To determine the concentration of ciclosporin in your blood in order to establish a dose regime, maintain therapeutic levels, and detect toxic levels
As soon as ciclosporin therapy begins, usually daily or 2-3 times a week, and periodically after that as dose is adjusted or maintained
A blood sample taken from a vein in your arm
None. Typically drawn 12 hours after the last dose; on mornings when you are scheduled to have your ciclosporin level checked, do not take the medicine until after your blood is drawn.
This test measures the amount of ciclosporin in the blood. Ciclosporin is an immunosuppressive drug used to dampen the body’s natural defences. When patients have an organ transplant, their immune system recognises the new organ as a foreign substance and will begin to attack it just as it would any invasive bacteria or virus. Ciclosporin affects the ability of certain white blood cells in the immune system to respond to this foreign tissue . The transplanted organ then has a better chance of survival and will not be as easily rejected by the patient’s system. Ciclosporin is used routinely in the transplantation of kidney, heart, liver, and other organs.
The immunosuppressive qualities of ciclosporin have also been found to be useful in treating symptoms of some autoimmune disease and other disorders. Ciclosporin helps to control the immune response in these cases, decreasing the severity of symptoms. These disorders include rheumatoid arthritis, psoriasis, severe eczema, aplastic anaemia, and ulcerative colitis.
When the symptoms in these cases are judged to be severe, extensive, and disabling, ciclosporin may be prescribed. Usually, the symptoms have not responded well to other treatments or medications. Ciclosporin is used with caution in these cases and needs to be carefully monitored with regular blood tests to detect changes in kidney function.
Testing ciclosporin levels in the blood can help ensure that drug levels are in a range that will be therapeutic for you. If the level is too low, the body may reject the organ (in the case of transplantation) or symptoms may reappear (autoimmune cases). It is also important to ensure levels are not too high and will not result in toxicity.
How is the sample collected for testing?
A blood sample is obtained by inserting a needle into a vein in the arm.
Is any test preparation needed to ensure the quality of the sample?
No test preparation is needed. Samples are typically drawn 12 hours after the last dose. On mornings when someone is scheduled to have their ciclosporin level checked, the person should not take the medicine until after their blood is drawn.
How is it used?
The test for ciclosporin is requested to measure the amount of drug in the blood to determine whether drug concentrations have reached therapeutic levels and are not in a toxic range. It is important to monitor levels of ciclosporin for several reasons:
There is not a close relationship, between the dose of ciclosporin given and level of drug in the blood.
Absorption and metabolism of oral doses of ciclosporin can vary greatly between patients and even in the same patient depending on the time of dose and what food is eaten.
There can be variation in blood levels due to the brand or preparation of ciclosporin prescribed.
In transplant patients, it is particularly important for graft survival to ensure that ciclosporin levels are high enough immediately following surgery to prevent rejection of the transplanted organ.
Blood levels need to be high enough in the case of rheumatoid arthritis or psoriasis to begin to give relief of symptoms.
In the case of kidney transplantation, blood levels may help to distinguish between kidney rejection and kidney damage due to high levels of ciclosporin.
Ciclosporin is associated with several toxic side effects that can be avoided if blood levels are monitored and the dose adjusted if the level detected is too high.
By monitoring ciclosporin blood levels, doctors can better ensure that each individual is receiving the right amount and formulation of drug needed to treat their particular case.
When is it requested?
Ciclosporin tests are requested frequently at the start of therapy, often on a daily basis when trying to establish the best dose to use. Once an appropriate dose has been determined, the level can be tested less frequently and may eventually be tested once every 1-2 months.
Often in transplantation, patients will begin with higher doses of cyclosporine at the start of therapy and then decrease the dose over the course of long-term therapy. In the cases of rheumatoid arthritis or psoriasis, if a patient appears to tolerate the drug well, the dose may be increased to further improve symptoms. With each change in dose, blood creatinine levels need to be measured to check the functioning of the kidneys.
The frequency of testing depends on a number of factors including type of organ transplanted, age, and general health status of the patient. For example, a patient with a transplanted liver may need to be monitored more regularly since ciclosporin is metabolized mainly by the liver, and poor liver function can slow removal of ciclosporin from the blood. Tests may also be requested more often when organ rejection or kidney toxicity is suspected.
What does the test result mean?
The target range for ciclosporin depends on both the method used to measure the drug and the type of transplant. Results obtained from different methods/laboratories are not interchangeable. Your doctor will be guided by the target range provided by the laboratory. Some laboratory methods are more specific for the ciclosporin parent drug while others measure the parent drug plus the metabolites so their respective ranges will differ.
Most hospitals use whole blood samples rather than serum or plasma and will collect samples 12 hours after the last dose or just before the next dose (trough levels).
If trough levels fall below the desired range, there is a risk of transplant rejection or symptom recurrence. If levels detected are above the range, there is a risk of toxic side effects or increased susceptibility to infection.
Some signs or symptoms of ciclosporin toxicity are:
high blood pressure
bleeding, swelling, overgrowth of gums
extra hair growth (hirsutism)
increased lipids in the blood (hyperlipidaemia)
Peak concentrations of samples collected 2 hours post dose are sometimes tested in transplant cases. High levels of ciclosporin in peak samples are correlated with reduced rejection rates, especially in the first year after transplant surgery.
Is there anything else I should know?
Because ciclosporin therapeutic ranges can vary with the type of method used by the laboratory, it is advisable for your blood samples to be tested by the same laboratory over the course of your treatment. Results will be more consistent and will correlate better with the reported therapeutic range.
For conditions other than transplants, ciclosporin may be prescribed with other medications such as non-steroidal anti-inflammatory drugs (NSAIDs). In transplant cases, other anti-rejection drugs may be used along with ciclosporin. These drugs will work together to treat your condition. In addition, ciclosporin blood levels can be affected by other drugs you may be taking. You should notify the doctor who is monitoring your ciclosporin levels of any additional drugs you are taking.
Ciclosporin can cause damage to the kidneys, especially with higher blood levels and over a longer period of time. Your doctor may want to monitor kidney function tests. Increases in blood lipid levels have been noted in some cases and liver function may be affected in ciclosporin therapy as well. Your doctor may order additional laboratory tests to detect high lipid levels or to see if your liver has been affected.
How long will I need to be on ciclosporin?
Transplant patients generally will stay on ciclosporin as long as that is the treatment of choice for them. If there are signs of rejection, even with blood levels in the therapeutic range, they may be switched to a different immunosuppressive drug. Also, there is a greater chance of toxic side effects the longer a patient is on ciclosporin, so a doctor may choose to alter drug therapy when a transplant patient has been on ciclosporin for more than 2-3 years.
Patients with an autoimmune disorder such as rheumatoid arthritis, Crohn’s disease, or psoriasis will be treated with ciclosporin only when their symptoms have developed rapidly and if other treatments have not been effective. It is not advised that these patients be on ciclosporin for more than a year due to the increase in the likelihood of toxic symptoms the longer they are on the medication. Short-term or intermittent courses of 12 weeks at a time are more advisable.
Who requests ciclosporin tests?
Ciclosporin will usually be monitored by doctors who have specific knowledge of the condition or disease for which the drug is prescribed. They tend to be very familiar with ciclosporin and its use in therapy, and they understand the importance of monitoring the drug. They may include your surgeon or your doctor treating you for your arthritis or psoriasis.
Can I test my ciclosporin level at home?