title: Combined immunosuppression with cyclosporine (neoral) and SDZ RAD in non-human primate lung transplantation: systematic pharmacokinetic-based trials to improve efficacy and tolerability.
abstract: BACKGROUND
  We studied the efficacy and tolerability of combined immunosuppressive therapy with cyclosporine A microemulsion (Neoral) plus the macrolide SDZ RAD 40-0 (2-hydroxyethyl) rapamycin (RAD) in a stringent cynomolgus monkey lung graft model in comparison with cyclosporine or SDZ RAD monotherapy.
  
  
  METHODS
  Thirty-nine cynomolgus monkeys received mixed lymphocyte reaction (MLR) mismatched unilateral lung transplants. Immunosuppressants were administered orally as single daily doses. The observation period was 28 days and follow-up included serial trough blood drug concentrations measured by high performance liquid chromatography/mass spectrometry, blood analyses, chest radiographs, open lung biopsies, as well as tissue drug concentrations and graft histology at necropsy.
  
  
  RESULTS
  Graft biopsies in monkeys treated with vehicle (n=4), Neoral (day 1-7: 150 mg/kg/day; day 8-28: 100 mg/kg/day; n=6; mean +/- SE trough level (MTL): 292+/-17 ng/ml) or SDZ RAD monotherapy (1.5 mg/kg/day; n=6; MTL: 15+/-1 ng/ml) showed severe rejection. Coadministration in two transplant monkeys of Neoral (150/100 mg/kg/day) and SDZ RAD (1.5 mg/kg/day) caused their early death. In both animals, SDZ RAD blood levels were more than 5-fold higher than under monotherapy (MTL: 82+/-18 ng/ml). Simultaneous administration (n=6) of Neoral (150/100 mg/kg/day; MTL: 217+/-16 ng/ml) and SDZ RAD (0.3 mg/kg/day; MTL: 24+/-2 ng/ml) improved graft outcome (mild rejection). Side effects included renal failure (n=2) and seizures (n=1). Three monkeys survived to day 28. In this group the MTL for cyclosporin was 143+/-13 and for RAD 38+/-3. Staggered treatment completely prevented rejection in four of six grafts. However, five of six monkeys had moderate to severe diarrhea. In a concentration-controlled trial of simultaneously administered Neoral and SDZ RAD in transplant monkeys (target SDZ RAD MTL: 20-40 ng/ml; cyclosporine MTL: 100-200 ng/ml) all six monkeys survived with improved drug tolerability and an average biopsy score of mild rejection.
  
  
  CONCLUSIONS
  Combination of orally administered SDZ RAD and Neoral showed excellent immunosuppressive efficacy in a stringent lung transplant model. The drug interaction and the narrow therapeutic index of this drug combination required careful dose adjustments to optimize tolerability and efficacy.
authors.affiliation: Transplantation Immunology, Department of Cardiothoracic Surgery, Stanford University, Palo Alto, CA 94305-5407, USA.
authors.forename: B
authors.initials: B
authors.lastname: Hausen
authors.forename: T
authors.initials: T
authors.lastname: Ikonen
authors.forename: N
authors.initials: N
authors.lastname: Briffa
authors.forename: G J
authors.initials: GJ
authors.lastname: Berry
authors.forename: U
authors.initials: U
authors.lastname: Christians
authors.forename: R C
authors.initials: RC
authors.lastname: Robbins
authors.forename: L
authors.initials: L
authors.lastname: Hook
authors.forename: N
authors.initials: N
authors.lastname: Serkova
authors.forename: L Z
authors.initials: LZ
authors.lastname: Benet
authors.forename: W
authors.initials: W
authors.lastname: Schuler
authors.forename: R E
authors.initials: RE
authors.lastname: Morris
mesh_terms: D000818:Animals; D001769:Blood / Q000378:metabolism; D001999:Bronchoscopy; D016572:Cyclosporine / Q000627:therapeutic use*; D004305:Dose-Response Relationship, Drug; D004359:Drug Therapy, Combination; D000068338:Everolimus; D006084:Graft Rejection / Q000473:pathology / Q000517:prevention & control; D007166:Immunosuppressive Agents / Q000627:therapeutic use*; D008168:Lung / Q000473:pathology / Q000503:physiopathology; D016040:Lung Transplantation; D008252:Macaca fascicularis; D020123:Sirolimus / Q000031:analogs & derivatives* / Q000097:blood / Q000627:therapeutic use
chemical_list: D007166:Immunosuppressive Agents; D016572:Cyclosporine; D000068338:Everolimus; D020123:Sirolimus