.Serum Lipid Prolfile5.Mg2+, K+, Serum Uric Acid
WARD
1.BP record twice daily
2.Urea, Creatinine, K, Mg, Uric Acid Twice in the first week Weekly thereafter till discharge
FOLLOW UP :•Examination :1.Re-evaluate every 2 weeks X 02 months then monthly 1.BP on each visit
•Lab inv.1.Urea, Creatinine, Urinanalysis, Se Electrolytes, Uric acid, Lipid profile2.Lab surveillance every 2 weeks X 02 months then Monthly till on CsA
Serum creatinine rises >30% above patient’s baseline
Repeat measurement within 2 weeks
Creatinine is sustained at >30% above patients baseline
Reduce CsA dose by at least 1 mg/kg/day (for at least 1 month)
• Reduce CsA dose by at least 1 mg/kg/day (for at least 1 month)
• Creatinine decreases Creat. remains >30% to <30% of baseline
• CsA can be continued stop CsA treatment at new dosage Creat returns to within 10% of baseline
CsA treatment can be resumed at lower dosage
Serum Creatinine rises by at least 50% above the baseline value, CsA should be discontinued until serum Creatinine returns to baseline.
THANK YOU