Cyclosporine dosage and troughs

[Hopeful]

Hi,

I'd like to take a poll on what cyclosporine dosage people are taking (per kg/day) and the corresponding trough reading.

I'm wondering if there is anybody else with a crazy metabolism like mine!

To achieve a trough of 200, I need a dosage of 8 mg/kg/day (!)
My kidneys can no longer tolerate this. So, I'm back down to 5 mg/kg/day. Now my trough is around 80

I'd be interested to here what others are experiencing.

Thanks!

[JEZ]

Originally Posted by Hopeful

Hi,

I'd like to take a poll on what cyclosporine dosage people are taking (per kg/day) and the corresponding trough reading.

I'm wondering if there is anybody else with a crazy metabolism like mine!

To achieve a trough of 200, I need a dosage of 8 mg/kg/day (!)
My kidneys can no longer tolerate this. So, I'm back down to 5 mg/kg/day. Now my trough is around 80

I'd be interested to here what others are experiencing.

Thanks!

I took 2.1 mg per kg. (100 mg twice per day). I did not pay attn. to trough but my doctor did tell me my cyclosporine level was 162 when labs were done about 7 hrs. after my AM dose. I was in remission after 2 years with normal labs but recently had to go off of cycylsporine as my creatinine was starting to climb (1.6) I am presently trying generic Imuran to see if I can substitute it with equally effective results but less kidney toxicity. Too early to say if it will work.

[sandra]

Hi Hopeful!

Which brand of CsA are you taking? The bioavailability for CsA is different for different formulations. And how EXACTLY do you take it? On an empty stomach, or with foods, etc?


Sandra

[Hopeful]

I currently take Gengraf. I tried Neoral, but my trough was actually lower with that.

My trough level is measured about 11 hours after my previous dosage - right before I take my next.

I usually take it with water about 1-2 hours after eating. I don't eat anything afterwards. I've read that this increases the concentration in the blood.

Does this seem correct?

I should probably try testing my level at 7-8 hrs post dosage, just to see what it is then.

[paulaespada]

Originally Posted by JEZ

I took 2.1 mg per kg. (100 mg twice per day). I did not pay attn. to trough but my doctor did tell me my cyclosporine level was 162 when labs were done about 7 hrs. after my AM dose. I was in remission after 2 years with normal labs but recently had to go off of cycylsporine as my creatinine was starting to climb (1.6) I am presently trying generic Imuran to see if I can substitute it with equally effective results but less kidney toxicity. Too early to say if it will work.

Hello!

My husband started with 300 mg/day (1 year ago). Now he is decreasing very slowly and is with 120 mg/day.
One thing we learned is that he needs to drink about 2.5 to 3 liters of water/day, no alcohol at all.
I wish you all the best and if there is anything more I can help, please let me now.

[sandra]

Originally Posted by Hopeful

I currently take Gengraf. I tried Neoral, but my trough was actually lower with that.

I usually take it with water about 1-2 hours after eating. I don't eat anything afterwards. I've read that this increases the concentration in the blood.

Does this seem correct?

Hi Hopeful,

Yeah, you seem to be doing all the right things. When you are saying that your kidneys don't like it anymore, what do you mean? Do you have elevated creatinine, BUN, high blood pressure?

I was asking about food because there are many studies that show that taking CsA with fatty foods or grapefruit juice increases the amount of CsA in the blood stream (more CsA gets absorbed from the gut). That would presumably allow for a smaller overall dose to get to the same through levels. However, your kidneys process the CsA that gets in the blood stream, so I'm not sure it would help.

Sandra

[Ruth Cuadra]

Just a word of warning about eating grapefruit or drinking grapefruit juice while taking cyclosporine: don't do it! Grapefruit interacts with the drug to produce widely varying levels of CSA in the blood. Trying to regulate your levels by fooling the body with grapefruit is not a good idea. There are lots of references to research in this area and cyclosporine manufacturers are all required to carry warnings on their patient information sheets advising against consuming grapefruit. See for example:

AA&MDSIF Glossary for cyclosporine

Cyclosporine AND food-drug interactions

Regards,
Ruth

[JEZ]

I have to admit my fluid intake was not great when I took the cyclosporine. I took it when I ate because I got very nausous otherwise. It worked great on my bone marrow. When diagnosed in Dec 2006 my platlets were 9000 and my hgl was 7. After ATG and 2 years on Neoral I had gradually improved to normal labs (platlets 158,000 and Hgl 12) but my creatinine recently went up to 1.6 and the GRF calc was only 33. I now take generic Imuran (AZAT). After one month my labs have dropped some but are not bad (platlets 131,000 and Hgl 10.8 and WBC 6.10). If they hold here or go up I am happy. Just hope they don't trend down. My creatinine is back down to 1.3 and GRF calc up to 42 (this is kidney function percent and I think it is best if >60). Time will tell how I do on the new drug but at least my platelets didn't crash!

[Hawaii Bill]

Hi Hopeful,

I weigh 230 pounds and take 200mg of Neoral twice a day, usually with a meal or soon after. What I eat varies, so I don't know if there is any effect from the type of food I eat. The enclosure that comes with my Neoral says that I should try to be consistent with whatever I eat, but I'm not terribly compliant with that. Of course, I have not eaten grapefruit for a LONG time; wow, how I miss a tall glass of icy grapefruit juice now and then!!!

For my weight, 5mg/kg works out to 500mg CsA per day, so my dosage is a little lower than 5mg/kg. Dr Paquette put me on this dosage last June, when I was transfusion dependent. It's been a very slow recovery, but I have not needed PRBC since last July. Latest counts: WBC 4.5, Hgb 11.2, and 71k platelets. Dr P says we should shoot for normal platelets before starting to taper the CsA, as long as there is no toxicity.

My trough level on Monday, 6/15, about 14 hours after my last CsA dose, was 159.

HTH

[Hopeful]

I've been doing a lot of research on Cyclosporine and dosing. One thing that I thought might benefit the group is that there are a number of articles (including a warning from the drug manufacturer) that "the risk of renal structural changes is greater if the serum creatinine increases more than 30% from the patient's baseline value." I don't think most doctors track a patient's baseline. So, it's up to us to monitor this and evaluate the risks.

My creatinine had increase 78% over my baseline and my GFR had fallen. So, we lowered my dosage to 5 mg/kg/day despite the fact that my trough is below 100 on this dosage. I'm still waiting to see how my kidneys recover.

I also read some articles that mentioned that for people like me with atypical metabolisms, measuring the levels 2 hours after dosage is more accurate for predicting the drug availability than the trough. When I had my level measured 2.5 hours after dosage, it was over 600 despite being on the lower dosage. So, I'm feeling more comfortable with my "low dosage and trough" and will never go on the mega-dosage again!

[Hawaii Bill]

My hematologist has not mentioned measuring creatinine based on my baseline. I will mention it to him next time, and report what he says. My GFR readings have been good whenever I brought them up with him.

At any rate, seems like you have a pretty "special" metabolism!

[Lisa V]

That does sound like a really high dosage, Hopeful.

Ken has had to lower his dosage several times. Since he's now several years post-ATG we're not too concerned with trying to maintain a therapeutic level, just a maintenance one, and 175 mg/day (roughly 2.25 mg/kg, if my math is right) allows him to keep his creatinine between 1.1-1.3, assuming he drinks LOTS of water. He takes Gengraf, generally with meals, but is not terribly strict with timing, etc. If he slacks off the water intake, though, or if the weather gets particularly hot and humid, the creat starts creeping up again. It was 1.0 when he was first admitted, so we're happy if he can keep it around 1.2.

He doesn't get CSA readings that often, but his trough levels when he was on 200 mg/day (2.55 mg/kg) ranged between about 80 and 180, and at the 175/day rate it's been between 50 and 80.