GENGRAF- cyclosporine solution
Only physicians experienced in the management of systemic immunosuppressive therapy for the indicated disease should prescribe Gengraf (cyclosporine oral solution, USP [MODIFIED ]). At doses used in solid organ transplantation, only physicians experienced in immunosuppressive therapy and management of organ transplant recipients should prescribe Gengraf. Patients receiving the drug should be managed in facilities equipped and staffed with adequate laboratory and supportive medical resources. The physician responsible for maintenance therapy should have complete information requisite for the follow-up of the patient.
Gengraf, a systemic immunosuppressant, may increase the susceptibility to infection and the development of neoplasia. In kidney, liver, and heart transplant patients Gengraf may be administered with other immunosuppressive agents. Increased susceptibility to infection and the possible development of lymphoma and other neoplasms may result from the increase in the degree of immunosuppression in transplant patients.
Gengraf (cyclosporine oral solution, USP [MODIFIED ]) has increased bioavailability in comparison to Sandimmune® * (cyclosporine oral solution, USP [Non-Modified]). Gengraf and Sandimmune* are not bioequivalent and cannot be used interchangeably without physician supervision. For a given trough concentration, cyclosporine exposure will be greater with Gengraf than with Sandimmune*. If a patient who is receiving exceptionally high doses of Sandimmune* is converted to Gengraf, particular caution should be exercised. Cyclosporine blood concentrations should be monitored in transplant and rheumatoid arthritis patients taking Gengraf to avoid toxicity due to high concentrations. Dose adjustments should be made in transplant patients to minimize possible organ rejection due to low concentrations. Comparison of blood concentrations in the published literature with blood concentrations obtained using current assays must be done with detailed knowledge of the assay methods employed.
For Psoriasis Patients (see also Boxed WARNINGS above) Psoriasis patients previously treated with PUVA and to a lesser extent, methotrexate or other immunosuppressive agents, UVB, coal tar, or radiation therapy, are at an increased risk of developing skin malignancies when taking Gengraf (cyclosporine oral solution, USP [MODIFIED ]).
Cyclosporine, the active ingredient in Gengraf, in recommended dosages, can cause systemic hypertension and nephrotoxicity. The risk increases with increasing dose and duration of cyclosporine therapy. Renal dysfunction, including structural kidney damage, is a potential consequence of cyclosporine, and therefore, renal function must be monitored during therapy.
Cyclosporine, the active principle in Gengraf Oral Solution, is a cyclic polypeptide immunosuppressant agent consisting of 11 amino acids. It is produced as a metabolite by the fungus species Aphanocladium album.
Chemically, cyclosporine is designated as [R-[R*,R*-(E)]]-cyclic-(L-alanyl-D-alanyl-N-methyl-L-leucyl-N -methyl-L-leucyl-N- methyl-L-valyl-3-hydroxy-N ,4-dimethyl-L-2-amino-6-octenoyl-L-α-amino-butyryl-N -methylglycyl-N -methyl-L-leucyl-L-valyl-N -methyl-L-leucyl).
Cyclosporine is a potent immunosuppressive agent that in animals prolongs survival of allogeneic transplants involving skin, kidney, liver, heart, pancreas, bone marrow, small intestine, and lung. Cyclosporine has been demonstrated to suppress some humoral immunity and to a greater extent, cell-mediated immune reactions such as allograft rejection, delayed hypersensitivity, experimental allergic encephalomyelitis, Freund’s adjuvant arthritis, and graft vs. host disease in many animal species for a variety of organs.
The effectiveness of cyclosporine results from specific and reversible inhibition of immunocompetent lymphocytes in the G0 -and G1 -phase of the cell cycle. T-lymphocytes are preferentially inhibited. The T-helper cell is the main target, although the T-suppressor cell may also be suppressed. Cyclosporine also inhibits lymphokine production and release including interleukin-2.
No effects on phagocytic function (changes in enzyme secretions, chemotactic migration of granulocytes, macrophage migration, carbon clearance in vivo) have been detected in animals. Cyclosporine does not cause bone marrow suppression in animal models or man.
The immunosuppressive activity of cyclosporine is primarily due to parent drug. Following oral administration, absorption of cyclosporine is incomplete. The extent of absorption of cyclosporine is dependent on the individual patient, the patient population, and the formulation. Elimination of cyclosporine is primarily biliary with only 6% of the dose (parent drug and metabolites) excreted in urine. The disposition of cyclosporine from blood is generally biphasic, with a terminal half-life of approximately 8.4 hours (range 5 to 18 hours). Following intravenous administration, the blood clearance of cyclosporine (assay: HPLC) is approximately 5 to 7 mL/min/kg in adult recipients of renal or liver allografts. Blood cyclosporine clearance appears to be slightly slower in cardiac transplant patients.
The Gengraf Capsules (cyclosporine capsules, USP [MODIFIED ]) and Gengraf Oral Solution (cyclosporine oral solution, USP [MODIFIED ]) are bioequivalent. Gengraf Oral Solution diluted with orange juice or with apple juice is bioequivalent to Gengraf Oral Solution diluted with water. The effect of milk on the bioavailability of cyclosporine when administered as Gengraf Oral Solution has not been evaluated.
The relationship between administered dose and exposure (area under the concentration versus time curve, AUC) is linear within the therapeutic dose range. The intersubject variability (total, % CV) of cyclosporine exposure (AUC) when cyclosporine (MODIFIED) or Sandimmune® is administered ranges from approximately 20% to 50% in renal transplant patients. This intersubject variability contributes to the need for individualization of the dosing regimen for optimal therapy (see DOSAGE AND ADMINISTRATION). Intrasubject variability of AUC in renal transplant recipients (% CV) was 9%-21% for cyclosporine (MODIFIED) and 19%-26% for Sandimmune®. In the same studies, intrasubject variability of trough concentrations (% CV) was 17%-30% for cyclosporine (MODIFIED) and 16%-38% for Sandimmune®.
Cyclosporine (MODIFIED) has increased bioavailability compared to Sandimmune®. The absolute bioavailability of cyclosporine administered as Sandimmune (cyclosporine) is dependent on the patient population, estimated to be less than 10% in liver transplant patients and as great as 89% in some renal transplant patients. The absolute bioavailability of cyclosporine administered as cyclosporine (MODIFIED) has not been determined in adults. In studies of renal transplant, rheumatoid arthritis and psoriasis patients, the mean cyclosporine AUC was approximately 20% to 50% greater and the peak blood cyclosporine concentration (Cmax ) was approximately 40% to 106% greater following administration of cyclosporine (MODIFIED) compared to following administration of Sandimmune®. The dose normalized AUC in de novo liver transplant patients administered cyclosporine (MODIFIED) 28 days after transplantation was 50% greater and Cmax was 90% greater than in those patients administered Sandimmune®. AUC and Cmax are also increased (cyclosporine [MODIFIED ] relative to Sandimmune®) in heart transplant patients, but data are very limited. Although the AUC and Cmax values are higher on cyclosporine (MODIFIED) relative to Sandimmune® , the pre-dose trough concentrations (dose-normalized) are similar for the two formulations.
Following oral administration of cyclosporine (MODIFIED), the time to peak blood cyclosporine concentrations (Tmax ) ranged from 1.5 to 2.0 hours. The administration of food with cyclosporine (MODIFIED) decreases the cyclosporine AUC and Cmax . A high fat meal (669 kcal, 45 grams fat) consumed within one-half hour before cyclosporine (MODIFIED) administration decreased the AUC by 13% and Cmax by 33%. The effects of a low fat meal (667 kcal, 15 grams fat) were similar.
The effect of T-tube diversion of bile on the absorption of cyclosporine from cyclosporine (MODIFIED) was investigated in eleven de novo liver transplant patients. When the patients were administered cyclosporine (MODIFIED) with and without T-tube diversion of bile, very little difference in absorption was observed, as measured by the change in maximal cyclosporine blood concentrations from pre-dose values with the T-tube closed relative to when it was open: 6.9 ± 41% (range -55% to 68%).
|Pharmacokinetic Parameters (mean ±SD)|
|Patient Population||Dose/day1 (mg/d)||Dose/ weight (mg/kg/d)||AUC2 (ng·hr/mL)||Cmax (ng/mL)||Trough3 (ng/mL)||CL/F(mL/min)||CL/F(mL/min/kg)|
|De novo renal transplant4 Week 4 (N = 37)||597 ± 174||7.95 ± 2.81||8772 ± 2089||1802 ± 428||361 ± 129||593 ± 204||7.8 ± 2.9|
|Stable renal transplant4 (N = 55)||344 ± 122||4.10 ± 1.58||6035 ± 2194||1333 ± 469||251 ± 116||492 ± 140||5.9 ± 2.1|
|De novo liver transplant5 Week 4 (N = 18)||458 ± 190||6.89 ± 3.68||7187 ± 2816||1555 ± 740||268 ± 101||577 ± 309||8.6 ± 5.7|
|De novo rheumatoid arthritis6 (N = 23)||182 ± 55.6||2.37 ± 0.36||2641 ± 877||728 ± 263||96.4 ± 37.7||613 ± 196||8.3 ± 2.8|
|De novo psoriasis6 Week 4 (N = 18)||189 ± 69.8||2.48 ± 0.65||2324 ± 1048||655 ± 186||74.9 ± 46.7||723 ± 186||10.2 ± 3.9|
|1 Total daily dose was divided into two doses administered every 12 hours.2 AUC was measured over one dosing interval.3 Trough concentration was measured just prior to the morning cyclosporine (MODIFIED) dose, approximately 12 hours after the previous dose.4 Assay: TDx specific monoclonal fluorescence polarization immunoassay.5 Assay: Cyclo-trac specific monoclonal radioimmunoassay.6 Assay: INCSTAR specific monoclonal radioimmunoassay.|
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