Cyclosporine

Also indexed as: Ciclosporin, Ciclosporine, Neoral, Sandimmun, Sandimmune, SangCya

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Cyclosporine is a drug that suppresses the immune system. It is used in combination with other immune suppressive drugs to prevent rejection of transplanted organs by the immune system. There are two different forms of cyclosporine, Sandimmune and Neoral. These products differ in important ways and each is used in combination with different additional immunosupressant drugs. Inadequate immune suppression may result in organ rejection and serious complications. People taking cyclosporine should follow their prescribing doctor’s directions exactly and discuss with their doctor any changes in drug therapy, vitamins, supplements, herbal products, or any other substances before making the changes.

Summary of Interactions with Vitamins, Herbs, and Foods
In some cases, a herb or supplement may appear in more than one category, which may seem contradictory. For clarification, read the full article for details about the summarized interactions.

Beneficial May Be Beneficial: Depletion or interference—The medication may deplete or interfere with the absorption or function of the nutrient. Taking these nutrients may help replenish them.

Magnesium

Red wine
Beneficial May Be Beneficial: Side effect reduction/prevention—Taking these supplements may help reduce the likelihood and/or severity of a potential side effect caused by the medication.

Ginkgo*

Omega-3 fatty acids*
Beneficial May Be Beneficial: Supportive interaction—Taking these supplements may support or otherwise help your medication work better.

Vitamin E*
Avoid Avoid: Reduced drug absorption/bioavailability—Avoid these supplements when taking this medication since the supplement may decrease the absorption and/or activity of the medication in the body.

Chinese scullcap

St. John’s wort*
Check Check: Other—Before taking any of these supplements or eating any of these foods with your medication, read this article in full for details.

Apple juice

Grapefruit juice

Milk

Orange juice

Pomegranate juice*

Quercetin
Adverse interaction

None known
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An asterisk (*) next to an item in the summary indicates that the interaction is supported only by weak, fragmentary, and/or contradictory scientific evidence.

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Interactions with Dietary Supplements

Magnesium
Cyclosporine has been associated with low blood magnesium levels and undesirable side effects.1 2 3 Some doctors suggest monitoring the level of magnesium in red blood cells, rather than in serum, as the red blood cell test may be more sensitive for evaluating magnesium status.

Potassium
Cyclosporine can cause excess retention of potassium, potentially leading to dangerous levels of the mineral in the blood (hyperkalemia).4 Potassium supplements, potassium-containing salt substitutes (No Salt, Morton Salt Substitute, and others), and even high-potassium foods (primarily fruit) should be avoided by people taking cyclosporine, unless directed otherwise by their doctor.

Omega-3 fatty acids
A few studies have shown that in organ transplant patients treated with cyclosporine, addition of 4–6 grams per day of omega-3 fatty acids from fish oil helped reduce high blood pressure,5 6 7 though not every study has found fish oil helpful.8 It remains unclear to what extent fish oil supplementation will help people with high blood pressure taking cyclosporine following organ transplant.

Vitamin E
Twenty-six liver transplant patients (both adults and children) unable to achieve or maintain therapeutic cyclosporine blood levels during the early post-transplant period were given water-soluble vitamin E in the amount of 6.25 IU/2.2 pounds of body weight two times per day.9 Addition of vitamin E in the early post-transplant period reduced the required amount of cyclosporine and the cost of cyclosporine therapy by 26%. These results imply that the addition of vitamin E to established cyclosporine therapy allows for a decrease in the amount of cyclosporine. Combining vitamin E and cyclosporine requires medical supervision to avoid cyclosporine toxicity.

Quercetin
In an animal study, oral administration of quercetin (50 mg per 2.2 pounds of body weight) at the same time as cyclosporine decreased the absorption of cyclosporine by 43%.10 However, in a study of healthy human volunteers, supplementing with quercetin along with cyclosporine significantly increased blood levels of cyclosporine, when compared with administering cyclosporine alone.11 Because the effect of quercetin supplementation on cyclosporine absorption or utilization appears to be unpredictable, individuals taking cyclosporine should not take quercetin without the supervision of a doctor.

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Interactions with Herbs

Chinese scullcap
In a study in rats, oral administration of Chinese scullcap at the same time as cyclosporine significantly reduced the absorption of cyclosporine.12 Chinese scullcap did not interfere with the availability of cyclosporine when cyclosporine was given intravenously. Because of the potential adverse interaction, people taking cyclosporine should not take Chinese scullcap.

Ginkgo
Ginkgo was reported to protect liver cells from damage caused by cyclosporine in a test tube experiment.13 A Ginkgo biloba extract partially reversed cyclosporine-induced reduced kidney function in a study of isolated rat kidneys.14 Human trials have not studied the actions of ginkgo to prevent or reduce the side effects of cyclosporine.

St. John’s wort 
Pharmacological research from Europe suggests that St. John’s wort (Hypericum perforatum) may reduce plasma levels of cyclosporine.15 Two case reports also describe heart transplant patients taking cyclosporine who showed signs of acute transplant rejection after taking St. John’s wort extract.16 In both cases, reduced plasma concentrations of cyclosporine were found. One report cites similar findings in three patients taking cyclosporine and St. John’s wort together.17 Finally, similar drops in cyclosporine blood levels were reported in 45 kidney or liver transplant patients who began taking St. John’s wort.18 Until more is known, people taking cyclosporine should avoid the use of St. John’s wort.

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Interactions with Foods and Other Compounds

Food
Food increases the absorption of cyclosporine.19 A change in the timing of food and cyclosporine dosing may alter cyclosporine blood levels, requiring dose adjustment.

Grapefruit juice
In a randomised study of nine adults with cyclosporine-treated auto-immune diseases, grapefruit juice (5 ounces two times per day with cyclosporine, for ten days) caused a significant increase in cyclosporine blood levels compared with cyclosporine with water.20 The rise in cyclosporine blood levels was associated with abdominal pain, lightheadedness, nausea, and tremor in one patient. Using grapefruit juice to reduce the amount of cyclosporine needed has not been sufficiently studied and cannot therefore be counted on to produce a predictable change in cyclosporine requirements. The same effects might be seen from eating grapefruit as from drinking its juice.

Pomegranate juice
Pomegranate juice has been shown to inhibit the same enzyme that is inhibited by grapefruit juice.21 22 The degree of inhibition is about the same for each of these juices. Therefore, it would be reasonable to expect that pomegranate juice might interact with cyclosporine in the same way that grapefruit juice does.

Red wine
Ingestion of red wine along with cyclosporine has been found to reduce blood levels of the drug.23 Individuals taking cyclosporine should, therefore, not consume red wine at the same time as they take the drug. It is not known whether red wine consumed at a different time of the day would affect the availability of cyclosporine. Until more is known, it seems prudent for people taking cyclosporine to avoid red wine altogether.

Milk, apple juice, and orange juice
Mixing Sandimmune solution with room-temperature milk, chocolate milk, orange juice, or apple juice may improve its flavour.24

Mixing Neoral solution with room temperature orange or apple juice may improve its flavour, but combining it with milk makes an unpalatable mix.25

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References
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