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Cyclosporine is an immunosuppressive agent used to treat organ rejection post-transplant. It also has use in certain other autoimmune diseases, treatment of organ rejection in kidney, liver, and heart allogeneic transplants, rheumatoid arthritis when the condition has not adequately responded to methotrexate. Also, it is a second-line agent for ALS and graft vs. host disease. It also has other FDA and non-FDA-approved indications. This activity reviews the mechanism of action, adverse event profile, toxicity, dosing, pharmacodynamics, and monitoring of cyclosporine, pertinent for interprofessional team members in treating conditions where cyclosporine is indicated. Objectives: Identify the mechanism of action of cyclosporine. Review the FDA and non-FDA-approved indications for cyclosporine. Explain the importance of monitoring for toxicity with cyclosporine. Summarize the importance of interprofessional communication in improving care coordination among the interprofessional team when initiating cyclosporine therapy. Access free multiple choice questions on this topic.

In the event of toxicity, establishing a patent airway is a priority. There is a need to watch for signs of respiratory insufficiency and provide ventilation assistance if needed. Also, the healthcare provider needs to monitor for shock and treat if necessary. They should anticipate seizures and treat if necessary, and initiate supportive and symptomatic treatment. When overdosage occurs in patients prescribed cyclosporine therapy, the healthcare provider may withhold the drug for a few days or initiate alternate-day therapy until the patient stabilizes.[12] Hemodialysis only eliminates 1% of the dose. Monitoring serum CsA levels is mandatory, and patients may need multiple dose adjustments during the treatment period. The CVC (central venous catheter) line is not used to infuse CsA and can be safely used to collect blood samples for serum CsA levels. The procedure can be performed immediately after interrupting the infusion if using the appropriate technique for discarding 5 mL of blood. Drugs that can decrease CsA levels include rifampicin, rifabutin, isoniazid, barbiturates, phenytoin, carbamazepine, intravenous trimethoprim, intravenous sulfadimidine, imipenem, cephalosporins, terbinafine, ciprofloxacin, ticlopidine, octreotide, and nefazodone. Conversely, drugs that can increase CsA levels include verapamil, diltiazem, amlodipine, nicardipine, ketoconazole, fluconazole, itraconazole, erythromycin, clarithromycin, azithromycin, saquinavir, indinavir, nelfinavir, ritonavir, methylprednisolone.

Cyclosporine is a widely used immunosuppressive drug, especially in transplant patients. The majority of patients on cyclosporine can be followed as outpatients by the nurse practitioner, primary care provider, internist, and specialist. The clinical staff must monitor cyclosporine levels regularly to prevent acute rejection, nephrotoxicity, and predictable dose-dependent adverse reactions. Further, the pharmacist and nurse should educate the patient on potential complications of the drug and the need to follow up regularly. Pharmacists should verify dosing, and also, given the extensive drug-drug interaction list for cyclosporine, thorough medication reconciliation is in order, with any red flags reported promptly to the rest of the healthcare team. Nursing can monitor both for treatment effectiveness and the adverse effects of the medication, alerting the treating physician of any concerns. Finally, patients on cyclosporine are at a slight risk of lymphoproliferative malignancies and infections; thus, a thorough history and physical exam are vital at each clinic visit. Cyclosporine therapy has a much higher opportunity for patient success with the communication and collaboration of an interprofessional healthcare team. [Level 5]