|
Interaction |
Clinical management |
Nephrotoxic drugs (e.g. aminoglycosides, amphotericin, contrast dye, frusemide, NSAIDs) |
Additive nephrotoxicity |
Avoid combination or monitor kidney function closely |
Potassium sparing drugs (e.g. amiloride, eplerenone, spironolactone, ACE inhibitors, angiotensin II receptor antagonists etc.) |
Additive risk of hyperkalaemia |
Monitor potassium level closely if combination is used |
Corticosteroids |
Corticosteroids are CYP3A4 substrates. Case reports of inhibition of CYP3A4 by corticosteroids, including high dose methylprednisolone and prednisolone, leading to increased levels of both agents |
If used in combination monitor ciclosporin level and assess for signs of steroid excess |
Digoxin |
Digitalis toxicity due to decreased digoxin clearance |
Avoid combination or monitor for digitalis toxicity; dose reduction or withdrawal may be required |
Etoposide |
Increased toxicity of etoposide possible due to reduced clearance |
Monitor for etoposide toxicity; adjust dose as needed |
Colchicine, HMG-CoA reductase inhibitors (statins) |
Reduced clearance of colchicine and statins and etoposide, thereby enhancing the potential of these drugs to induce muscular toxicity, including muscle pain and weakness, myositis and occasionally rhabdomyolysis. |
If used concurrently, monitor closely for myotoxicity. Consider lower initial and maintenance dose of statin and cease immediately if signs and symptoms of myopathy occur |
CYP3A4 inhibitors (e.g. aprepitant, azole antifungals, clarithromycin, erythromycin, grapefruit juice, ritonavir etc.) |
Increased toxicity of ciclosporin possible due to reduced clearance |
Avoid combination or monitor for ciclosporin toxicity |
CYP3A4 inducers (e.g. carbamazepine, phenytoin, phenobarbitone, rifampicin, St John's wort etc.) |
Reduced efficacy of ciclosporin possible due to increased clearance |
Avoid combination or monitor for decreased clinical response to ciclosporin |
Drugs metabolised by CYP3A4 (e.g. atorvastatin, benzodiazepines, calcineurin inhibitors, clarithromycin, dihydroergotamine, simvastatin, etc.) |
Increased effect/toxicity of these drugs possible due to inhibition of CYP3A4 by ciclosporin resulting in reduced clearance |
Avoid combination or monitor for increased effect/toxicity Note: simvastatin and ivabradine contraindicated |
Drugs undergoing P-gp-mediated elimination (e.g. dabigatran, loperamide, phenytoin etc.) |
Increased effects/toxicity of these drugs possible due to inhibition of P-gp by ciclosporin resulting in reduced clearance |
Avoid combination or monitor for increased effect/toxicity |
Infliximab |
Reduced ciclosporin concentrations possible due to increased clearance |
Monitor ciclosporin blood concentrations; adjust dosage as appropriate |