Neoral (ciclosporin) is an immunosuppressant medicine used to suppress the immune system in several situations:

• Preventing rejection of transplanted organs (kidney, liver, heart, and other transplants)
• Treating severe rheumatoid arthritis that has not responded to other treatments
• Treating severe plaque psoriasis
• Treating severe atopic dermatitis (eczema)

Ciclosporin works by blocking the activation of T-lymphocytes, the main immune cells responsible for rejection and immune-mediated inflammation. Neoral is a microemulsion formulation that provides more consistent and predictable absorption compared to older ciclosporin formulations.

Take Neoral twice daily, at the same times each day. It can be taken with or without food, but always take it the same way: either consistently with food or consistently without. Changing your habits can affect drug levels.

Swallow capsules whole. If you need to take the capsules from a different manufacturer, tell your doctor as different ciclosporin products are not always interchangeable.

Do not eat grapefruit or drink grapefruit juice while taking Neoral. Grapefruit increases ciclosporin levels and can cause toxicity.

Do not stop taking Neoral without speaking to your transplant specialist or specialist doctor.

Take the missed dose as soon as you remember. If it is nearly time for your next dose, skip the missed dose and continue your schedule. Never take a double dose. Tell your doctor if you miss doses, as this can affect drug levels and rejection risk.

Seek urgent medical attention. Signs of toxicity include kidney problems, excessive tremor, and elevated blood pressure. Blood levels can be measured to confirm toxicity.

• Store below 25°C
• Keep in the original blister pack
• Once opened, capsules must be used within two months
• Keep out of reach of children
  

Neoral capsules may look slightly oily or have a slight odour: this is normal.

Side effects are common, especially with long-term use.

Very common side effects:

• Kidney problems (nephrotoxicity): elevated creatinine is common. Kidney function is monitored closely with blood tests
• High blood pressure (hypertension): blood pressure monitoring is required
• Gum overgrowth (gingival hyperplasia): regular dental hygiene is important
• Excessive hair growth (hypertrichosis)
• Tremor (shakiness)

Common side effects:

• Headache
• Nausea
• Raised cholesterol and triglycerides

Serious side effects:

• Serious kidney damage: ciclosporin is one of the main causes of long-term kidney injury in transplant patients. Drug levels and kidney function must be monitored closely
• Infections: immunosuppression increases infection risk
• Skin cancer and lymphoma with long-term use: sun protection is essential

Blood tests to measure ciclosporin levels (trough levels), kidney function, liver function, and blood pressure are part of regular monitoring.

Ciclosporin has very many interactions. Key ones include:

• Grapefruit juice: increases ciclosporin levels significantly. Avoid completely
• Rifampicin, carbamazepine, phenytoin, St John's Wort: dramatically reduce ciclosporin levels, risking rejection
• Macrolide antibiotics (erythromycin, clarithromycin), antifungals (fluconazole, ketoconazole), calcium channel blockers (diltiazem, verapamil): increase ciclosporin levels, increasing toxicity risk
• Statins: ciclosporin significantly increases statin levels, raising the risk of serious muscle side effects. Your doctor will review which statins are safe and at what dose
• NSAIDs (ibuprofen, naproxen): increase kidney toxicity risk

Always tell every healthcare provider you are on ciclosporin. Never start a new medicine without checking for interactions first.

How do I know if my ciclosporin level is right?

Your doctor will measure a blood sample taken just before your morning dose (called a trough level). This is the lowest level in your blood before the next dose and gives the best indication of whether your dose is in the therapeutic range: high enough to prevent rejection, but not so high that it causes kidney or liver damage. Keep your blood test appointments consistent and always take your blood test at the same time relative to your dose.

Why can't I switch to a different brand of ciclosporin?

Different ciclosporin products (Neoral, Sandimmun Neoral, and generic ciclosporin) may have different absorption characteristics. Even small differences in blood levels can affect transplant outcomes. Your transplant team will specify which product to take and will not recommend switching without a plan for monitoring your levels during the changeover.

Ace provides accurate and independent information medically reviewed on prescription medications. This material is provided for educational purposes only and is not intended for medical advice, diagnosis or treatment.