Cyclosporine microemulsion formulation (Neoral) in transplantation: pharmacokinetic/pharmacodynamic relationships

Effect of Bicyclol Tablets on Drug Induced Liver Injuries after Kidney Transplantation

Liver injury is one of the most common complications in patients after kidney transplantation. Bicyclol tablets possess obvious anti-inflammatory and liver-protective functions. This study aimed to explore the clinical effect of preventive application of Bicyclol on drug induced liver injuries at an early stage after kidney transplantation.

A total of 1600 patients who accepted kidney transplantations at our hospital from January 2009 to May 2015 were enrolled in this study, and divided into the prevention group (Bicyclol) and the control group (no hepatic protectors) based on whether or not hepatic protectors were regularly administered after the operation. The occurrence of liver injuries at an early stage after the operation and their influencing factors were analyzed.

Total of 745 cases were included in the final analysis of which 82 developed liver injuries post-operation, with 22 in the prevention group (4.82%) as compared to 60 in the control group (20.76%) (P= 0.001). As compared to the control group, OR (95% CI) of the prevention group was 0.197 (0.116, 0.334) after revising HBsAg status, age and maintenance immunosuppression.

Prophylactic application of Bicyclol as liver-protective treatment was a protective factor against drug induced liver injuries at an early stage after kidney transplantation.

The influence of immunosuppressants on the fertility of males who undergo renal transplantation and on the immune function of their offspring

AIM

To investigate the influence of immunosuppressants on the fertility of males who undergo renal transplantation as well as on the immune function of their offspring.

METHODS

A survey was performed on the fertility of 164 male renal transplant recipients who underwent a long-term treatment with cyclosporine A (CsA), azathioprine (Aza) and prednisone (Pred). The immune function of the recipients' children was also surveyed.

RESULTS

The 164 renal transplant recipients produced successful impregnation 15-204 (54.48+/-27.48)months after transplantation, resulting in the births of 167 children (three recipients fathered two children each), including 85 boys and 82 girls. Seven infants (4.2%) were premature. The weight of newborn infants was 2000-4600 (3274+/-395)g. Among the 167 children, 18 children were prone to respiratory tract infection. Examination of serum immunoglobulin from the children aged 1-3 years revealed that the IgA level was slightly lower than the normal reference range, but the difference was not significant (P>0.05). The IgM level of the children aged 7-12 years was higher than the normal reference range (P<0.01). Other immune indexes did not exhibit significant changes (P>0.05).

CONCLUSION

A long-term treatment with small-dose immunosuppressants has no obvious effect on the fertility of males who undergo renal transplantation. However, whether immunosuppressants influence the immune function of the offspring of such transplant recipients remains to be clarified by long-term follow up and prospective studies.

Clinical evaluation of efficacy and safety of cyclosporine (Imusporin) in renal transplant patients with stable graft function maintained on neoral or bioral

Objective:

Previous pharmacokinetic studies have demonstrated bioequivalence of Imusporin (microemulsion preparation of cyclosporine, Cipla) to the innovator product Neoral (Novartis, Switzerland). This study was done to evaluate the clinical efficacy and safety of Imusporin in patients who have already undergone renal transplant and have stable graft function maintained on cyclosporine preparation other than Imusporin.

Materials and Methods:

Twenty-two renal allograft recipients (mean age of 31.77 years, range 18-53 years), with stable graft function, previously on Neoral or Bioral were switched over to Imusporin after recording their relevant baseline clinical and biochemical parameters. These were repeated on 1, 4, 7, 15, 30 and 90 days after the start of therapy. Change in dosage required to maintain C2 levels at each visit were analyzed by paired sample t-test. Safety of the drug was assessed by the type and severity of adverse events developed during the therapy. Cost analysis was done assuming an average maintenance immunosuppression dose of 150 mg/day of cyclosporine.

Results:

Twenty-one patients completed the study. One patient was lost to follow-up. Mean C2 value before switchover was 894 ± 208 ng/ml, which was not significantly different from the mean values of C2 after switchover therapy (P>0.30). Change in dosage required to maintain C2 levels was not significantly different from the baseline dose of 2.34 mg/ kg body weight (P>0.1). No patient developed graft rejection after switchover therapy at a median follow-up of 16 months (14-18 months). Mean baseline SCr was similar to SCr at day 90 (1.38 vs. 1.37 mg/dl, P=0.930). No severe adverse events were reported. Mild side-effects included headache (4), somnolence (2), dry mouth (5) and generalized fatigue (6). Use of Imusporin (Cipla, India) results in an annual savings of Rs. 19892 over Neoral (Novartis, Switzerland) and Rs. 2263 over Bioral (Panacea Biotech, India).

Conclusions:

Imusporin is clinically as safe and efficacious as other cyclosporine preparations available while significantly reducing the cost of treatment.

Cicloral versus neoral: A bioequivalence study in healthy volunteers on the influence of a fat-rich meal on the bioavailability of cicloral

The bioavailability of cyclosporine a (CyA) was assessed in 2 cross-over studies with 12 healthy male volunteers each. Study A compared the bioavailability of Cicloral (test) with the microemulsion Neoral (reference) in the fasting state. Study B examined the influence of a fat-rich meal composed according to the Food and Drug Administration (FDA) recommendations on the bioavailability of Cicloral. Each volunteer received a single dose of 200 mg CyA in each period. Whole blood CyA concentrations were determined using HPLC up to 48 hours after drug administration. The pharmacokinetic parameters were determined using standard noncompartmental methods. The mean bioavailability of Cicloral compared with Neoral amounted to 83% (AUC) and 78% (Cmax), respectively. When administered after a fat-rich meal, the bioavailability of Cicloral was 121% (AUC) and 132% (Cmax) compared with fasting administration. Time to Cmax was 1.3 to 1.4 hours for both medications and modes of administration. Bioequivalence could not be proven either between Cicloral and Neoral, or between Cicloral fasting versus after a fat-rich meal. We conclude that the lower bioavailability and the influence of food on the bioavailability of Cicloral must be taken into account when switching from Neoral to the generic formulation.

Human jejunal permeability of cyclosporin A: influence of surfactants on P-glycoprotein efflux in Caco-2 cells

PURPOSE

The purpose of this work was to determine the jejunal permeability of cyclosporin A (CsA) in humans and whether formulation variables modulate the effects of P-glycoprotein (P-gp) on the permeability of CsA in Caco-2 cells.

METHODS

A solution containing CsA, phenylalanine, propranolol, polyethyleneglycol (PEG) 400, and PEG 4000 was perfused through a 10-cm jejunal segment in 12 subjects. Caco-2 transport studies were performed using previously reported methodology.

RESULTS

The mean Peff (+/- SD) of CsA in humans was 1.65 (0.53). The mean permeabilities for phenylalanine, propranolol, and PEG 400 were 4.54 (2.39), 2.90 (1.28), and 0.83 (0.51) x 10(-4) cm/s, respectively. The presence of surfactants significantly decreased the permeabilities of CsA in both directions in Caco-2 cells.

CONCLUSIONS

The results suggest that the effects of surfactants via micellar solubilization and inhibition of P-gp efflux on CsA transport in Caco-2 cells are significant. CsA can rightly be classified as a low solubility-high permeability Class II BCS drug and its highly variable absorption from Sandimmune oral formulations is the result of poor dissolution characteristics.

Neoral use in the renal transplant recipient

This review and critical analysis of current trends of immunosuppression management in pediatric transplantation provides evidence and support for the continued role of Neoral as an indispensable part of immunosuppressive protocols. CyA formulation influences clinical outcomes such as acute rejection, as confirmed by several multicenter studies. The CyA microemulsion formulation reduces pharmacokinetic variability and its consequent impact on outcomes over the long term. An advanced TDM strategy can improve the effectiveness and safety of immunosuppression in both de novo and maintenance renal transplant patients. There are potential risks resulting from CyA withdrawal strategies. Neoral is an indispensable part of combination protocols in renal transplantation.