Kidney, Liver, and Heart Transplantation
The principal adverse reactions of cyclosporine therapy are renal dysfunction, tremor, hirsutism, hypertension, and gum hyperplasia.
Hypertension, which is usually mild to moderate, may occur in approximately 50% of patients following renal transplantation and in most cardiac transplant patients.
Glomerular Capillary Thrombosis
Glomerular capillary thrombosis has been found in patients treated with cyclosporine and may progress to graft failure. The pathologic changes resembled those seen in the hemolytic-uremic syndrome and included thrombosis of the renal microvasculature, with platelet-fibrin thrombi occluding glomerular capillaries and afferent arterioles, microangiopathic hemolytic anemia, thrombocytopenia, and decreased renal function. Similar findings have been observed when other immunosuppressives have been employed post-transplantation.
Hypomagnesemia has been reported in some, but not all, patients exhibiting convulsions while on cyclosporine therapy. Although magnesium-depletion studies in normal subjects suggest that hypomagnesemia is associated with neurologic disorders, multiple factors, including hypertension, high dose methylprednisolone, hypocholesterolemia, and nephrotoxicity associated with high plasma concentrations of cyclosporine appear to be related to the neurological manifestations of cyclosporine toxicity.
In controlled studies, the nature, severity, and incidence of the adverse events that were observed in 493 transplanted patients treated with Neoral® were comparable with those observed in 208 transplanted patients who received Sandimmune® in these same studies when the dosage of the two drugs was adjusted to achieve the same cyclosporine blood trough concentrations.
Based on the historical experience with Sandimmune®, the following reactions occurred in 3% or greater of 892 patients involved in clinical trials of kidney, heart, and liver transplants.
|Body System||Adverse Reactions||Randomized Kidney Patients||Cyclosporine Patients (Sandimmune®)|
|Cramps||4||< 1||2||< 1||0|
|Central Nervous System||Tremor||12||0||21||31||55|
|Hepatotoxicity Abdominal||< 1||< 1||4||7||4|
|Discomfort||< 1||0||< 1||7||0|
|Autonomic Nervous System||Paresthesia||3||0||1||2||1|
|Miscellaneous||Gynecomastia||< 1||0||< 1||4||3|
Among 705 kidney transplant patients treated with cyclosporine oral solution (Sandimmune®) in clinical trials, the reason for treatment discontinuation was renal toxicity in 5.4%, infection in 0.9%, lack of efficacy in 1.4%, acute tubular necrosis in 1.0%, lymphoproliferative disorders in 0.3%, hypertension in 0.3%, and other reasons in 0.7% of the patients.
The following reactions occurred in 2% or less of cyclosporine-treated patients: allergic reactions, anemia, anorexia, confusion, conjunctivitis, edema, fever, brittle fingernails, gastritis, hearing loss, hiccups, hyperglycemia, migraine (Neoral®) muscle pain, peptic ulcer, thrombocytopenia, tinnitus.
The following reactions occurred rarely: anxiety, chest pain, constipation, depression, hair breaking, hematuria, joint pain, lethargy, mouth sores, myocardial infarction, night sweats, pancreatitis, pruritus, swallowing difficulty, tingling, upper GI bleeding, visual disturbance, weakness, weight loss.
Patients receiving immunosuppressive therapies, including cyclosporine and cyclosporine -containing regimens, are at increased risk of infections (viral, bacterial, fungal, parasitic). Both generalized and localized infections can occur. Pre-existing infections may also be aggravated. Fatal outcomes have been reported. (see WARNINGS)
Infectious Complications in Historical Randomized Studies in Renal Transplant Patients Using Sandimmune®
% of Complications
|Azathioprine with Steroids*
% of Complications
|Systemic Fungal Infection||2.2||3.9|
|Local Fungal Infection||7.5||9.6|
|Other Viral Infections||15.9||18.4|
|Urinary Tract Infections||21.1||20.2|
|Wound and Skin Infections||7.0||10.1|
|*Some patients also received ALG.|
Postmarketing Experience, Kidney, Liver and Heart Transplantation
Cases of hepatotoxicity and liver injury including cholestasis, jaundice, hepatitis and liver failure; serious and/or fatal outcomes have been reported. [See WARNINGS/Hepatotoxicity]
Increased Risk of Infections
Cases of JC virus-associated progressive multifocal leukoencephalopathy (PML), sometimes fatal; and polyoma virus-associated nephropathy (PVAN), especially BK virus resulting in graft loss have been reported. [See WARNINGS/ Polyoma Virus Infection]
Headache, including Migraine
Cases of migraine have been reported. In some cases, patients have been unable to continue cyclosporine, however, the final decision on treatment discontinuation should be made by the treating physician following the careful assessment of benefits versus risks.
The principal adverse reactions associated with the use of cyclosporine in rheumatoid arthritis are renal dysfunction (see WARNINGS), hypertension (see PRECAUTIONS), headache, gastrointestinal disturbances, and hirsutism/hypertrichosis.
In rheumatoid arthritis patients treated in clinical trials within the recommended dose range, cyclosporine therapy was discontinued in 5.3% of the patients because of hypertension and in 7% of the patients because of increased creatinine. These changes are usually reversible with timely dose decrease or drug discontinuation. The frequency and severity of serum creatinine elevations increase with dose and duration of cyclosporine therapy. These elevations are likely to become more pronounced without dose reduction or discontinuation.
The following adverse events occurred in controlled clinical trials:
Neoral®/Sandimmune® Rheumatoid Arthritis Percentage of Patients with Adverse Events ≥ 3% in any Cyclosporine Treated Group
|Studies 651+652+2008||Study 302||Study 654||Study 654||Study 302||Studies 651+652+2008|
|Methotrexate & Sandimmune®
|Methotrexate & Placebo
|Autonomic Nervous System Disorders|
|Body As A Whole-General Disorders|
|Edema NOS*||5%||14%||12%||4%||10%||< 1%|
|Influenza-like symptoms||< 1%||6%||1%||0%||3%||2%|
|Central and Peripheral Nervous System Disorders|
|Gastrointestinal System Disorders|
|Gastrointestinal Disorder NOS*||0%||2%||1%||4%||4%||0%|
|Hearing and Vestibular Disorders|
|Ear Disorder NOS*||0%||5%||0%||0%||1%||0%|
|Metabolic and Nutritional Disorders|
|Musculoskeletal System Disorders|
|Arthropathy Leg Cramps / Involuntary||0%||5%||0%||1%||4%||0%|
|Creatinine elevations ≥ 30%||43%||39%||55%||19%||48%||13%|
|Creatinine elevations ≥ 50%||24%||18%||26%||8%||18%||3%|
|Reproductive Disorders, Female|
|Respiratory System Disorders|
|Upper Respiratory Tract||0%||14%||23%||15%||13%||0%|
|Skin and Appendages Disorders|
|Urinary System Disorders|
|Urinary Tract Infection||0%||3%||5%||4%||3%||0%|
|Vascular (Extracardiac) Disorders|
|† Includes patients in 2.5 mg/kg/day dose group only.
*NOS = Not Otherwise Specified.
In addition, the following adverse events have been reported in 1% to < 3% of the rheumatoid arthritis patients in the cyclosporine treatment group in controlled clinical trials.
Autonomic Nervous System: dry mouth, increased sweating;
Body as a Whole: allergy, asthenia, hot flushes, malaise, overdose, procedure NOS*, tumor NOS*, weight decrease, weight increase;
Cardiovascular: abnormal heart sounds, cardiac failure, myocardial infarction, peripheral ischemia;
Central and Peripheral Nervous System:hypoesthesia, neuropathy, vertigo;
Gastrointestinal: constipation, dysphagia, enanthema, eructation, esophagitis, gastric ulcer, gastritis, gastroenteritis, gingival bleeding, glossitis, peptic ulcer, salivary gland enlargement, tongue disorder, tooth disorder;
Infection: abscess, bacterial infection, cellulitis, folliculitis, fungal infection, herpes simplex, herpes zoster, renal abscess, moniliasis, tonsillitis, viral infection;
Hematologic: anemia, epistaxis, leukopenia, lymphadenopathy;
Liver and Biliary System: bilirubinemia;
Metabolic and Nutritional: diabetes mellitus, hyperkalemia, hyperuricemia, hypoglycemia;
Musculoskeletal System: arthralgia, bone fracture, bursitis, joint dislocation, myalgia, stiffness, synovial cyst, tendon disorder;
Neoplasms: breast fibroadenosis, carcinoma;
Psychiatric: anxiety, confusion, decreased libido, emotional lability, impaired concentration, increased libido, nervousness, paroniria, somnolence;
Reproductive (Female): breast pain, uterine hemorrhage;
Respiratory System: abnormal chest sounds, bronchospasm;
Skin and Appendages: abnormal pigmentation, angioedema, dermatitis, dry skin, eczema, nail disorder, pruritus, skin disorder, urticaria;
Special Senses: abnormal vision, cataract, conjunctivitis, deafness, eye pain, taste perversion, tinnitus, vestibular disorder;
Urinary System: abnormal urine, hematuria, increased BUN, micturition urgency, nocturia, polyuria, pyelonephritis, urinary incontinence.
*NOS = Not Otherwise Specified.
The principal adverse reactions associated with the use of cyclosporine in patients with psoriasis are renal dysfunction, headache, hypertension, hypertriglyceridemia, hirsutism/hypertrichosis, paresthesia or hyperesthesia, influenza-like symptoms, nausea/vomiting, diarrhea, abdominal discomfort, lethargy, and musculoskeletal or joint pain.
In psoriasis patients treated in US controlled clinical studies within the recommended dose range, cyclosporine therapy was discontinued in 1.0% of the patients because of hypertension and in 5.4% of the patients because of increased creatinine. In the majority of cases, these changes were reversible after dose reduction or discontinuation of cyclosporine.
There has been one reported death associated with the use of cyclosporine in psoriasis. A 27-year-old male developed renal deterioration and was continued on cyclosporine. He had progressive renal failure leading to death.
Frequency and severity of serum creatinine increases with dose and duration of cyclosporine therapy. These elevations are likely to become more pronounced and may result in irreversible renal damage without dose reduction or discontinuation.
Adverse Events Occurring in 3% or More of Psoriasis Patients in Controlled Clinical Trials
|Body System*||Preferred Term||Neoral®
|Infection or Potential Infection||24.7%||24.3%|
|Upper Respiratory Tract Infections||7.7%||11.3%|
|Central and Peripheral Nervous System||26.4%||20.5%|
|Body As a Whole-General||29.1%||22.2%|
|Metabolic and Nutritional||9.3%||9.7%|
|Reproductive, Female||8.5% (4 of 47 females)||11.5% (6 of 52 females)|
|Skin and Appendages||17.6%||15.1%|
|Bronchospasm, Coughing, Dyspnea, Rhinitis||5.0%||4.9%|
|White cell and RES||4.4%||2.7%|
|*Total percentage of events within the system
**Newly occurring hypertension = SBP ≥ 160 mm Hg and/or DBP ≥ 90 mm Hg
The following events occurred in 1% to less than 3% of psoriasis patients treated with cyclosporine:
Body as a Whole: fever, flushes, hot flushes;
Cardiovascular: chest pain;
Central and Peripheral Nervous System:appetite increased, insomnia, dizziness, nervousness, vertigo;
Gastrointestinal: abdominal distention, constipation, gingival bleeding;
Liver and Biliary System: hyperbilirubinemia;
Neoplasms: skin malignancies [squamous cell (0.9%) and basal cell (0.4%) carcinomas];
Reticuloendothelial: platelet, bleeding, and clotting disorders, red blood cell disorder;
Respiratory: infection, viral and other infection;
Skin and Appendages: acne, folliculitis, keratosis, pruritus, rash, dry skin;
Urinary System: micturition frequency;
Vision: abnormal vision.
Mild hypomagnesemia and hyperkalemia may occur but are asymptomatic. Increases in uric acid may occur and attacks of gout have been rarely reported. A minor and dose related hyperbilirubinemia has been observed in the absence of hepatocellular damage. Cyclosporine therapy may be associated with a modest increase of serum triglycerides or cholesterol. Elevations of triglycerides ( > 750 mg/dL) occur in about 15% of psoriasis patients; elevations of cholesterol ( > 300 mg/dL) are observed in less than 3% of psoriasis patients. Generally these laboratory abnormalities are reversible upon dose reduction or discontinuation of cyclosporine.