cyclosporine (Rx)

Brand and Other Names:Neoral, Sandimmune, more...Gengraf
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Dosing & Uses

AdultPediatric

Dosage Forms & Strengths

capsule

  • 25mg (Gengraf, Neoral, Sandimmune)
  • 50mg (Gengraf, Sandimmune)
  • 100mg (Gengraf, Neoral, Sandimmune)

oral solution

  • 100mg/mL (Gengraf, Neoral, Sandimmune)

injectable solution

  • 50mg/mL (Sandimmune)

Solid Organ Transplantation

Prophylaxis of organ rejection in kidney, liver, and heart allogeneic transplants; has been used in combination with azathioprine and corticosteroids

Adjust dosage according to trough levels, general dosage guidelines listed below

Oral

  • 4-12 hr pre-transplant: 15 mg/kg PO for 1 dose  
  • 1-2 wk post-transplant: 15 mg/kg/day PO divided BID
  • Reduce 5% per wk until: 5-10 mg/kg/day PO divided BID

IV

  • 4-12 hr pre-transplant IV: 5-6 mg/kg IV for 1 dose over 2-6 hours
  • Post-transplant, until can tolerate oral therapy: 5-6 mg/kg IV qDay

Rheumatoid Arthritis

Indicated for severe active, rheumatoid arthritis where the disease has not adequately responded to methotrexate; may be used in combination with methotrexate

Gengraf or Neoral: 1.25 mg/kg PO BID; may increase by 0.5-0.75 mg/kg/day after 8 weeks and again after 12 wk if needed, not to exceed 4 mg/kg/day  

Discontinue if no improvement observed by 16 wk

Decrease dose by 25-50% at any time to control adverse effects (eg, hypertension, elevations in serum creatine >30% pretreatment level

Psoriasis

Indicated for treatment of adult, nonimmunocompromised patients with severe, recalcitrant, plaque psoriasis who have failed to respond to at least 1 systemic therapy (eg, PUVA, retinoids, or methotrexate) or in patients for whom other systemic therapies are contraindicated, or cannot be tolerated

Gengraf or Neoral: 1.25 mg/kg PO BID; may increase by 0.5 mg/kg/day after 4 wk and q2wk if needed, not to exceed 4 mg/kg/day  

Discontinue if no improvement observed at 6 weeks on maximum daily dose of 4 mg/kg/day

Decrease dose by 25-50% at any time to control adverse effects (eg, hypertension, elevations in serum creatine >30% pretreatment level

Orphan Designations

ALS

  • Treatment of amyotropohic lateral sclerosis and its variants
  • Orphan sponsor: Maas Biolab,LLC; Tecnology Ventures, Corporation Technopolis 1155 University Blvd., SE; Albuquerque, NM 87106

Traumatic Brain Injury

  • Treatment of moderate-to-severe traumatic brain injury
  • Orphan sponsor: NeuroVive Pharmaceutical AB, Biomedical Center SE-221 84; Lund, Sweden

Lung Transplant

  • Prophylaxis of organ rejection in patients receiving allogeneic lung transplant
  • Treatment of acute rejection in recipients of allogeneic lung transplants
  • Orphan sponsor: APT Pharmaceuticals, Inc; 700 Airport Blvd, Suite 350; Burlingame, CA 94010

GVHD

  • Prophylaxis and treatment of graft versus host disease
  • Orphan sponsor: Sigmoid Pharma LTD; Dublin City University; Ireland

Lung Allograft Rejection

  • Liposomal: For aerosolized administration in the prevention and treatment of lung allograft rejection
  • Orphan sponsor: Vernon Knight, M.D.; Baylor College of Medicine, Dept. of Molecular Phy, One Baylor Plaza; Houston, TX 77030

Pulmonary Rejection With BMT

  • Liposomal: For aerosolized administration in the prevention and treatment of pulmonary rejection events associated with bone marrow transplant (BMT)
  • Orphan sponsor: Vernon Knight, M.D.; Baylor College of Medicine, Dept. of Molecular Phy, One Baylor Plaza; Houston, TX 77030

Bronchioitis Obliterans (Orphan)

  • Liposomal cyclosporine for inhalation
  • Orphan sponsor: PARI Pharma GmbH; Moosstrasse 3; Germany

Dosage Forms & Strengths

capsule

  • 25mg (Gengraf, Neoral, Sandimmune)
  • 50mg (Gengraf, Sandimmune)
  • 100mg (Gengraf, Neoral, Sandimmune)

oral solution

  • 100mg/mL (Gengraf, Neoral, Sandimmune)

injectable solution

  • 50mg/mL (Sandimmune)

Solid Organ Transplantation (Off-Label)

Prophylaxis of organ rejection in kidney, liver, and heart allogeneic transplants; has been used in combination with azathioprine and corticosteroids

Children as young as 6 months have received cyclosporine to prevent solid organ transplant rejection

Dosage is same as adults, although children may require higher mg/kg dose than adults

Adjust dosage according to trough levels, general dosage guidelines listed below

Oral

  • 4-12 hr pretransplant: 15 mg/kg PO for 1 dose  
  • 1-2 wk post-transplant: 15 mg/kg/day PO divided BID
  • Reduce 5% per wk until: 5-10 mg/kg/day PO divided BID

IV

  • 4-12 hr pre-transplant IV: 5-6 mg/kg IV for 1 dose over 2-6 hr
  • Posttransplant, until can tolerate oral therapy: 5-6 mg/kg IV qDay
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Interactions

Interaction Checker

and cyclosporine

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            Contraindicated (13)

            • amphotericin B deoxycholate

              amphotericin B deoxycholate and cyclosporine both increase nephrotoxicity and/or ototoxicity. Contraindicated.

            • atorvastatin

              cyclosporine increases toxicity of atorvastatin by Other (see comment). Contraindicated. Comment: OATP1B1 inhibitors may increase risk of myopathy.

            • bosentan

              cyclosporine will increase the level or effect of bosentan by Other (see comment). Contraindicated. may increase plasma concentrations of OATP substrates

            • cidofovir

              cidofovir and cyclosporine both increase nephrotoxicity and/or ototoxicity. Contraindicated.

            • dronedarone

              cyclosporine will increase the level or effect of dronedarone by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • elagolix

              cyclosporine will increase the level or effect of elagolix by Other (see comment). Contraindicated. Concomitant use of elagolix and strong OATP1B1 inhibitors is contraindicated.

            • elbasvir/grazoprevir

              cyclosporine increases levels of elbasvir/grazoprevir by Other (see comment). Contraindicated. Comment: Coadministration with strong OATP1B1/3 inhibitors may increase the risk of ALT elevations owing to a significant increase in grazoprevir plasma concentrations.

            • flibanserin

              cyclosporine will increase the level or effect of flibanserin by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated. Coadministration of flibanserin with moderate or strong CYP3A4 inhibitors is contraindicated. Severe hypotension or syncope can occur.

            • lonafarnib

              cyclosporine will increase the level or effect of lonafarnib by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated. Lonafarnib is a sensitive CYP3A4 substrate. Coadministration with strong or moderate CYP3A4 inhibitors is contraindicated.

            • mifepristone

              mifepristone increases levels of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated. Contraindicated with CYP3A substrates that have a narrow therapeutic index .

            • pimozide

              cyclosporine will increase the level or effect of pimozide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • pitavastatin

              cyclosporine increases toxicity of pitavastatin by Other (see comment). Contraindicated. Comment: OATP1B1 inhibitors may increase risk of myopathy.

            • simvastatin

              cyclosporine will increase the level or effect of simvastatin by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated. Contraindicated. Increased risk for rhabdomyolysis with drugs that increase simvastatin systemic exposure.

              cyclosporine will increase the level or effect of simvastatin by Other (see comment). Contraindicated. OATP1B1 inhibitors may increase risk of myopathy

            Serious - Use Alternative (148)

            • abametapir

              abametapir will increase the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. For 2 weeks after abametapir application, avoid taking drugs that are CYP3A4 substrates. If not feasible, avoid use of abametapir.

            • adalimumab

              adalimumab and cyclosporine both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

            • adenovirus types 4 and 7 live, oral

              cyclosporine decreases effects of adenovirus types 4 and 7 live, oral by pharmacodynamic antagonism. Contraindicated. Avoid live vaccines in immunocompromised patients due to the risk of developing a clinical infection from the live vaccine. Inadequate immune response to the vaccine may also occur in the presence of immunosuppressants. Avoid live vaccines for at least 3 months after cessation of immunosuppressant therapy unless the benefit of vaccine administration outweighs the potential risk.

            • afatinib

              cyclosporine increases levels of afatinib by P-glycoprotein (MDR1) efflux transporter. Avoid or Use Alternate Drug. Reduce afatinib daily dose by 10 mg if not tolerated when coadministered with P-gp inhibitors.

            • aliskiren

              cyclosporine will increase the level or effect of aliskiren by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Avoid concurrent use. Coadministration of 200 mg and 600 mg cyclosporine, with 75 mg aliskiren resulted in an approximately 2.5-fold increase in Cmax and 5-fold increase in AUC of aliskiren

              cyclosporine will increase the level or effect of aliskiren by P-glycoprotein (MDR1) efflux transporter. Avoid or Use Alternate Drug. Avoid concurrent use. Coadministration of 200 mg and 600 mg cyclosporine, with 75 mg aliskiren resulted in an approximately 2.5-fold increase in Cmax and 5-fold increase in AUC of aliskiren

            • alpelisib

              cyclosporine will increase the level or effect of alpelisib by Other (see comment). Avoid or Use Alternate Drug. Coadministration of alpelisib (BCRP substrate) with a BCRP inhibitor may increase alpelisib concentration, which may increase the risk of toxicities. If unable to avoid or use alternant drugs, closely monitor for increased adverse reactions.

            • ambrisentan

              cyclosporine will increase the level or effect of ambrisentan by Other (see comment). Avoid or Use Alternate Drug. may increase plasma concentrations of OATP substrates

            • amikacin

              amikacin and cyclosporine both increase nephrotoxicity and/or ototoxicity. Avoid or Use Alternate Drug.

            • amiloride

              amiloride and cyclosporine both increase serum potassium. Avoid or Use Alternate Drug. Coadministration not recommended

            • anakinra

              anakinra and cyclosporine both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

            • anthrax vaccine

              cyclosporine decreases effects of anthrax vaccine by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

            • antithymocyte globulin equine

              antithymocyte globulin equine and cyclosporine both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

            • antithymocyte globulin rabbit

              antithymocyte globulin rabbit and cyclosporine both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

            • apalutamide

              apalutamide will decrease the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Coadministration of apalutamide, a strong CYP3A4 inducer, with drugs that are CYP3A4 substrates can result in lower exposure to these medications. Avoid or substitute another drug for these medications when possible. Evaluate for loss of therapeutic effect if medication must be coadministered. Adjust dose according to prescribing information if needed.

            • atorvastatin

              cyclosporine will increase the level or effect of atorvastatin by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Coadministration increases risk of statin-associated myopathy including rhabdomyolysis

            • avapritinib

              cyclosporine will increase the level or effect of avapritinib by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Avoid coadministration of avapritinib with moderate CYP3A4 inhibitors. If unable to avoid, reduce avapritinib starting dose. See drug monograph Dosage Modifications.

            • axitinib

              cyclosporine increases levels of axitinib by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. If unable to avoid coadministration with moderate CYP3A4 inhibitors, monitor closely and reduce dose if necessary .

            • bacitracin

              cyclosporine and bacitracin both increase nephrotoxicity and/or ototoxicity. Avoid or Use Alternate Drug. Avoid concurrent use of bacitracin with other nephrotoxic drugs

            • baricitinib

              baricitinib, cyclosporine. Either increases toxicity of the other by immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug. Baricitinib is not recommended in combination with other JAK inhibitors, biologic DMARDs, or potent immunosuppressives.

            • BCG vaccine live

              cyclosporine decreases effects of BCG vaccine live by pharmacodynamic antagonism. Contraindicated. Avoid live vaccines in immunocompromised patients due to the risk of developing a clinical infection from the live vaccine. Inadequate immune response to the vaccine may also occur in the presence of immunosuppressants. Avoid live vaccines for at least 3 months after cessation of immunosuppressant therapy unless the benefit of vaccine administration outweighs the potential risk.

            • bosentan

              cyclosporine will increase the level or effect of bosentan by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • bosutinib

              cyclosporine increases levels of bosutinib by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

              cyclosporine increases levels of bosutinib by P-glycoprotein (MDR1) efflux transporter. Avoid or Use Alternate Drug.

            • bremelanotide

              bremelanotide will decrease the level or effect of cyclosporine by Other (see comment). Avoid or Use Alternate Drug. Bremelanotide may slow gastric emptying and potentially reduces the rate and extent of absorption of concomitantly administered oral medications. Avoid use when taking any oral drug that is dependent on threshold concentrations for efficacy. Interactions listed are representative examples and do not include all possible clinical examples.

            • brigatinib

              brigatinib will decrease the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Brigatinib induces CYP3A4 in vitro. Coadministration with CYP3A4 substrates, particularly those with a narrow therapeutic index, can result in decreased concentrations and loss of efficacy. If unable to avoid coadministration, monitor CYP3A4 substrate levels and adjust dose as needed.

            • canakinumab

              canakinumab and cyclosporine both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug. Formation of CYP450 enzymes can be altered by increased levels of certain cytokines during chronic inflammation; thus, canakinumab could normalize the formation of CYP450 enzymes. Upon initiation or discontinuation of canakinumab in patients who are receiving concomitant CYP450 substrates, particularly those with a narrow therapeutic index, consider monitoring for therapeutic effect.

            • caspofungin

              cyclosporine will increase the level or effect of caspofungin by Other (see comment). Avoid or Use Alternate Drug. may increase plasma concentrations of OATP substrates

            • ceritinib

              ceritinib increases levels of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Avoid concurrent use of CYP3A substrates known to have narrow therapeutic indices or substrates primarily metabolized by CYP3A during treatment with ceritinib; if use of these medications is unavoidable, consider dose reduction.

            • chloramphenicol

              chloramphenicol will increase the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • cholera vaccine

              cyclosporine decreases effects of cholera vaccine by pharmacodynamic antagonism. Contraindicated. Avoid live vaccines in immunocompromised patients due to the risk of developing a clinical infection from the live vaccine. Inadequate immune response to the vaccine may also occur in the presence of immunosuppressants. Avoid live vaccines for at least 3 months after cessation of immunosuppressant therapy unless the benefit of vaccine administration outweighs the potential risk.

            • cimetidine

              cimetidine will increase the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • clarithromycin

              clarithromycin will increase the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • cobimetinib

              cyclosporine will increase the level or effect of cobimetinib by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. If concurrent short term (14 days or less) use of moderate CYP3A inhibitors is unavoidable for patients who are taking cobimetinib 60 mg, reduce the cobimetinib dose to 20 mg. After discontinuation of a moderate CYP3A inhibitor, resume cobimetinib 60 mg. Use an alternative to a moderate CYP3A inhibitor in patients who are taking a reduced dose of cobimetinib (40 or 20 mg daily).

            • colchicine

              cyclosporine will increase the level or effect of colchicine by Other (see comment). Avoid or Use Alternate Drug. Colchicine is a P-gp and CYP3A4 substrate. Avoid use with drugs that are both P-gp and strong CYP3A4 inhibitors. If coadministration is necessary, decrease colchicine dose or frequency as recommended in prescribing information. Use of any colchicine product in conjunction with strong CYP3A4 inhibitors is contraindicated in patients with renal or hepatic impairment.

            • contrast media (iodinated)

              contrast media (iodinated) and cyclosporine both increase nephrotoxicity and/or ototoxicity. Avoid or Use Alternate Drug.

            • danazol

              danazol increases effects of cyclosporine by decreasing metabolism. Avoid or Use Alternate Drug.

            • dengue vaccine

              cyclosporine decreases effects of dengue vaccine by pharmacodynamic antagonism. Contraindicated. Avoid live vaccines in immunocompromised patients due to the risk of developing a clinical infection from the live vaccine. Inadequate immune response to the vaccine may also occur in the presence of immunosuppressants. Avoid live vaccines for at least 3 months after cessation of immunosuppressant therapy unless the benefit of vaccine administration outweighs the potential risk.

            • digoxin

              cyclosporine increases levels of digoxin by decreasing renal clearance. Avoid or Use Alternate Drug.

            • dihydroergotamine

              cyclosporine will increase the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • dihydroergotamine intranasal

              cyclosporine will increase the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • diphtheria & tetanus toxoids

              cyclosporine decreases effects of diphtheria & tetanus toxoids by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

            • diphtheria & tetanus toxoids/ acellular pertussis vaccine

              cyclosporine decreases effects of diphtheria & tetanus toxoids/ acellular pertussis vaccine by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

            • diphtheria & tetanus toxoids/acellular pertussis/poliovirus, inactivated vaccine

              cyclosporine decreases effects of diphtheria & tetanus toxoids/acellular pertussis/poliovirus, inactivated vaccine by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

            • Ebola Zaire vaccine

              cyclosporine decreases effects of Ebola Zaire vaccine by pharmacodynamic antagonism. Contraindicated. Avoid live vaccines in immunocompromised patients due to the risk of developing a clinical infection from the live vaccine. Inadequate immune response to the vaccine may also occur in the presence of immunosuppressants. Avoid live vaccines for at least 3 months after cessation of immunosuppressant therapy unless the benefit of vaccine administration outweighs the potential risk.

            • edoxaban

              cyclosporine will increase the level or effect of edoxaban by P-glycoprotein (MDR1) efflux transporter. Avoid or Use Alternate Drug. Dose adjustment may be required with strong P-gp inhibitors. DVT/PE treatment: Decrease dose to 30 mg PO once daily. NVAF: No dose reduction recommended

            • eliglustat

              cyclosporine increases levels of eliglustat by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Moderate CYP3A4 inhibitors are not recommended with eliglustat poor or intermediate metabolizers; reduce eliglustat dose from 84 mg BID to 84 mg once daily in extensive metabolizers .

            • eluxadoline

              cyclosporine increases levels of eluxadoline by decreasing metabolism. Avoid or Use Alternate Drug. Decrease eluxadoline dose to 75 mg PO BID if coadministered with OATP1B1 inhibitors. .

            • encorafenib

              cyclosporine will increase the level or effect of encorafenib by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. If concomitant use of a moderate CYP3A4 inhibitor is unavoidable, reduce encorafenib dose to one-half of the dose (eg, reduce from 450 mg/day to 225 mg/day). After discontinuing the inhibitor for 3-5 elimination half-lives, resume previous encorafenib dose.

            • entrectinib

              cyclosporine will increase the level or effect of entrectinib by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Avoid coadministration of moderate CYP3A4 inhibitors with entrectinib, a CYP3A4 substrate. If coadministration unavoidable, reduce dose to 200 mg/day for patients aged 12 y or older with BSA >1.50m2. Resume previous entrectinib dose after discontinuing moderate CYP3A inhibitor for 3-5 elimination half-lives.

            • erdafitinib

              erdafitinib will increase the level or effect of cyclosporine by P-glycoprotein (MDR1) efflux transporter. Avoid or Use Alternate Drug. If coadministration unavoidable, separate administration by at least 6 hr before or after administration of P-gp substrates with narrow therapeutic index.

            • ergotamine

              cyclosporine will increase the level or effect of ergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • erythromycin base

              cyclosporine will increase the level or effect of erythromycin base by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

              erythromycin base will increase the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • erythromycin ethylsuccinate

              erythromycin ethylsuccinate will increase the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

              cyclosporine will increase the level or effect of erythromycin ethylsuccinate by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • erythromycin lactobionate

              erythromycin lactobionate will increase the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

              cyclosporine will increase the level or effect of erythromycin lactobionate by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • erythromycin stearate

              erythromycin stearate will increase the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

              cyclosporine will increase the level or effect of erythromycin stearate by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • etanercept

              cyclosporine and etanercept both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

            • ethotoin

              ethotoin decreases levels of cyclosporine by increasing metabolism. Avoid or Use Alternate Drug.

            • ezetimibe

              cyclosporine, ezetimibe. Either increases effects of the other by Other (see comment). Avoid or Use Alternate Drug. Comment: Monitor for potential adverse effects of cyclosporine and ezetimibe if coadministered, especially in patients with severe renal impairment.

            • fentanyl

              cyclosporine will increase the level or effect of fentanyl by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. If coadministration of CYP3A4 inhibitors with fentanyl is necessary, monitor patients for respiratory depression and sedation at frequent intervals and consider fentanyl dose adjustments until stable drug effects are achieved.

            • fentanyl intranasal

              cyclosporine will increase the level or effect of fentanyl intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. If coadministration of CYP3A4 inhibitors with fentanyl is necessary, monitor patients for respiratory depression and sedation at frequent intervals and consider fentanyl dose adjustments until stable drug effects are achieved.

            • fentanyl transdermal

              cyclosporine will increase the level or effect of fentanyl transdermal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. If coadministration of CYP3A4 inhibitors with fentanyl is necessary, monitor patients for respiratory depression and sedation at frequent intervals and consider fentanyl dose adjustments until stable drug effects are achieved.

            • fentanyl transmucosal

              cyclosporine will increase the level or effect of fentanyl transmucosal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. If coadministration of CYP3A4 inhibitors with fentanyl is necessary, monitor patients for respiratory depression and sedation at frequent intervals and consider fentanyl dose adjustments until stable drug effects are achieved.

            • fexinidazole

              fexinidazole will increase the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Fexinidazole inhibits CYP3A4. Coadministration may increase risk for adverse effects of CYP3A4 substrates.

            • fluvastatin

              cyclosporine increases toxicity of fluvastatin by Other (see comment). Avoid or Use Alternate Drug. Comment: OATP1B1 inhibitors may increase risk of myopathy. OATP1B1 inhibitors may increase risk of myopathy. Limit fluvastatin to 20 mg BID in patients who are also receiving cyclosporine.

            • glecaprevir/pibrentasvir

              cyclosporine will increase the level or effect of glecaprevir/pibrentasvir by decreasing metabolism. Avoid or Use Alternate Drug. Coadministration of cyclosporine (a moderate CYP3A4 inhibitor and P-gp inhibitor) with glecaprevir (CYP3A4 and P-gp substrate) and pibrentasvir (P-gp substrate) is not recommended if cyclosporine dose exceeds 100 mg/day.

            • golimumab

              cyclosporine and golimumab both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

            • grapefruit

              grapefruit will increase the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • hepatitis a/typhoid vaccine

              cyclosporine decreases effects of hepatitis a/typhoid vaccine by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

            • hydrochlorothiazide

              cyclosporine, hydrochlorothiazide. Either increases toxicity of the other by pharmacodynamic synergism. Avoid or Use Alternate Drug. Increased risk of systemic hyponatremia.

            • idelalisib

              idelalisib will increase the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Idelalisib is a strong CYP3A inhibitor; avoid coadministration with sensitive CYP3A substrates

            • infigratinib

              cyclosporine will increase the level or effect of infigratinib by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • infliximab

              cyclosporine and infliximab both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

            • influenza virus vaccine quadrivalent, intranasal

              cyclosporine decreases effects of influenza virus vaccine quadrivalent, intranasal by pharmacodynamic antagonism. Contraindicated. Avoid live vaccines in immunocompromised patients due to the risk of developing a clinical infection from the live vaccine. Inadequate immune response to the vaccine may also occur in the presence of immunosuppressants. Avoid live vaccines for at least 3 months after cessation of immunosuppressant therapy unless the benefit of vaccine administration outweighs the potential risk.

            • ivabradine

              cyclosporine will increase the level or effect of ivabradine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Avoid coadministration of ivabradine with moderate CYP3A4 inhibitors.

            • ivosidenib

              ivosidenib will decrease the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Avoid coadministration of sensitive CYP3A4 substrates with ivosidenib or replace with alternate therapies. If coadministration is unavoidable, monitor patients for loss of therapeutic effect of these drugs.

            • lasmiditan

              lasmiditan increases levels of cyclosporine by P-glycoprotein (MDR1) efflux transporter. Avoid or Use Alternate Drug.

            • lefamulin

              cyclosporine will increase the level or effect of lefamulin by Other (see comment). Avoid or Use Alternate Drug. Coadministration of lefamulin (a CY3A4 and P-gp substrate) with cyclosporine (a weak CYP3A4 and P-gp inhibitor) increases lefamulin AUC, which may increase the risk of toxicities with lefamulin.

            • leflunomide

              cyclosporine and leflunomide both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

            • lemborexant

              cyclosporine will increase the level or effect of lemborexant by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Avoid coadministration of lemborexant with moderate or strong CYP3A inhibitors.

            • lopinavir

              lopinavir will increase the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • lorlatinib

              lorlatinib will decrease the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Avoid use of lorlatinib with CYP3A substrates, where minimal concentration changes may lead to serious therapeutic failures of the substrate. If concomitant use is unavoidable, increase CYP3A substrate dosage in accordance with approved product labeling.

            • lovastatin

              cyclosporine will increase the level or effect of lovastatin by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Do not exceed 20 mg/day of lovastatin

            • lumacaftor/ivacaftor

              lumacaftor/ivacaftor will decrease the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Lumacaftor is a strong inducer of CYP3A. Avoid coadministration with sensitive CYP3A substrates or CYP3A substrates with a narrow therapeutic index.

            • lurbinectedin

              cyclosporine will increase the level or effect of lurbinectedin by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • measles (rubeola) vaccine

              cyclosporine decreases effects of measles (rubeola) vaccine by pharmacodynamic antagonism. Contraindicated. Avoid live vaccines in immunocompromised patients due to the risk of developing a clinical infection from the live vaccine. Inadequate immune response to the vaccine may also occur in the presence of immunosuppressants. Avoid live vaccines for at least 3 months after cessation of immunosuppressant therapy unless the benefit of vaccine administration outweighs the potential risk.

            • measles mumps and rubella vaccine, live

              cyclosporine decreases effects of measles mumps and rubella vaccine, live by pharmacodynamic antagonism. Contraindicated. Avoid live vaccines in immunocompromised patients due to the risk of developing a clinical infection from the live vaccine. Inadequate immune response to the vaccine may also occur in the presence of immunosuppressants. Avoid live vaccines for at least 3 months after cessation of immunosuppressant therapy unless the benefit of vaccine administration outweighs the potential risk.

            • measles, mumps, rubella and varicella vaccine, live

              cyclosporine decreases effects of measles, mumps, rubella and varicella vaccine, live by pharmacodynamic antagonism. Contraindicated. Avoid live vaccines in immunocompromised patients due to the risk of developing a clinical infection from the live vaccine. Inadequate immune response to the vaccine may also occur in the presence of immunosuppressants. Avoid live vaccines for at least 3 months after cessation of immunosuppressant therapy unless the benefit of vaccine administration outweighs the potential risk.

            • mesterolone

              mesterolone increases effects of cyclosporine by decreasing metabolism. Avoid or Use Alternate Drug. Androgens may potentiate the hepatoxic effects of cyclosporine, when coadministered.

            • methyltestosterone

              methyltestosterone increases effects of cyclosporine by decreasing metabolism. Avoid or Use Alternate Drug. Androgens may potentiate the hepatoxic effects of cyclosporine, when coadministered.

            • midazolam

              cyclosporine will increase the level or effect of midazolam by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • midazolam intranasal

              cyclosporine will increase the level or effect of midazolam intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Coadministration of moderate CYP3A4 inhibitors with midazolam intranasal causes higher midazolam systemic exposure, which may prolong sedation.

            • mobocertinib

              cyclosporine will increase the level or effect of mobocertinib by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. If use of moderate CYP3A4 inhibitor unavoidable, reduce mobocertinib dose by ~50% (eg, 160 to 80 mg); closely monitor QTc interval.

            • muromonab CD3

              cyclosporine and muromonab CD3 both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

            • naloxegol

              cyclosporine will increase the level or effect of naloxegol by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. If coadministation of naloxegol with moderate CYP3A4 inhibitors is unavoidable, reduce naloxegol dose to 12.5 mg qDay

            • nelfinavir

              nelfinavir will increase the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • neratinib

              cyclosporine will increase the level or effect of neratinib by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Avoid coadministration of neratinib with strong/moderate CYP3A4 inhibitors.

              cyclosporine will increase the level or effect of neratinib by P-glycoprotein (MDR1) efflux transporter. Avoid or Use Alternate Drug. Cyclosporine (CYP3A4 and P-gp inhibitor) may increase level or effect of neratinib (a CYP3A4 and P-gp substrate).

            • olaparib

              cyclosporine will increase the level or effect of olaparib by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. If coadministration with moderate CYP3A inhibitors cannot be avoided, reduce olaparib dose to 200 mg (capsule) or 150 mg (tablet) PO BID. Do not substitute tablets with capsules.

              cyclosporine and olaparib both increase pharmacodynamic synergism. Avoid or Use Alternate Drug. Coadministration with other other myelosuppressive anticancer agents, including DNA damaging agents, may potentiate and prolongate the myelosuppressive toxicity.

            • oxandrolone

              oxandrolone increases effects of cyclosporine by decreasing metabolism. Avoid or Use Alternate Drug.

            • oxymetholone

              oxymetholone increases effects of cyclosporine by decreasing metabolism. Avoid or Use Alternate Drug.

            • ozanimod

              cyclosporine increases toxicity of ozanimod by Other (see comment). Avoid or Use Alternate Drug. Comment: Coadministration of ozanimod (a BCRP substrate) with BCRP inhibitors increases the exposure of the minor (RP101988, RP101075) and major active metabolites (CC112273, CC1084037) of ozanimod, which may increase the risk of ozanimod adverse reactions. .

              ozanimod, cyclosporine. Either increases effects of the other by immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug. Coadministration with immunosuppressive therapies may increase the risk of additive immune effects during therapy and in the weeks following administration. When switching from drugs with prolonged immune effects, consider the half-life and mode of action of these drugs in order to avoid unintended additive immunosuppressive effects.

            • pemigatinib

              cyclosporine will increase the level or effect of pemigatinib by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. If coadministration with strong or moderate CYP3A4 inhibitors is unavoidable, reduce pemigatinib dose (refer to drug monograph dosage modifications). After discontinuing the CYP3A4 inhibitor for 3 elimination half-lives, may resume previous pemigatinib dose.

            • pexidartinib

              cyclosporine will increase the level or effect of pexidartinib by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. If coadministration with strong or moderate CYP3A4 inhibitors is unavoidable, reduce pexidartinib dose (refer to drug monograph dosage modifications). After discontinuing the CYP3A4 inhibitor for 3 elimination half-lives, may resume previous pexidartinib dose.

              pexidartinib will decrease the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. If concomitant use is unavoidable, increase the CYP3A substrate dosage in accordance with approved product labeling.

            • phenytoin

              phenytoin decreases levels of cyclosporine by increasing metabolism. Avoid or Use Alternate Drug.

            • pomalidomide

              cyclosporine increases levels of pomalidomide by P-glycoprotein (MDR1) efflux transporter. Avoid or Use Alternate Drug.

            • potassium phosphates, IV

              cyclosporine and potassium phosphates, IV both increase serum potassium. Avoid or Use Alternate Drug.

            • pravastatin

              cyclosporine increases toxicity of pravastatin by Other (see comment). Avoid or Use Alternate Drug. Comment: Cyclosporine, an OATP1B1 inhibitor, with pravastatin, OATP1B1 substrate, may increase risk of myopathy. Initiate pravastatin dose at 10 mg/day and not to exceed 20 mg/day in patients who are also receiving cyclosporine.

            • ranolazine

              cyclosporine will increase the level or effect of ranolazine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • red yeast rice

              cyclosporine will increase the level or effect of red yeast rice by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. May increase creatine kinase levels and increase risk of myopathy or rhabdomyolysis; red yeast rice contains monocolin K (reportedly identical to lovastatin)

            • revefenacin

              cyclosporine increases levels of revefenacin by Other (see comment). Avoid or Use Alternate Drug. Comment: OATP1B1 and OATP1B3 transport inhibitors may increase systemic exposure of revefenacin's active metabolite. Coadministration not recommended.

            • rilonacept

              cyclosporine and rilonacept both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

            • rimegepant

              cyclosporine will increase the level or effect of rimegepant by P-glycoprotein (MDR1) efflux transporter. Avoid or Use Alternate Drug.

              cyclosporine will increase the level or effect of rimegepant by Other (see comment). Avoid or Use Alternate Drug. Avoid coadministration of rimegepant (a BCRP substrate) with inhibitors of BCRP.

            • riociguat

              cyclosporine will increase the level or effect of riociguat by decreasing metabolism. Avoid or Use Alternate Drug. Coadministration of riociguat (BCRP/ABCG2 substrate) with BCRP/ABCG2 inhibitors may require a decreased initial dose of 0.5 mg PO TID; monitor for signs of hypotension and reduce dose if needed.

              cyclosporine will increase the level or effect of riociguat by P-glycoprotein (MDR1) efflux transporter. Avoid or Use Alternate Drug. Coadministration of riociguat (P-gp substrate) with strong P-gp inhibitors may require a decreased initial dose of 0.5 mg PO TID; monitor for signs of hypotension and reduce dose if needed

            • rosuvastatin

              cyclosporine increases toxicity of rosuvastatin by Other (see comment). Avoid or Use Alternate Drug. Comment: OATP1B1 inhibitors may increase risk of myopathy.

            • rotavirus oral vaccine, live

              cyclosporine decreases effects of rotavirus oral vaccine, live by pharmacodynamic antagonism. Contraindicated. Avoid live vaccines in immunocompromised patients due to the risk of developing a clinical infection from the live vaccine. Inadequate immune response to the vaccine may also occur in the presence of immunosuppressants. Avoid live vaccines for at least 3 months after cessation of immunosuppressant therapy unless the benefit of vaccine administration outweighs the potential risk.

            • rubella vaccine

              cyclosporine decreases effects of rubella vaccine by pharmacodynamic antagonism. Contraindicated. Avoid live vaccines in immunocompromised patients due to the risk of developing a clinical infection from the live vaccine. Inadequate immune response to the vaccine may also occur in the presence of immunosuppressants. Avoid live vaccines for at least 3 months after cessation of immunosuppressant therapy unless the benefit of vaccine administration outweighs the potential risk.

            • selumetinib

              cyclosporine will increase the level or effect of selumetinib by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. If coadministration with strong or moderate CYP3A4 inhibitors cannot be avoided, reduce selumetinib dosage (refer to selumetinib monograph for further information). After discontinuation of the strong or moderate CYP3A4 inhibitor for 3 elimination half-lives, resume selumetinib dose that was taken before initiating the inhibitor.

            • silodosin

              cyclosporine will increase the level or effect of silodosin by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

              cyclosporine will increase the level or effect of silodosin by P-glycoprotein (MDR1) efflux transporter. Avoid or Use Alternate Drug.

            • siponimod

              cyclosporine will increase the level or effect of siponimod by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Coadministration of siponimod with a moderate or strong CYP3A4 inhibitor PLUS a moderate or strong CYP2C9 inhibitor is not recommended.

            • smallpox (vaccinia) and monkeypox vaccine, live, nonreplicating

              cyclosporine decreases effects of smallpox (vaccinia) vaccine, attenuated by pharmacodynamic antagonism. Contraindicated. Avoid live vaccines in immunocompromised patients due to the risk of developing a clinical infection from the live vaccine. Inadequate immune response to the vaccine may also occur in the presence of immunosuppressants. Avoid live vaccines for at least 3 months after cessation of immunosuppressant therapy unless the benefit of vaccine administration outweighs the potential risk.

            • smallpox (vaccinia) vaccine, attenuated

              cyclosporine decreases effects of smallpox (vaccinia) vaccine, attenuated by pharmacodynamic antagonism. Contraindicated. Avoid live vaccines in immunocompromised patients due to the risk of developing a clinical infection from the live vaccine. Inadequate immune response to the vaccine may also occur in the presence of immunosuppressants. Avoid live vaccines for at least 3 months after cessation of immunosuppressant therapy unless the benefit of vaccine administration outweighs the potential risk.

            • smallpox (vaccinia) vaccine, live

              cyclosporine decreases effects of smallpox (vaccinia) vaccine, live by pharmacodynamic antagonism. Contraindicated. Avoid live vaccines in immunocompromised patients due to the risk of developing a clinical infection from the live vaccine. Inadequate immune response to the vaccine may also occur in the presence of immunosuppressants. Avoid live vaccines for at least 3 months after cessation of immunosuppressant therapy unless the benefit of vaccine administration outweighs the potential risk.

            • sonidegib

              cyclosporine will increase the level or effect of sonidegib by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Avoid coadministration of sonidegib with moderate CYP3A4 inhibitors. If a moderate CYP3A inhibitor must be used, administer the moderate CYP3A inhibitor for <14 days and monitor closely for adverse reactions, particularly musculoskeletal adverse reactions.

            • sotorasib

              sotorasib will decrease the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. If use is unavoidable, refer to the prescribing information of the CYP3A4 substrate for dosage modifications

              sotorasib will decrease the level or effect of cyclosporine by P-glycoprotein (MDR1) efflux transporter. Avoid or Use Alternate Drug. If use is unavoidable, refer to the prescribing information of the P-gp substrate for dosage modifications.

            • spironolactone

              spironolactone and cyclosporine both increase serum potassium. Avoid or Use Alternate Drug. Coadministration not recommended

            • St John's Wort

              St John's Wort will decrease the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

              St John's Wort will decrease the level or effect of cyclosporine by P-glycoprotein (MDR1) efflux transporter. Avoid or Use Alternate Drug.

            • tacrolimus

              cyclosporine, tacrolimus. Other (see comment). Avoid or Use Alternate Drug. Comment: Coadministration of tacrolimus with cyclosporine may increase the risk of nephrotoxicity and immunosuppressive effects. Additionally, both agents are CYP3A4 and P-gp substrates and may elevate serum levels of either agent when coadministered. Discontinue tacrolimus or cyclosporine therapy at least 24 hours before initiating therapy with the other agent.

            • talazoparib

              cyclosporine will increase the level or effect of talazoparib by Other (see comment). Avoid or Use Alternate Drug. BCRP inhibitors may increase systemic exposure of talazoparib (a BCRP substrate). If coadministration cannot be avoided, monitor for potential adverse reactions.

            • tazemetostat

              cyclosporine will increase the level or effect of tazemetostat by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Avoid coadministration of tazemetostat with moderate CYP3A4 inhibitors. If coadministration is unavoidable, reduce tazemetostat current dose (see drug monograph Dosage Modifications).

            • teicoplanin

              cyclosporine and teicoplanin both increase nephrotoxicity and/or ototoxicity. Avoid or Use Alternate Drug.

            • temsirolimus

              cyclosporine and temsirolimus both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

            • tenofovir DF

              cyclosporine and tenofovir DF both increase nephrotoxicity and/or ototoxicity. Avoid or Use Alternate Drug.

            • tepotinib

              tepotinib will increase the level or effect of cyclosporine by P-glycoprotein (MDR1) efflux transporter. Avoid or Use Alternate Drug. If concomitant use unavoidable, reduce the P-gp substrate dosage if recommended in its approved product labeling.

            • testosterone

              testosterone increases effects of cyclosporine by decreasing metabolism. Avoid or Use Alternate Drug.

            • testosterone buccal system

              testosterone buccal system increases effects of cyclosporine by decreasing metabolism. Avoid or Use Alternate Drug.

            • testosterone topical

              testosterone topical increases effects of cyclosporine by decreasing metabolism. Avoid or Use Alternate Drug.

            • tipranavir

              tipranavir will increase the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • tofacitinib

              cyclosporine, tofacitinib. Either increases toxicity of the other by immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

            • tolvaptan

              cyclosporine will increase the level or effect of tolvaptan by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • tongkat ali

              cyclosporine and tongkat ali both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

            • topotecan

              cyclosporine will increase the level or effect of topotecan by P-glycoprotein (MDR1) efflux transporter. Avoid or Use Alternate Drug. Product labeling for PO topotecan recommends avoiding concomitant use of P-gp inhibitors; the interaction with IV topotecan may be less severe but is still likely of clinical significance. Additionally, topotecan is a substrate of the BCRP efflux transporter. Cylcosporine also inhibits BCRP.

            • triamterene

              triamterene and cyclosporine both increase serum potassium. Avoid or Use Alternate Drug. Coadministration not recommended

            • typhoid polysaccharide vaccine

              cyclosporine decreases effects of typhoid polysaccharide vaccine by pharmacodynamic antagonism. Contraindicated. Avoid live vaccines in immunocompromised patients due to the risk of developing a clinical infection from the live vaccine. Inadequate immune response to the vaccine may also occur in the presence of immunosuppressants. Avoid live vaccines for at least 3 months after cessation of immunosuppressant therapy unless the benefit of vaccine administration outweighs the potential risk.

            • typhoid vaccine live

              cyclosporine decreases effects of typhoid vaccine live by pharmacodynamic antagonism. Contraindicated. Avoid live vaccines in immunocompromised patients due to the risk of developing a clinical infection from the live vaccine. Inadequate immune response to the vaccine may also occur in the presence of immunosuppressants. Avoid live vaccines for at least 3 months after cessation of immunosuppressant therapy unless the benefit of vaccine administration outweighs the potential risk.

            • ustekinumab

              cyclosporine and ustekinumab both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

            • varicella virus vaccine live

              cyclosporine decreases effects of varicella virus vaccine live by pharmacodynamic antagonism. Contraindicated. Avoid live vaccines in immunocompromised patients due to the risk of developing a clinical infection from the live vaccine. Inadequate immune response to the vaccine may also occur in the presence of immunosuppressants. Avoid live vaccines for at least 3 months after cessation of immunosuppressant therapy unless the benefit of vaccine administration outweighs the potential risk.

            • venetoclax

              cyclosporine will increase the level or effect of venetoclax by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. If a moderate CYP3A inhibitor must be used, reduce the venetoclax dose by at least 50%. Monitor more closely for signs of venetoclax toxicities.

              cyclosporine will increase the level or effect of venetoclax by P-glycoprotein (MDR1) efflux transporter. Avoid or Use Alternate Drug. If a P-gp inhibitor must be used, reduce the venetoclax dose by at least 50%. Monitor more closely for signs of venetoclax toxicities.

              venetoclax will increase the level or effect of cyclosporine by P-glycoprotein (MDR1) efflux transporter. Avoid or Use Alternate Drug. In vitro data suggest venetoclax may inhibit P-gp substrates at therapeutic dose levels in the gut. Avoid coadministration of narrow therapeutic index P-gp substrates with venetoclax. If a narrow therapeutic index P-gp substrate must be used, it should be taken at least 6 hr before venetoclax.

            • voxelotor

              voxelotor will increase the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Voxelotor increases systemic exposure of sensitive CYP3A4 substrates. Avoid coadministration with sensitive CYP3A4 substrates with a narrow therapeutic index. Consider dose reduction of the sensitive CYP3A4 substrate(s) if unable to avoid.

            • yellow fever vaccine

              cyclosporine decreases effects of yellow fever vaccine by pharmacodynamic antagonism. Contraindicated. Avoid live vaccines in immunocompromised patients due to the risk of developing a clinical infection from the live vaccine. Inadequate immune response to the vaccine may also occur in the presence of immunosuppressants. Avoid live vaccines for at least 3 months after cessation of immunosuppressant therapy unless the benefit of vaccine administration outweighs the potential risk.

            • zoster vaccine live

              cyclosporine decreases effects of zoster vaccine live by pharmacodynamic antagonism. Contraindicated. Avoid live vaccines in immunocompromised patients due to the risk of developing a clinical infection from the live vaccine. Inadequate immune response to the vaccine may also occur in the presence of immunosuppressants. Avoid live vaccines for at least 3 months after cessation of immunosuppressant therapy unless the benefit of vaccine administration outweighs the potential risk.

            Monitor Closely (398)

            • abiraterone

              cyclosporine increases levels of abiraterone by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • acalabrutinib

              cyclosporine will increase the level or effect of acalabrutinib by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Decrease acalabrutinib dose to 100 mg once daily if coadministered with a moderate CYP3A inhibitor.

            • acyclovir

              acyclovir and cyclosporine both increase nephrotoxicity and/or ototoxicity. Modify Therapy/Monitor Closely.

            • adefovir

              adefovir and cyclosporine both increase nephrotoxicity and/or ototoxicity. Use Caution/Monitor.

            • alitretinoin

              cyclosporine will increase the level or effect of alitretinoin by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • almotriptan

              cyclosporine will increase the level or effect of almotriptan by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • alprazolam

              cyclosporine will increase the level or effect of alprazolam by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • aluminum hydroxide

              aluminum hydroxide decreases levels of cyclosporine by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor. Separate by 2 hours.

            • ambrisentan

              cyclosporine will increase the level or effect of ambrisentan by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. 2-fold increase in ambrisentan exposure; limit ambrisentan dose to 5 mg/day when coadministered with cyclosporine

            • amikacin

              cyclosporine will increase the level or effect of amikacin by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • amiodarone

              cyclosporine will increase the level or effect of amiodarone by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              amiodarone will increase the level or effect of cyclosporine by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • amitriptyline

              cyclosporine will increase the level or effect of amitriptyline by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              cyclosporine will increase the level or effect of amitriptyline by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • amlodipine

              cyclosporine will increase the level or effect of amlodipine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              amlodipine increases levels of cyclosporine by unspecified interaction mechanism. Modify Therapy/Monitor Closely. A prospective study in renal transplant recipients averaged a 40% increase in cyclosporine trough levels.

            • amobarbital

              amobarbital will decrease the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • anthrax vaccine adsorbed

              cyclosporine decreases effects of anthrax vaccine adsorbed by pharmacodynamic antagonism. Modify Therapy/Monitor Closely. If possible, complete all age-appropriate vaccinations at least 2 weeks before initiating immunosuppressant therapy. Patients vaccinated <14 days before starting immunosuppressive therapy or during immunosuppressive therapy should be revaccinated at least 3 months after therapy is discontinued if immune competence has been restored. Longer waiting periods may be required for drugs that maintain their immunosuppressive effects for more than 3 months after discontinuation (eg, ocrelizumab). .

            • aprepitant

              aprepitant will increase the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              cyclosporine will increase the level or effect of aprepitant by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • aripiprazole

              cyclosporine will increase the level or effect of aripiprazole by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • armodafinil

              armodafinil will decrease the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • artemether/lumefantrine

              artemether/lumefantrine will decrease the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              cyclosporine will increase the level or effect of artemether/lumefantrine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • aspirin/citric acid/sodium bicarbonate

              aspirin/citric acid/sodium bicarbonate increases toxicity of cyclosporine by pharmacodynamic antagonism. Use Caution/Monitor. NSAIDs decrease prostaglandin synthesis, increasing the risk of nephrotoxicity.

            • astragalus

              cyclosporine increases and astragalus decreases immunosuppressive effects; risk of infection. Effect of interaction is not clear, use caution. Use Caution/Monitor.

            • atazanavir

              atazanavir will increase the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • atogepant

              cyclosporine will increase the level or effect of atogepant by Other (see comment). Modify Therapy/Monitor Closely. Recommended dosage of atogepant (an OATP1B1 substrate) with concomitant use of OATP inhibitors is 10 mg or 30 mg qDay.

            • avanafil

              cyclosporine will increase the level or effect of avanafil by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. CYP3A4 inhibitors may reduce avanafil clearance increasing systemic exposure to avanafil; increased levels may result in increased associated adverse events; the maximum recommended dose of STENDRA is 50 mg, not to exceed once every 24 hours for patients taking concomitant moderate CYP3A4 inhibitors

            • azithromycin

              azithromycin will increase the level or effect of cyclosporine by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • bazedoxifene/conjugated estrogens

              cyclosporine will increase the level or effect of bazedoxifene/conjugated estrogens by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              cyclosporine will increase the level or effect of bazedoxifene/conjugated estrogens by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • belatacept

              cyclosporine will decrease the level or effect of belatacept by decreasing metabolism. Modify Therapy/Monitor Closely. Monitor for a need to adjust concomitant mycophenolate mofetil (MMF) dosage when patient?s therapy is switched between cyclosporine and belatacept,

            • belzutifan

              belzutifan will decrease the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. If unable to avoid coadministration of belzutifan with sensitive CYP3A4 substrates, consider increasing the sensitive CYP3A4 substrate dose in accordance with its prescribing information.

            • benazepril

              benazepril and cyclosporine both increase nephrotoxicity and/or ototoxicity. Use Caution/Monitor. May increase risk of acute renal failure.

            • berotralstat

              cyclosporine increases levels of berotralstat by Other (see comment). Modify Therapy/Monitor Closely. Comment: Reduced dose of berotralstat (a BCRP and P-gp substrate) to 110 mg/day when coadministered with cyclosporine (a P-gp and BCRP inhibitor).

              berotralstat will increase the level or effect of cyclosporine by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor. Monitor or titrate P-gp substrate dose if coadministered.

              berotralstat will increase the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Monitor or titrate substrate dose when berotralstat is coadministered with narrow therapeutic index drugs that are CYP3A substrates.

            • betamethasone

              betamethasone, cyclosporine. Other (see comment). Use Caution/Monitor. Comment: Corticosteroids may increase or decrease cyclosporine concentrations. Also, cyclosporine may increase the plasma concentrations of the corticosteroids. Monitor for changes in cyclosporine concentrations and for toxicities of corticosteroids and/or cyclosporine.

            • betrixaban

              cyclosporine increases levels of betrixaban by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor. Decrease betrixaban dose to 80 mg PO once, then 40 mg PO qDay if coadministered with a P-gp inhibitor.

            • bexarotene

              cyclosporine will increase the level or effect of bexarotene by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • blinatumomab

              blinatumomab increases levels of cyclosporine by decreasing metabolism. Modify Therapy/Monitor Closely. Treatment initiation causes transient release of cytokines that may suppress CYP450 enzymes; highest drug-drug interaction risk is during the first 9 days of the first cycle and the first 2 days of the 2nd cycle in patients who are receiving concomitant CYP450 substrates, particularly those with a narrow therapeutic index.

            • bortezomib

              cyclosporine will increase the level or effect of bortezomib by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • brexpiprazole

              cyclosporine will increase the level or effect of brexpiprazole by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Administer a quarter of brexpiprazole dose if coadministered with a moderate CYP3A4 inhibitor PLUS a strong/moderate CYP2D6 inhibitor.

            • brodalumab

              brodalumab, cyclosporine. Other (see comment). Use Caution/Monitor. Comment: Formation of CYP450 enzymes can be altered by increased levels of certain cytokines during chronic inflammation; thus, brodalumab could normalize the formation of CYP450 enzymes. Upon initiation or discontinuation of brodalumab in patients who are receiving concomitant CYP450 substrates, particularly those with a narrow therapeutic index, consider monitoring for therapeutic effect.

            • bromocriptine

              bromocriptine increases levels of cyclosporine by unknown mechanism. Use Caution/Monitor.

            • budesonide

              cyclosporine will increase the level or effect of budesonide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              cyclosporine will increase the level or effect of budesonide by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • buprenorphine subdermal implant

              cyclosporine will increase the level or effect of buprenorphine subdermal implant by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Monitor patients already on buprenorphine subdermal implant who require newly-initiated treatment with CYP3A4 inhibitors for signs and symptoms of overmedication. If the dose of the concomitant CYP3A4 inhibitor cannot be reduced or discontinued, implant removal may be necessary and the patient should then be treated with a buprenorphine dosage form that permits dose adjustments. If a CYP3A4 inhibitor is discontinued in a patient who has been stabilized on buprenorphine, monitor the patient for withdrawal.

            • buprenorphine, long-acting injection

              cyclosporine will increase the level or effect of buprenorphine, long-acting injection by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Patients who transfer to buprenorphine long-acting injection from transmucosal buprenorphine coadministered with CYP3A4 inhibitors should be monitored to ensure buprenorphine plasma levels are adequate. Within 2 weeks, if signs and symptoms of buprenorphine toxicity or overdose occur and the concomitant CYP3A4 inhibitor cannot be reduced or discontinued, transition the patient back to a buprenorphine formulation that permits dose adjustments.

            • bupropion

              cyclosporine increases toxicity of bupropion by unspecified interaction mechanism. Use Caution/Monitor. May lower seizure threshold; keep bupropion dose as low as possible.

            • buspirone

              cyclosporine will increase the level or effect of buspirone by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • butabarbital

              butabarbital will decrease the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • butalbital

              butalbital will decrease the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • cabazitaxel

              cyclosporine will increase the level or effect of cabazitaxel by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Caution should be exercised with concomitant use of moderate CYP3A4 inhibitors.

            • cabozantinib

              cyclosporine will increase the level or effect of cabozantinib by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • calcium carbonate

              calcium carbonate decreases levels of cyclosporine by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor. Separate by 2 hours.

            • canagliflozin

              cyclosporine and canagliflozin both increase serum potassium. Use Caution/Monitor.

            • cannabidiol

              cyclosporine will increase the level or effect of cannabidiol by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Consider reducing the cannabidiol dose when coadministered with a moderate CYP3A4 inhibitor.

            • capreomycin

              capreomycin and cyclosporine both increase nephrotoxicity and/or ototoxicity. Modify Therapy/Monitor Closely.

            • carbamazepine

              cyclosporine will increase the level or effect of carbamazepine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              carbamazepine will decrease the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely.

            • carboplatin

              carboplatin and cyclosporine both increase nephrotoxicity and/or ototoxicity. Use Caution/Monitor.

            • celecoxib

              celecoxib, cyclosporine. Either increases toxicity of the other by nephrotoxicity and/or ototoxicity. Modify Therapy/Monitor Closely.

            • cenobamate

              cenobamate will decrease the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Increase dose of CYP3A4 substrate, as needed, when coadministered with cenobamate.

            • ceritinib

              cyclosporine increases levels of ceritinib by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • chloroquine

              chloroquine increases levels of cyclosporine by decreasing metabolism. Use Caution/Monitor.

            • chlorpropamide

              chlorpropamide, cyclosporine. unknown mechanism. Use Caution/Monitor. Cyclosporine may decrease the effects of sulfonylureas. Sulfonylureas may increase the effects of cyclosporine.

            • cholera vaccine

              cyclosporine decreases effects of cholera vaccine by immunosuppressive effects; risk of infection. Modify Therapy/Monitor Closely. Immunosuppressive therapies, including irradiation, antimetabolites, alkylating agents, cytotoxic drugs and corticosteroids (used in greater than physiologic doses), may reduce the immune response to cholera vaccine.

            • cholic acid

              cyclosporine increases toxicity of cholic acid by decreasing elimination. Modify Therapy/Monitor Closely. Avoid concomitant use of inhibitors of the bile salt efflux pump (BSEP). May exacerbate accumulation of conjugated bile salts in the liver and result in clinical symptoms. If concomitant use is necessary, monitor serum transaminases and bilirubin.

            • cilostazol

              cyclosporine will increase the level or effect of cilostazol by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • cinacalcet

              cyclosporine will increase the level or effect of cinacalcet by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • cisplatin

              cisplatin and cyclosporine both increase nephrotoxicity and/or ototoxicity. Use Caution/Monitor.

            • clarithromycin

              clarithromycin will increase the level or effect of cyclosporine by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • clobetasone

              cyclosporine will increase the level or effect of clobetasone by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              cyclosporine will increase the level or effect of clobetasone by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • clomipramine

              cyclosporine will increase the level or effect of clomipramine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • clopidogrel

              cyclosporine will decrease the level or effect of clopidogrel by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Inhibition of CYP3A4 will reduce clopidogrel bioactivation

            • clotrimazole

              clotrimazole will decrease the level or effect of cyclosporine by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • clozapine

              cyclosporine will increase the level or effect of clozapine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • cobicistat

              cobicistat will increase the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely.

            • colchicine

              colchicine increases effects of cyclosporine by pharmacodynamic synergism. Use Caution/Monitor.

            • colesevelam

              colesevelam decreases levels of cyclosporine by drug binding in GI tract. Use Caution/Monitor. Concomitant administration decreases cyclosporine absorption; however, absorption is not reduced when cyclosporine is administered 4 hr before colesevelam.

            • colistin

              colistin and cyclosporine both increase nephrotoxicity and/or ototoxicity. Modify Therapy/Monitor Closely.

            • conivaptan

              conivaptan will increase the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              cyclosporine will increase the level or effect of conivaptan by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • conjugated estrogens

              cyclosporine will increase the level or effect of conjugated estrogens by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              cyclosporine will increase the level or effect of conjugated estrogens by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              cyclosporine will increase the level or effect of conjugated estrogens by Other (see comment). Use Caution/Monitor. may increase plasma concentrations of organic anion transporter protein substrates

            • conjugated estrogens, vaginal

              cyclosporine will increase the level or effect of conjugated estrogens, vaginal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              cyclosporine will increase the level or effect of conjugated estrogens, vaginal by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • corticotropin

              corticotropin, cyclosporine. Other (see comment). Use Caution/Monitor. Comment: Corticosteroids may increase or decrease cyclosporine concentrations. Also, cyclosporine may increase the plasma concentrations of the corticosteroids. Monitor for changes in cyclosporine concentrations and for toxicities of corticosteroids and/or cyclosporine.

            • cortisone

              cyclosporine will increase the level or effect of cortisone by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              cyclosporine will increase the level or effect of cortisone by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              cortisone, cyclosporine. Other (see comment). Use Caution/Monitor. Comment: Corticosteroids may increase or decrease cyclosporine concentrations. Also, cyclosporine may increase the plasma concentrations of the corticosteroids. Monitor for changes in cyclosporine concentrations and for toxicities of corticosteroids and/or cyclosporine.

            • crizotinib

              crizotinib increases levels of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Coadministration of crizotinib with CYP3A substrates with narrow therapeutic indices should be avoided.

              cyclosporine increases levels of crizotinib by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Caution should be exercised with concomitant use of moderate CYP3A inhibitors. .

            • crofelemer

              crofelemer increases levels of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Crofelemer has the potential to inhibit CYP3A4 at concentrations expected in the gut; unlikely to inhibit systemically because minimally absorbed.

            • dabigatran

              cyclosporine will increase the level or effect of dabigatran by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor. Atrial fibrillation: Avoid coadministering dabigatran with P-gp inhibitors if CrCl <30 mL/min. DVT/PE treatment: Avoid coadministering dabigatran with P-gp inhibitors if CrCl <50 mL/min

            • dabrafenib

              dabrafenib will decrease the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely.

            • darifenacin

              cyclosporine will increase the level or effect of darifenacin by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • darolutamide

              cyclosporine will increase the level or effect of darolutamide by Other (see comment). Modify Therapy/Monitor Closely. Darolutamide is a P-gp and CYP3A4 substrate. Closely monitor for increased adverse reactions and modify dose of darolutamide as needed when coadministered with drugs that are both P-gp and strong or moderate CYP3A4 inhibitors.

            • darunavir

              cyclosporine will increase the level or effect of darunavir by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              darunavir will increase the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely.

            • dasatinib

              cyclosporine will increase the level or effect of dasatinib by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • daunorubicin

              cyclosporine will increase the level or effect of daunorubicin by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • deferasirox

              deferasirox will decrease the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • deflazacort

              cyclosporine will increase the level or effect of deflazacort by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Decrease deflazacort dose to one-third of the recommended dose if coadministered with moderate or strong CYP3A4 inhibitors.

              cyclosporine will increase the level or effect of deflazacort by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              deflazacort, cyclosporine. Other (see comment). Use Caution/Monitor. Comment: Corticosteroids may increase or decrease cyclosporine concentrations. Also, cyclosporine may increase the plasma concentrations of the corticosteroids. Monitor for changes in cyclosporine concentrations and for toxicities of corticosteroids and/or cyclosporine.

            • dengue vaccine

              cyclosporine decreases effects of dengue vaccine by immunosuppressive effects; risk of infection. Use Caution/Monitor. Immunosuppressive therapies (eg, irradiation, antimetabolites, alkylating agents, cytotoxic drugs, corticosteroids [greater than physiologic doses]) may reduce immune response to dengue vaccine.

            • denosumab

              cyclosporine, denosumab. Other (see comment). Use Caution/Monitor. Comment: Caution should be taken in patients on concomitant immunosuppressants or with impaired immune systems because of increased risk for serious infections.

            • desipramine

              cyclosporine will increase the level or effect of desipramine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • dexamethasone

              cyclosporine will increase the level or effect of dexamethasone by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              cyclosporine will increase the level or effect of dexamethasone by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              dexamethasone, cyclosporine. Other (see comment). Use Caution/Monitor. Comment: Corticosteroids may increase or decrease cyclosporine concentrations. Also, cyclosporine may increase the plasma concentrations of the corticosteroids. Monitor for changes in cyclosporine concentrations and for toxicities of corticosteroids and/or cyclosporine.

            • dexlansoprazole

              cyclosporine, dexlansoprazole. Either increases toxicity of the other by Other (see comment). Use Caution/Monitor. Comment: When used for prolonged periods of time PPIs may cause hypomagnesemia and the risk is further increased when used concomitantly with drugs that also have the same effects.

            • DHEA, herbal

              DHEA, herbal will increase the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • diazepam

              cyclosporine will increase the level or effect of diazepam by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • diazepam intranasal

              cyclosporine will increase the level or effect of diazepam intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Strong or moderate CYP3A4 inhibitors may decrease rate of diazepam elimination, thereby increasing adverse reactions to diazepam.

            • diclofenac

              diclofenac, cyclosporine. Either increases toxicity of the other by nephrotoxicity and/or ototoxicity. Modify Therapy/Monitor Closely. Potential for dangerous interaction. Use with caution and monitor closely.

            • diflunisal

              diflunisal, cyclosporine. Either increases toxicity of the other by nephrotoxicity and/or ototoxicity. Modify Therapy/Monitor Closely. Potential for dangerous interaction. Use with caution and monitor closely.

            • digoxin

              cyclosporine will increase the level or effect of digoxin by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • diltiazem

              diltiazem will increase the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Monitor serum cyclosporine concentrations if diltiazem or verapamil are initiated/ discontinued. During coadministration of cyclosporine and diltiazem, monitor for decreases in blood pressure.

            • docetaxel

              cyclosporine will increase the level or effect of docetaxel by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • doxorubicin

              cyclosporine will increase the level or effect of doxorubicin by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              cyclosporine will increase the level or effect of doxorubicin by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              cyclosporine increases levels of doxorubicin by decreasing renal clearance. Use Caution/Monitor.

            • doxorubicin liposomal

              cyclosporine will increase the level or effect of doxorubicin liposomal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              cyclosporine will increase the level or effect of doxorubicin liposomal by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              cyclosporine increases levels of doxorubicin liposomal by decreasing renal clearance. Use Caution/Monitor.

            • dronabinol

              dronabinol increases levels of cyclosporine by plasma protein binding competition. Modify Therapy/Monitor Closely. Dronabinol is highly bound to plasma proteins and may displace and increase the free fraction of other concomitantly administered highly protein-bound drugs. This has not been confirmed in vivo. Caution with narrow therapeutic index drugs that are highly protein bound when initiating or increasing the dose of dronabinol.

            • drospirenone

              drospirenone, cyclosporine. Mechanism: pharmacodynamic synergism. Use Caution/Monitor. Monitor serum cyclosporine concentrations, and for signs and symptoms of renal and hepatic toxicity.

            • dulaglutide

              dulaglutide, cyclosporine. Other (see comment). Use Caution/Monitor. Comment: Dulaglutide slows gastric emptying and may impact absorption of concomitantly administered oral medications; be particularly cautious when coadministered with drugs that have a narrow therapeutic index.

            • dupilumab

              dupilumab, cyclosporine. Other (see comment). Use Caution/Monitor. Comment: Formation of CYP450 enzymes can be altered by increased levels of certain cytokines during chronic inflammation; thus, dupilumab could normalize the formation of CYP450 enzymes. Upon initiation or discontinuation of dupilumab in patients who are receiving concomitant CYP450 substrates, particularly those with a narrow therapeutic index, consider monitoring for therapeutic effect.

            • duvelisib

              duvelisib will increase the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. will increase the level or effect of

              cyclosporine will increase the level or effect of duvelisib by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              cyclosporine will increase the level or effect of duvelisib by Other (see comment). Use Caution/Monitor. Coadministration of duvelisib (a BCRP substrate) with a BCRP transport inhibitor may increase levels or effects of duvelisib.

            • echinacea

              cyclosporine increases and echinacea decreases immunosuppressive effects; risk of infection. Effect of interaction is not clear, use caution. Use Caution/Monitor.

            • efavirenz

              efavirenz will decrease the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Closely monitor cyclosporine concentrations when starting, stopping, or adjusting dose of concurrent efavirez, especially within first 2 weeks.

            • eletriptan

              cyclosporine will increase the level or effect of eletriptan by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • eliglustat

              eliglustat increases levels of cyclosporine by P-glycoprotein (MDR1) efflux transporter. Modify Therapy/Monitor Closely. Monitor therapeutic drug concentrations, as indicated, or consider reducing the dosage of the P-gp substrate and titrate to clinical effect.

            • eluxadoline

              eluxadoline increases levels of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Caution when CYP3A substrates that have a narrow therapeutic index are coadministered with eluxadoline.

            • elvitegravir/cobicistat/emtricitabine/tenofovir DF

              elvitegravir/cobicistat/emtricitabine/tenofovir DF increases levels of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Cobicistat is a CYP3A4 inhibitor; contraindicated with CYP3A4 substrates for which elevated plasma concentrations are associated with serious and/or life-threatening events.

              cyclosporine and elvitegravir/cobicistat/emtricitabine/tenofovir DF both increase nephrotoxicity and/or ototoxicity. Use Caution/Monitor.

            • encorafenib

              encorafenib, cyclosporine. affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Encorafenib both inhibits and induces CYP3A4 at clinically relevant plasma concentrations. Coadministration of encorafenib with sensitive CYP3A4 substrates may result in increased toxicity or decreased efficacy of these agents.

            • enzalutamide

              enzalutamide will decrease the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • epoetin alfa

              epoetin alfa, cyclosporine. Other (see comment). Use Caution/Monitor. Comment: Cyclosporine may potentiate hypertensive effects with erythropoiesis-stimulating agents (ESAs). Additionally, use of ESAs may alter cyclosporine blood levels, since cyclosporine is bound by red blood cells.

            • epoetin beta

              epoetin beta, cyclosporine. Other (see comment). Use Caution/Monitor. Comment: Cyclosporine may potentiate hypertensive effects with erythropoiesis-stimulating agents (ESAs). Additionally, use of ESAs may alter cyclosporine blood levels, since cyclosporine is bound by red blood cells.

            • epoetin delta

              epoetin delta, cyclosporine. Other (see comment). Use Caution/Monitor. Comment: Cyclosporine may potentiate hypertensive effects with erythropoiesis-stimulating agents (ESAs). Additionally, use of ESAs may alter cyclosporine blood levels, since cyclosporine is bound by red blood cells.

            • epoetin zeta

              epoetin zeta, cyclosporine. Other (see comment). Use Caution/Monitor. Comment: Cyclosporine may potentiate hypertensive effects with erythropoiesis-stimulating agents (ESAs). Additionally, use of ESAs may alter cyclosporine blood levels, since cyclosporine is bound by red blood cells.

            • erlotinib

              cyclosporine will increase the level or effect of erlotinib by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              cyclosporine will increase the level or effect of erlotinib by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • erythromycin base

              erythromycin base will increase the level or effect of cyclosporine by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              cyclosporine will increase the level or effect of erythromycin base by Other (see comment). Use Caution/Monitor. may increase plasma concentrations of organic anion transporter protein substrates

            • erythromycin ethylsuccinate

              erythromycin ethylsuccinate will increase the level or effect of cyclosporine by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              cyclosporine will increase the level or effect of erythromycin ethylsuccinate by Other (see comment). Use Caution/Monitor. may increase plasma concentrations of organic anion transporter protein substrates

            • erythromycin lactobionate

              erythromycin lactobionate will increase the level or effect of cyclosporine by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              cyclosporine will increase the level or effect of erythromycin lactobionate by Other (see comment). Use Caution/Monitor. may increase plasma concentrations of organic anion transporter protein substrates

            • erythromycin stearate

              erythromycin stearate will increase the level or effect of cyclosporine by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              cyclosporine will increase the level or effect of erythromycin stearate by Other (see comment). Use Caution/Monitor. may increase plasma concentrations of organic anion transporter protein substrates

            • eslicarbazepine acetate

              eslicarbazepine acetate will decrease the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • esomeprazole

              cyclosporine, esomeprazole. Either increases toxicity of the other by Other (see comment). Use Caution/Monitor. Comment: When used for prolonged periods of time PPIs may cause hypomagnesemia and the risk is further increased when used concomitantly with drugs that also have the same effects.

            • estradiol

              cyclosporine will increase the level or effect of estradiol by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              cyclosporine will increase the level or effect of estradiol by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • estrogens conjugated synthetic

              cyclosporine will increase the level or effect of estrogens conjugated synthetic by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              cyclosporine will increase the level or effect of estrogens conjugated synthetic by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • estrogens esterified

              cyclosporine will increase the level or effect of estrogens esterified by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • estropipate

              cyclosporine will increase the level or effect of estropipate by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              cyclosporine will increase the level or effect of estropipate by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • ethinylestradiol

              ethinylestradiol increases levels of cyclosporine by unknown mechanism. Use Caution/Monitor.

            • etodolac

              etodolac, cyclosporine. Either increases toxicity of the other by nephrotoxicity and/or ototoxicity. Modify Therapy/Monitor Closely. Potential for dangerous interaction. Use with caution and monitor closely.

            • etonogestrel

              cyclosporine will increase the level or effect of etonogestrel by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • etoposide

              cyclosporine will increase the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              cyclosporine will increase the level or effect of etoposide by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • etravirine

              etravirine will decrease the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • everolimus

              cyclosporine will increase the level or effect of everolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Everolimus is a CYP3A4 and P-gp substrate. Prescribing information for coadministration with cyclosporine (a CYP3A4 and P-gp strong inhibitor) depends on everolimus indication and brand. Avoid coadministration if used for renal cell carcinoma (Afinitor). If used for kidney transplant immunosuppression (Zortress), reduce cyclosporine dose and use target serum concentration to reduce nephrotoxicity.

            • famotidine

              famotidine will increase the level or effect of cyclosporine by unknown mechanism. Use Caution/Monitor. Delayed resorption of cyclosporine has been reported when famotidine is coadministered with cyclosporine.

            • fedratinib

              fedratinib will increase the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Adjust dose of drugs that are CYP3A4 substrates as necessary.

            • felodipine

              cyclosporine will increase the level or effect of felodipine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              felodipine will increase the level or effect of cyclosporine by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • fenofibrate

              fenofibrate increases levels of cyclosporine by unspecified interaction mechanism. Use Caution/Monitor.

            • fenofibrate micronized

              fenofibrate micronized increases levels of cyclosporine by unspecified interaction mechanism. Use Caution/Monitor.

            • fenoprofen

              fenoprofen, cyclosporine. Either increases toxicity of the other by nephrotoxicity and/or ototoxicity. Modify Therapy/Monitor Closely. Potential for dangerous interaction. Use with caution and monitor closely.

            • ferric maltol

              ferric maltol, cyclosporine. Either increases levels of the other by unspecified interaction mechanism. Modify Therapy/Monitor Closely. Coadministration of ferric maltol with certain oral medications may decrease the bioavailability of either ferric maltol and some oral drugs. For oral drugs where reductions in bioavailability may cause clinically significant effects on its safety or efficacy, separate administration of ferric maltol from these drugs. Duration of separation may depend on the absorption of the medication concomitantly administered (eg, time to peak concentration, whether the drug is an immediate or extended release product).

            • fesoterodine

              cyclosporine will increase the level or effect of fesoterodine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • finerenone

              cyclosporine will increase the level or effect of finerenone by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Monitor serum potassium during initiation and dosage adjustment of either finererone or moderate CYP3A4 inhibitors. Adjust finererone dosage as needed.

              cyclosporine and finerenone both increase serum potassium. Modify Therapy/Monitor Closely. Finerenone dose adjustment based on current serum potassium concentration. Monitor serum potassium and adjust finerenone dose as described in the prescribing information as necessary.

            • fingolimod

              cyclosporine increases effects of fingolimod by immunosuppressive effects; risk of infection. Modify Therapy/Monitor Closely. Concomitant therapy is expected to increase the risk of immunosuppression. Use caution when switching patients from long-acting therapies with immune effects. .

            • flibanserin

              flibanserin increases levels of cyclosporine by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor. Increase monitoring of concentrations of drugs transported by P-gp that have a narrow therapeutic index if coadministered with flibanserin.

            • fluconazole

              fluconazole will increase the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • fludrocortisone

              cyclosporine will increase the level or effect of fludrocortisone by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              cyclosporine will increase the level or effect of fludrocortisone by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              fludrocortisone, cyclosporine. Other (see comment). Use Caution/Monitor. Comment: Corticosteroids may increase or decrease cyclosporine concentrations. Also, cyclosporine may increase the plasma concentrations of the corticosteroids. Monitor for changes in cyclosporine concentrations and for toxicities of corticosteroids and/or cyclosporine.

            • flurbiprofen

              flurbiprofen, cyclosporine. Either increases toxicity of the other by nephrotoxicity and/or ototoxicity. Modify Therapy/Monitor Closely.

            • fluvoxamine

              fluvoxamine will increase the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely.

            • fosamprenavir

              cyclosporine will increase the level or effect of fosamprenavir by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              fosamprenavir will increase the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • foscarnet

              cyclosporine and foscarnet both increase nephrotoxicity and/or ototoxicity. Use Caution/Monitor.

            • fosphenytoin

              fosphenytoin will decrease the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              fosphenytoin will decrease the level or effect of cyclosporine by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • fostamatinib

              fostamatinib will increase the level or effect of cyclosporine by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor. Concomitant use of fostamatinib may increase concentrations of P-gp substrates. Monitor for toxicities of the P-gp substrate drug that may require dosage reduction when given concurrently with fostamatinib.

            • furosemide

              cyclosporine increases toxicity of furosemide by Other (see comment). Use Caution/Monitor. Comment: Concomitant use of cyclosporine and furosemide is associated with increased risk of gouty arthritis secondary to furosemide-induced hyperurecemia and cyclosporine impairment of renal urate excretion.

            • gentamicin

              cyclosporine and gentamicin both increase nephrotoxicity and/or ototoxicity. Modify Therapy/Monitor Closely.

            • glimepiride

              glimepiride, cyclosporine. unknown mechanism. Use Caution/Monitor. Cyclosporine may decrease the effects of sulfonylureas. Sulfonylureas may increase the effects of cyclosporine.

            • glipizide

              glipizide, cyclosporine. unknown mechanism. Use Caution/Monitor. Cyclosporine may decrease the effects of sulfonylureas. Sulfonylureas may increase the effects of cyclosporine.

            • glyburide

              glyburide, cyclosporine. unknown mechanism. Use Caution/Monitor. Cyclosporine may decrease the effects of sulfonylureas. Sulfonylureas may increase the effects of cyclosporine.

            • glycerol phenylbutyrate

              glycerol phenylbutyrate will decrease the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Glycerol phenylbutyrate is a weak inducer of CYP3A4. Monitor for decreased efficacy of CYP3A4 substrates that have a narrow therapeutic index.

            • griseofulvin

              griseofulvin will decrease the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • guanfacine

              cyclosporine will increase the level or effect of guanfacine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Strong or moderate CYP3A4 inhibitors significantly increase guanfacine plasma concentrations. FDA-approved labeling for extended-release (ER) guanfacine recommends that, if coadministered, the guanfacine dosage should be decreased to half of the recommended dose. Specific recommendations for immediate-release (IR) guanfacine are not available.

            • guselkumab

              guselkumab, cyclosporine. Other (see comment). Use Caution/Monitor. Comment: Formation of CYP450 enzymes can be altered by increased levels of certain cytokines during chronic inflammation; thus, normalizing the formation of CYP450 enzymes. Upon initiation or discontinuation of guselkumab in patients who are receiving concomitant CYP450 substrates, particularly those with a narrow therapeutic index, consider monitoring for therapeutic effect.

            • haemophilus influenzae type b vaccine

              cyclosporine decreases effects of haemophilus influenzae type b vaccine by pharmacodynamic antagonism. Modify Therapy/Monitor Closely. If possible, complete all age-appropriate vaccinations at least 2 weeks before initiating immunosuppressant therapy. Patients vaccinated <14 days before starting immunosuppressive therapy or during immunosuppressive therapy should be revaccinated at least 3 months after therapy is discontinued if immune competence has been restored. Longer waiting periods may be required for drugs that maintain their immunosuppressive effects for more than 3 months after discontinuation (eg, ocrelizumab). .

            • hepatitis A vaccine inactivated

              cyclosporine decreases effects of hepatitis A vaccine inactivated by pharmacodynamic antagonism. Modify Therapy/Monitor Closely. If possible, complete all age-appropriate vaccinations at least 2 weeks before initiating immunosuppressant therapy. Patients vaccinated <14 days before starting immunosuppressive therapy or during immunosuppressive therapy should be revaccinated at least 3 months after therapy is discontinued if immune competence has been restored. Longer waiting periods may be required for drugs that maintain their immunosuppressive effects for more than 3 months after discontinuation (eg, ocrelizumab). .

            • hepatitis a/b vaccine

              cyclosporine decreases effects of hepatitis a/b vaccine by pharmacodynamic antagonism. Modify Therapy/Monitor Closely. If possible, complete all age-appropriate vaccinations at least 2 weeks before initiating immunosuppressant therapy. Patients vaccinated <14 days before starting immunosuppressive therapy or during immunosuppressive therapy should be revaccinated at least 3 months after therapy is discontinued if immune competence has been restored. Longer waiting periods may be required for drugs that maintain their immunosuppressive effects for more than 3 months after discontinuation (eg, ocrelizumab). .

            • hepatitis b vaccine

              cyclosporine decreases effects of hepatitis b vaccine by pharmacodynamic antagonism. Modify Therapy/Monitor Closely. If possible, complete all age-appropriate vaccinations at least 2 weeks before initiating immunosuppressant therapy. Patients vaccinated <14 days before starting immunosuppressive therapy or during immunosuppressive therapy should be revaccinated at least 3 months after therapy is discontinued if immune competence has been restored. Longer waiting periods may be required for drugs that maintain their immunosuppressive effects for more than 3 months after discontinuation (eg, ocrelizumab). .

            • HIV vaccine

              cyclosporine decreases effects of HIV vaccine by pharmacodynamic antagonism. Modify Therapy/Monitor Closely. If possible, complete all age-appropriate vaccinations at least 2 weeks before initiating immunosuppressant therapy. Patients vaccinated <14 days before starting immunosuppressive therapy or during immunosuppressive therapy should be revaccinated at least 3 months after therapy is discontinued if immune competence has been restored. Longer waiting periods may be required for drugs that maintain their immunosuppressive effects for more than 3 months after discontinuation (eg, ocrelizumab). .

            • human papillomavirus vaccine, nonavalent

              cyclosporine decreases effects of human papillomavirus vaccine, nonavalent by pharmacodynamic antagonism. Modify Therapy/Monitor Closely. If possible, complete all age-appropriate vaccinations at least 2 weeks before initiating immunosuppressant therapy. Patients vaccinated <14 days before starting immunosuppressive therapy or during immunosuppressive therapy should be revaccinated at least 3 months after therapy is discontinued if immune competence has been restored. Longer waiting periods may be required for drugs that maintain their immunosuppressive effects for more than 3 months after discontinuation (eg, ocrelizumab). .

            • human papillomavirus vaccine, quadrivalent

              cyclosporine decreases effects of human papillomavirus vaccine, quadrivalent by pharmacodynamic antagonism. Modify Therapy/Monitor Closely. If possible, complete all age-appropriate vaccinations at least 2 weeks before initiating immunosuppressant therapy. Patients vaccinated <14 days before starting immunosuppressive therapy or during immunosuppressive therapy should be revaccinated at least 3 months after therapy is discontinued if immune competence has been restored. Longer waiting periods may be required for drugs that maintain their immunosuppressive effects for more than 3 months after discontinuation (eg, ocrelizumab). .

            • hydrochlorothiazide

              cyclosporine increases toxicity of hydrochlorothiazide by unspecified interaction mechanism. Use Caution/Monitor. Coadministration of hydrochlorothiazide with cyclosporine may increase the risk of hypermagnesemia, hyperuricemia, and possible nephrotoxicity.

            • hydrocortisone

              cyclosporine will increase the level or effect of hydrocortisone by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              cyclosporine will increase the level or effect of hydrocortisone by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              hydrocortisone, cyclosporine. Other (see comment). Use Caution/Monitor. Comment: Corticosteroids may increase or decrease cyclosporine concentrations. Also, cyclosporine may increase the plasma concentrations of the corticosteroids. Monitor for changes in cyclosporine concentrations and for toxicities of corticosteroids and/or cyclosporine.

            • hydroxychloroquine sulfate

              hydroxychloroquine sulfate will increase the level or effect of cyclosporine by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • hydroxyprogesterone caproate

              hydroxyprogesterone caproate will increase the level or effect of cyclosporine by Other (see comment). Use Caution/Monitor. Progestins may potentiate the risk of hepatoxicity. Consider alternative forms of contraception.

            • ibrutinib

              cyclosporine increases levels of ibrutinib by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Coadministration with moderate CYP3A4 inhibitors, reduce ibrutinib dose to 280 mg qDay (B-cell malignancies) or 420 mg qDay (graft versus host disease). After CYP3A inhibitor discontinuation, resume previous dose of ibrutinib.

            • ibuprofen

              ibuprofen, cyclosporine. Either increases toxicity of the other by nephrotoxicity and/or ototoxicity. Use Caution/Monitor. NSAIDs decrease prostaglandin synthesis, increasing the risk of nephrotoxicity.

            • ibuprofen IV

              ibuprofen IV increases toxicity of cyclosporine by pharmacodynamic antagonism. Use Caution/Monitor. NSAIDs decrease prostaglandin synthesis, increasing the risk of nephrotoxicity.

            • ibuprofen/famotidine

              ibuprofen/famotidine, cyclosporine. Either increases toxicity of the other by nephrotoxicity and/or ototoxicity. Use Caution/Monitor. NSAIDs decrease prostaglandin synthesis, increasing the risk of nephrotoxicity.

            • iloperidone

              cyclosporine will increase the level or effect of iloperidone by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              iloperidone increases levels of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Iloperidone is a time-dependent CYP3A inhibitor and may lead to increased plasma levels of drugs predominantly eliminated by CYP3A4.

            • imatinib

              cyclosporine will increase the level or effect of imatinib by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              imatinib increases levels of cyclosporine by decreasing metabolism. Use Caution/Monitor.

              cyclosporine will increase the level or effect of imatinib by Other (see comment). Use Caution/Monitor. may increase plasma concentrations of organic anion transporter protein substrates

            • imidapril

              imidapril, cyclosporine. Mechanism: unspecified interaction mechanism. Use Caution/Monitor. Risk of acute renal failure.

            • imipenem/cilastatin

              cyclosporine, imipenem/cilastatin. Other (see comment). Use Caution/Monitor. Comment: Cyclosporine may increase the neurotoxic effects of imipenem. Cases reports describe imipenem increasing or decreasing cyclosporine serum concentration levels.

            • imipenem/cilastatin/relebactam

              cyclosporine, imipenem/cilastatin/relebactam. Other (see comment). Use Caution/Monitor. Comment: Cyclosporine may increase the neurotoxic effects of imipenem. Cases reports describe imipenem increasing or decreasing cyclosporine serum concentration levels.

            • imipramine

              cyclosporine will increase the level or effect of imipramine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • indinavir

              indinavir will increase the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              indinavir will increase the level or effect of cyclosporine by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • indomethacin

              indomethacin, cyclosporine. Either increases toxicity of the other by nephrotoxicity and/or ototoxicity. Modify Therapy/Monitor Closely.

            • influenza A (H5N1) vaccine

              cyclosporine decreases effects of influenza A (H5N1) vaccine by pharmacodynamic antagonism. Modify Therapy/Monitor Closely. If possible, complete all age-appropriate vaccinations at least 2 weeks before initiating immunosuppressant therapy. Patients vaccinated <14 days before starting immunosuppressive therapy or during immunosuppressive therapy should be revaccinated at least 3 months after therapy is discontinued if immune competence has been restored. Longer waiting periods may be required for drugs that maintain their immunosuppressive effects for more than 3 months after discontinuation (eg, ocrelizumab). .

            • influenza virus vaccine (H5N1), adjuvanted

              cyclosporine decreases effects of influenza virus vaccine (H5N1), adjuvanted by pharmacodynamic antagonism. Modify Therapy/Monitor Closely. If possible, complete all age-appropriate vaccinations at least 2 weeks before initiating immunosuppressant therapy. Patients vaccinated <14 days before starting immunosuppressive therapy or during immunosuppressive therapy should be revaccinated at least 3 months after therapy is discontinued if immune competence has been restored. Longer waiting periods may be required for drugs that maintain their immunosuppressive effects for more than 3 months after discontinuation (eg, ocrelizumab). .

            • influenza virus vaccine quadrivalent

              cyclosporine decreases effects of influenza virus vaccine quadrivalent by pharmacodynamic antagonism. Modify Therapy/Monitor Closely. If possible, complete all age-appropriate vaccinations at least 2 weeks before initiating immunosuppressant therapy. Patients vaccinated <14 days before starting immunosuppressive therapy or during immunosuppressive therapy should be revaccinated at least 3 months after therapy is discontinued if immune competence has been restored. Longer waiting periods may be required for drugs that maintain their immunosuppressive effects for more than 3 months after discontinuation (eg, ocrelizumab). .

            • influenza virus vaccine quadrivalent, adjuvanted

              cyclosporine decreases effects of influenza virus vaccine quadrivalent, adjuvanted by pharmacodynamic antagonism. Modify Therapy/Monitor Closely. If possible, complete all age-appropriate vaccinations at least 2 weeks before initiating immunosuppressant therapy. Patients vaccinated <14 days before starting immunosuppressive therapy or during immunosuppressive therapy should be revaccinated at least 3 months after therapy is discontinued if immune competence has been restored. Longer waiting periods may be required for drugs that maintain their immunosuppressive effects for more than 3 months after discontinuation (eg, ocrelizumab). .

            • influenza virus vaccine quadrivalent, cell-cultured

              cyclosporine decreases effects of influenza virus vaccine quadrivalent, cell-cultured by pharmacodynamic antagonism. Modify Therapy/Monitor Closely. If possible, complete all age-appropriate vaccinations at least 2 weeks before initiating immunosuppressant therapy. Patients vaccinated <14 days before starting immunosuppressive therapy or during immunosuppressive therapy should be revaccinated at least 3 months after therapy is discontinued if immune competence has been restored. Longer waiting periods may be required for drugs that maintain their immunosuppressive effects for more than 3 months after discontinuation (eg, ocrelizumab). .

            • influenza virus vaccine quadrivalent, recombinant

              cyclosporine decreases effects of influenza virus vaccine quadrivalent, recombinant by pharmacodynamic antagonism. Modify Therapy/Monitor Closely. If possible, complete all age-appropriate vaccinations at least 2 weeks before initiating immunosuppressant therapy. Patients vaccinated <14 days before starting immunosuppressive therapy or during immunosuppressive therapy should be revaccinated at least 3 months after therapy is discontinued if immune competence has been restored. Longer waiting periods may be required for drugs that maintain their immunosuppressive effects for more than 3 months after discontinuation (eg, ocrelizumab). .

            • influenza virus vaccine trivalent

              cyclosporine decreases effects of influenza virus vaccine trivalent by pharmacodynamic antagonism. Modify Therapy/Monitor Closely. If possible, complete all age-appropriate vaccinations at least 2 weeks before initiating immunosuppressant therapy. Patients vaccinated <14 days before starting immunosuppressive therapy or during immunosuppressive therapy should be revaccinated at least 3 months after therapy is discontinued if immune competence has been restored. Longer waiting periods may be required for drugs that maintain their immunosuppressive effects for more than 3 months after discontinuation (eg, ocrelizumab). .

            • influenza virus vaccine trivalent, adjuvanted

              cyclosporine decreases effects of influenza virus vaccine trivalent, adjuvanted by pharmacodynamic antagonism. Modify Therapy/Monitor Closely. If possible, complete all age-appropriate vaccinations at least 2 weeks before initiating immunosuppressant therapy. Patients vaccinated <14 days before starting immunosuppressive therapy or during immunosuppressive therapy should be revaccinated at least 3 months after therapy is discontinued if immune competence has been restored. Longer waiting periods may be required for drugs that maintain their immunosuppressive effects for more than 3 months after discontinuation (eg, ocrelizumab). .

            • influenza virus vaccine trivalent, recombinant

              cyclosporine decreases effects of influenza virus vaccine trivalent, recombinant by pharmacodynamic antagonism. Modify Therapy/Monitor Closely. If possible, complete all age-appropriate vaccinations at least 2 weeks before initiating immunosuppressant therapy. Patients vaccinated <14 days before starting immunosuppressive therapy or during immunosuppressive therapy should be revaccinated at least 3 months after therapy is discontinued if immune competence has been restored. Longer waiting periods may be required for drugs that maintain their immunosuppressive effects for more than 3 months after discontinuation (eg, ocrelizumab). .

            • irinotecan

              cyclosporine will increase the level or effect of irinotecan by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              cyclosporine will increase the level or effect of irinotecan by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • irinotecan liposomal

              cyclosporine will increase the level or effect of irinotecan liposomal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              cyclosporine will increase the level or effect of irinotecan liposomal by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • isavuconazonium sulfate

              cyclosporine will increase the level or effect of isavuconazonium sulfate by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              isavuconazonium sulfate will increase the level or effect of cyclosporine by Other (see comment). Use Caution/Monitor. Isavuconazonium sulfate, an inhibitor of P-gp and CYP3A4, may increase the effects or levels of sensitive P-gp or CYP3A4 substrates, which may require dose adjustment.

              cyclosporine and isavuconazonium sulfate both decrease immunosuppressive effects; risk of infection. Use Caution/Monitor.

            • istradefylline

              istradefylline will increase the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Istradefylline 40 mg/day increased peak levels and AUC of CYP3A4 substrates in clinical trials. This effect was not observed with istradefylline 20 mg/day. Consider dose reduction of sensitive CYP3A4 substrates.

              istradefylline will increase the level or effect of cyclosporine by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor. Istradefylline 40 mg/day increased peak levels and AUC of P-gp substrates in clinical trials. Consider dose reduction of sensitive P-gp substrates.

            • itraconazole

              itraconazole will increase the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • ivacaftor

              cyclosporine will increase the level or effect of ivacaftor by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Reduce ivacaftor dose if coadministered with moderate CYP3A4 inhibitors. See specific ivacaftor-containing product for precise dosage modification.

              ivacaftor increases levels of cyclosporine by P-glycoprotein (MDR1) efflux transporter. Modify Therapy/Monitor Closely. Ivacaftor and its M1 metabolite has the potential to inhibit P-gp; may significantly increase systemic exposure to sensitive P-gp substrates with a narrow therapeutic index.

            • ixabepilone

              cyclosporine will increase the level or effect of ixabepilone by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • ixekizumab

              ixekizumab, cyclosporine. Other (see comment). Use Caution/Monitor. Comment: Formation of CYP450 enzymes can be altered by increased levels of certain cytokines during chronic inflammation; thus, ixekizumab could normalize the formation of CYP450 enzymes. Upon initiation or discontinuation of ixekizumab in patients who are receiving concomitant CYP450 substrates, particularly those with a narrow therapeutic index, consider monitoring for therapeutic effect.

            • Japanese encephalitis virus vaccine

              cyclosporine decreases effects of Japanese encephalitis virus vaccine by pharmacodynamic antagonism. Modify Therapy/Monitor Closely. If possible, complete all age-appropriate vaccinations at least 2 weeks before initiating immunosuppressant therapy. Patients vaccinated <14 days before starting immunosuppressive therapy or during immunosuppressive therapy should be revaccinated at least 3 months after therapy is discontinued if immune competence has been restored. Longer waiting periods may be required for drugs that maintain their immunosuppressive effects for more than 3 months after discontinuation (eg, ocrelizumab). .

            • ketoconazole

              ketoconazole will increase the level or effect of cyclosporine by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • ketoprofen

              ketoprofen, cyclosporine. Either increases toxicity of the other by nephrotoxicity and/or ototoxicity. Modify Therapy/Monitor Closely.

            • ketorolac

              ketorolac, cyclosporine. Either increases toxicity of the other by nephrotoxicity and/or ototoxicity. Modify Therapy/Monitor Closely.

            • lanreotide

              lanreotide decreases levels of cyclosporine by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor.

            • lapatinib

              cyclosporine will increase the level or effect of lapatinib by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              lapatinib will increase the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              cyclosporine will increase the level or effect of lapatinib by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              lapatinib will increase the level or effect of cyclosporine by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • letermovir

              letermovir, cyclosporine. Either increases levels of the other by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Decrease letermovir dosage to 240 mg/day. Frequently monitor cyclosporine concentrations during treatment and after discontinuation of letermovir and adjust cyclosporine dose accordingly.

            • levamlodipine

              cyclosporine will increase the level or effect of levamlodipine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Coadministration with moderate and strong CYP3A inhibitors results in increased systemic exposure to amlodipine and may require dose reduction. Monitor for symptoms of hypotension and edema when amlodipine is coadministered with CYP3A inhibitors to determine the need for dose adjustment.

              levamlodipine will increase the level or effect of cyclosporine by unspecified interaction mechanism. Modify Therapy/Monitor Closely. Amlodipine may increase the systemic exposure of cyclosporine or tacrolimus when coadministered. Frequent monitoring of trough blood levels of cyclosporine and tacrolimus is recommended and adjust the dose when appropriate.

            • levonorgestrel intrauterine

              levonorgestrel intrauterine, cyclosporine. Either increases levels of the other by decreasing metabolism. Use Caution/Monitor. Combined oral contraceptives containing EE may inhibit the metabolism and increase plasma concentrations of cyclosporine.

            • levonorgestrel oral

              levonorgestrel oral, cyclosporine. Either increases levels of the other by decreasing metabolism. Use Caution/Monitor. Combined oral contraceptives containing EE may inhibit the metabolism and increase plasma concentrations of cyclosporine.

            • levonorgestrel oral/ethinylestradiol/ferrous bisglycinate

              levonorgestrel oral/ethinylestradiol/ferrous bisglycinate, cyclosporine. Either increases levels of the other by decreasing metabolism. Use Caution/Monitor. Combined oral contraceptives containing EE may inhibit the metabolism and increase plasma concentrations of cyclosporine.

            • levonorgestrel transdermal

              levonorgestrel transdermal, cyclosporine. Either increases levels of the other by decreasing metabolism. Use Caution/Monitor. Combined oral contraceptives containing EE may inhibit the metabolism and increase plasma concentrations of cyclosporine.

            • lomitapide

              cyclosporine increases levels of lomitapide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Consider reducing dose when used concomitantly with lomitapide.

              lomitapide increases levels of cyclosporine by P-glycoprotein (MDR1) efflux transporter. Modify Therapy/Monitor Closely. Consider reducing dose when used concomitantly with lomitapide.

            • loperamide

              cyclosporine will increase the level or effect of loperamide by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • lopinavir

              cyclosporine will increase the level or effect of lopinavir by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • lornoxicam

              lornoxicam increases toxicity of cyclosporine by pharmacodynamic antagonism. Use Caution/Monitor. NSAIDs decrease prostaglandin synthesis, increasing the risk of nephrotoxicity.

            • lumefantrine

              cyclosporine will increase the level or effect of lumefantrine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • maraviroc

              cyclosporine will increase the level or effect of maraviroc by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              cyclosporine will increase the level or effect of maraviroc by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • meclofenamate

              meclofenamate, cyclosporine. Either increases toxicity of the other by nephrotoxicity and/or ototoxicity. Modify Therapy/Monitor Closely. Potential for dangerous interaction. Use with caution and monitor closely.

            • mefenamic acid

              mefenamic acid, cyclosporine. Either increases toxicity of the other by nephrotoxicity and/or ototoxicity. Modify Therapy/Monitor Closely.

            • mefloquine

              cyclosporine will increase the level or effect of mefloquine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • meloxicam

              meloxicam, cyclosporine. Either increases toxicity of the other by nephrotoxicity and/or ototoxicity. Modify Therapy/Monitor Closely.

            • melphalan

              melphalan, cyclosporine. Either increases effects of the other by immunosuppressive effects; risk of infection. Use Caution/Monitor. Melphalan may enhance the nephrotoxic effects of cyclosporine. Monitor for increased nephrotoxicity in cyclosporine-treated patient who receive melphalan.

              melphalan increases toxicity of cyclosporine by nephrotoxicity and/or ototoxicity. Use Caution/Monitor.

            • meningococcal A C Y and W polysaccharide tetanus toxoid conjugate vaccine

              cyclosporine decreases effects of meningococcal A C Y and W polysaccharide tetanus toxoid conjugate vaccine by pharmacodynamic antagonism. Modify Therapy/Monitor Closely. If possible, complete all age-appropriate vaccinations at least 2 weeks before initiating immunosuppressant therapy. Patients vaccinated <14 days before starting immunosuppressive therapy or during immunosuppressive therapy should be revaccinated at least 3 months after therapy is discontinued if immune competence has been restored. Longer waiting periods may be required for drugs that maintain their immunosuppressive effects for more than 3 months after discontinuation (eg, ocrelizumab). .

            • meningococcal A C Y and W-135 diphtheria conjugate vaccine

              cyclosporine decreases effects of meningococcal A C Y and W-135 diphtheria conjugate vaccine by pharmacodynamic antagonism. Modify Therapy/Monitor Closely. If possible, complete all age-appropriate vaccinations at least 2 weeks before initiating immunosuppressant therapy. Patients vaccinated <14 days before starting immunosuppressive therapy or during immunosuppressive therapy should be revaccinated at least 3 months after therapy is discontinued if immune competence has been restored. Longer waiting periods may be required for drugs that maintain their immunosuppressive effects for more than 3 months after discontinuation (eg, ocrelizumab). .

            • meningococcal A C Y and W-135 polysaccharide vaccine combined

              cyclosporine decreases effects of meningococcal A C Y and W-135 polysaccharide vaccine combined by pharmacodynamic antagonism. Modify Therapy/Monitor Closely. If possible, complete all age-appropriate vaccinations at least 2 weeks before initiating immunosuppressant therapy. Patients vaccinated <14 days before starting immunosuppressive therapy or during immunosuppressive therapy should be revaccinated at least 3 months after therapy is discontinued if immune competence has been restored. Longer waiting periods may be required for drugs that maintain their immunosuppressive effects for more than 3 months after discontinuation (eg, ocrelizumab). .

            • meningococcal C and Y/haemophilus influenza type B vaccine

              cyclosporine decreases effects of meningococcal C and Y/haemophilus influenza type B vaccine by pharmacodynamic antagonism. Modify Therapy/Monitor Closely. If possible, complete all age-appropriate vaccinations at least 2 weeks before initiating immunosuppressant therapy. Patients vaccinated <14 days before starting immunosuppressive therapy or during immunosuppressive therapy should be revaccinated at least 3 months after therapy is discontinued if immune competence has been restored. Longer waiting periods may be required for drugs that maintain their immunosuppressive effects for more than 3 months after discontinuation (eg, ocrelizumab). .

            • meningococcal group B vaccine

              cyclosporine decreases effects of meningococcal group B vaccine by pharmacodynamic antagonism. Modify Therapy/Monitor Closely. If possible, complete all age-appropriate vaccinations at least 2 weeks before initiating immunosuppressant therapy. Patients vaccinated <14 days before starting immunosuppressive therapy or during immunosuppressive therapy should be revaccinated at least 3 months after therapy is discontinued if immune competence has been restored. Longer waiting periods may be required for drugs that maintain their immunosuppressive effects for more than 3 months after discontinuation (eg, ocrelizumab). .

            • mercaptopurine

              cyclosporine and mercaptopurine both increase immunosuppressive effects; risk of infection. Use Caution/Monitor.

            • mestranol

              cyclosporine will increase the level or effect of mestranol by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              cyclosporine will increase the level or effect of mestranol by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              mestranol increases levels of cyclosporine by unknown mechanism. Use Caution/Monitor.

            • methadone

              cyclosporine will increase the level or effect of methadone by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • methotrexate

              cyclosporine, methotrexate. Either increases levels of the other by Other (see comment). Use Caution/Monitor. Comment: Close monitoring of cyclosporine and methotrexate concentrations, renal function, and liver enzymes is recommended during concurrent therapy. .

            • methylprednisolone

              cyclosporine will increase the level or effect of methylprednisolone by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Seizures reported when high dose methylprednisolone coadministered with cyclosporine

              methylprednisolone, cyclosporine. Other (see comment). Use Caution/Monitor. Comment: Corticosteroids may increase or decrease cyclosporine concentrations. Also, cyclosporine may increase the plasma concentrations of the corticosteroids. Monitor for changes in cyclosporine concentrations and for toxicities of corticosteroids and/or cyclosporine.

            • metoclopramide

              metoclopramide increases levels of cyclosporine by enhancing GI absorption. Applies only to oral form of both agents. Use Caution/Monitor.

            • metoclopramide intranasal

              metoclopramide intranasal will increase the level or effect of cyclosporine by Other (see comment). Use Caution/Monitor. Metoclopramide may increase the absorption of cyclosporine. Monitor therapeutic drug concentrations and adjust the dose as needed.

            • metronidazole

              metronidazole will increase the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • mitotane

              mitotane decreases levels of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • mitoxantrone

              cyclosporine increases toxicity of mitoxantrone by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor. Therapeutic and toxic effects of mitoxantrone may be increased by cyclosporine. Close clinical and laboratory monitoring are indicated.

            • modafinil

              modafinil will decrease the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • mometasone sinus implant

              mometasone sinus implant, cyclosporine. Other (see comment). Use Caution/Monitor. Comment: Corticosteroids may increase or decrease cyclosporine concentrations. Also, cyclosporine may increase the plasma concentrations of the corticosteroids. Monitor for changes in cyclosporine concentrations and for toxicities of corticosteroids and/or cyclosporine.

            • nabumetone

              nabumetone, cyclosporine. Either increases toxicity of the other by nephrotoxicity and/or ototoxicity. Modify Therapy/Monitor Closely.

            • nafcillin

              nafcillin will decrease the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • naldemedine

              cyclosporine increases levels of naldemedine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Monitor naldemedine for potential adverse effects if coadministered with strong or moderate CYP3A4 inhibitors.

              cyclosporine increases levels of naldemedine by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor. Monitor naldemedine for potential adverse effects if coadministered with P-gp inhibitors.

            • naproxen

              naproxen, cyclosporine. Either increases toxicity of the other by nephrotoxicity and/or ototoxicity. Modify Therapy/Monitor Closely.

            • nefazodone

              nefazodone will increase the level or effect of cyclosporine by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • nelfinavir

              cyclosporine will increase the level or effect of nelfinavir by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              cyclosporine will increase the level or effect of nelfinavir by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • neomycin PO

              cyclosporine will increase the level or effect of neomycin PO by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • nevirapine

              nevirapine will decrease the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • nicardipine

              cyclosporine will increase the level or effect of nicardipine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              nicardipine will increase the level or effect of cyclosporine by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              nicardipine increases levels of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • nifedipine

              nifedipine will increase the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • nilotinib

              nilotinib will increase the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              cyclosporine will increase the level or effect of nilotinib by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • nimodipine

              cyclosporine will increase the level or effect of nimodipine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • nintedanib

              cyclosporine increases levels of nintedanib by P-glycoprotein (MDR1) efflux transporter. Modify Therapy/Monitor Closely. If nintedanib adverse effects occur, management may require interruption, dose reduction, or discontinuation of therapy.

            • nisoldipine

              cyclosporine will increase the level or effect of nisoldipine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • nizatidine

              nizatidine will increase the level or effect of cyclosporine by unknown mechanism. Use Caution/Monitor.

            • nortriptyline

              cyclosporine will increase the level or effect of nortriptyline by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • ocrelizumab

              cyclosporine and ocrelizumab both increase immunosuppressive effects; risk of infection. Use Caution/Monitor. Coadministration of ocrelizumab with immunosuppessants is expected to increase the risk of immunosuppression.

            • octreotide

              octreotide decreases levels of cyclosporine by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor.

            • octreotide (Antidote)

              octreotide (Antidote) decreases levels of cyclosporine by inhibition of GI absorption. Applies only to oral form of both agents. Use Caution/Monitor.

            • ofatumumab SC

              ofatumumab SC, cyclosporine. Either increases effects of the other by immunosuppressive effects; risk of infection. Use Caution/Monitor. Consider the risk of additive immune system effects when coadministering immunosuppressive therapies with coadministration. When switching from therapies with immune effects, take into account the duration and mechanism of action of these therapies when initiating ofatumumab SC.

            • oliceridine

              cyclosporine will increase the level or effect of oliceridine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. If concomitant use is necessary, may require less frequent oliceridine dosing. Closely monitor for respiratory depression and sedation and titrate subsequent doses accordingly. If inhibitor is discontinued, consider increase oliceridine dosage until stable drug effects are achieved. Monitor for signs of opioid withdrawal.

            • ombitasvir/paritaprevir/ritonavir & dasabuvir

              ombitasvir/paritaprevir/ritonavir & dasabuvir will increase the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. When initiating therapy with Viekira Pak, reduce cyclosporine dose to 1/5th of the patient?s current cyclosporine dose; measure cyclosporine blood concentrations to determine subsequent dose modifications; upon completion of Viekira Pak, the appropriate time to resume pre-Viekira Pak dose of cyclosporine should be guided by assessment of cyclosporine blood concentrations; also monitor renal function and cyclosporine-related side effects when coadministered

            • omeprazole

              omeprazole, cyclosporine. Either increases toxicity of the other by Other (see comment). Use Caution/Monitor. Comment: Long-term use of PPIs may cause hypomagnesemia and increase this risk when coadministered with drugs that may also decrease magnesium levels.

            • orlistat

              orlistat decreases levels of cyclosporine by inhibition of GI absorption. Applies only to oral form of both agents. Modify Therapy/Monitor Closely. Administer cyclosporine 3 hours after orlistat .

            • oxaliplatin

              cyclosporine and oxaliplatin both increase nephrotoxicity and/or ototoxicity. Use Caution/Monitor.

              oxaliplatin and cyclosporine both increase immunosuppressive effects; risk of infection. Use Caution/Monitor. Use of oxaliplatin with concomitant immunosuppressants or with impaired immune systems may increased risk for serious infections.

            • oxaprozin

              oxaprozin, cyclosporine. Either increases toxicity of the other by nephrotoxicity and/or ototoxicity. Modify Therapy/Monitor Closely.

            • oxcarbazepine

              oxcarbazepine will decrease the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • paclitaxel

              cyclosporine will increase the level or effect of paclitaxel by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              cyclosporine will increase the level or effect of paclitaxel by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • paclitaxel protein bound

              cyclosporine will increase the level or effect of paclitaxel protein bound by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              cyclosporine will increase the level or effect of paclitaxel protein bound by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • palbociclib

              palbociclib will increase the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Consider reducing the dose of sensitive CYP3A4 substrates with a narrow therapeutic index when coadministered with palbociclib.

            • pantoprazole

              pantoprazole, cyclosporine. Either increases toxicity of the other by Other (see comment). Use Caution/Monitor. Comment: When used for prolonged periods of time PPIs may cause hypomagnesemia and the risk is further increased when used concomitantly with drugs that also have the same effects.

            • parecoxib

              parecoxib, cyclosporine. Either increases toxicity of the other by nephrotoxicity and/or ototoxicity. Use Caution/Monitor. NSAIDs decrease prostaglandin synthesis, increasing the risk of nephrotoxicity.

            • pasireotide

              pasireotide decreases levels of cyclosporine by unspecified interaction mechanism. Use Caution/Monitor. Coadministration may decrease bioavailability of oral cyclosporine.

            • pazopanib

              cyclosporine will increase the level or effect of pazopanib by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • pentamidine

              cyclosporine and pentamidine both increase nephrotoxicity and/or ototoxicity. Use Caution/Monitor.

            • pentobarbital

              pentobarbital will decrease the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • phenobarbital

              phenobarbital will decrease the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              phenobarbital will decrease the level or effect of cyclosporine by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • phenytoin

              phenytoin will decrease the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              phenytoin will decrease the level or effect of cyclosporine by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • piroxicam

              piroxicam, cyclosporine. Either increases toxicity of the other by nephrotoxicity and/or ototoxicity. Modify Therapy/Monitor Closely.

            • pitolisant

              pitolisant will decrease the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Pitolisant is a borderline/weak inducer of CYP3A4. Monitor sensitive CYP3A4 substrates for reduced effectiveness if coadministered.

            • pneumococcal vaccine 13-valent

              cyclosporine decreases effects of pneumococcal vaccine 13-valent by pharmacodynamic antagonism. Modify Therapy/Monitor Closely. If possible, complete all age-appropriate vaccinations at least 2 weeks before initiating immunosuppressant therapy. Patients vaccinated <14 days before starting immunosuppressive therapy or during immunosuppressive therapy should be revaccinated at least 3 months after therapy is discontinued if immune competence has been restored. Longer waiting periods may be required for drugs that maintain their immunosuppressive effects for more than 3 months after discontinuation (eg, ocrelizumab). .

            • pneumococcal vaccine heptavalent

              cyclosporine decreases effects of pneumococcal vaccine heptavalent by pharmacodynamic antagonism. Modify Therapy/Monitor Closely. If possible, complete all age-appropriate vaccinations at least 2 weeks before initiating immunosuppressant therapy. Patients vaccinated <14 days before starting immunosuppressive therapy or during immunosuppressive therapy should be revaccinated at least 3 months after therapy is discontinued if immune competence has been restored. Longer waiting periods may be required for drugs that maintain their immunosuppressive effects for more than 3 months after discontinuation (eg, ocrelizumab). .

            • pneumococcal vaccine polyvalent

              cyclosporine decreases effects of pneumococcal vaccine polyvalent by pharmacodynamic antagonism. Modify Therapy/Monitor Closely. If possible, complete all age-appropriate vaccinations at least 2 weeks before initiating immunosuppressant therapy. Patients vaccinated <14 days before starting immunosuppressive therapy or during immunosuppressive therapy should be revaccinated at least 3 months after therapy is discontinued if immune competence has been restored. Longer waiting periods may be required for drugs that maintain their immunosuppressive effects for more than 3 months after discontinuation (eg, ocrelizumab). .

            • poliovirus vaccine inactivated

              cyclosporine decreases effects of poliovirus vaccine inactivated by pharmacodynamic antagonism. Modify Therapy/Monitor Closely. If possible, complete all age-appropriate vaccinations at least 2 weeks before initiating immunosuppressant therapy. Patients vaccinated <14 days before starting immunosuppressive therapy or during immunosuppressive therapy should be revaccinated at least 3 months after therapy is discontinued if immune competence has been restored. Longer waiting periods may be required for drugs that maintain their immunosuppressive effects for more than 3 months after discontinuation (eg, ocrelizumab). .

            • polymyxin B

              cyclosporine and polymyxin B both increase nephrotoxicity and/or ototoxicity. Modify Therapy/Monitor Closely.

            • ponatinib

              ponatinib increases levels of cyclosporine by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • ponesimod

              ponesimod and cyclosporine both increase immunosuppressive effects; risk of infection. Use Caution/Monitor. Caution if coadministered because of additive immunosuppressive effects during such therapy and in the weeks following administration. When switching from drugs with prolonged immune effects, consider the half-life and mode of action of these drugs to avoid unintended additive immunosuppressive effects.

            • posaconazole

              posaconazole will increase the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Perform frequent monitoring of cyclosporine trough concentrations during and at discontinuation of posaconazole treatment and cyclosporine dose adjusted accordingly.

              cyclosporine will increase the level or effect of posaconazole by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • potassium citrate

              cyclosporine and potassium citrate both increase serum potassium. Use Caution/Monitor.

            • potassium citrate/citric acid

              cyclosporine and potassium citrate/citric acid both increase serum potassium. Use Caution/Monitor.

            • prednisolone

              cyclosporine, prednisolone. Either increases levels of the other by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              cyclosporine, prednisolone. Either increases levels of the other by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              prednisolone, cyclosporine. Other (see comment). Use Caution/Monitor. Comment: Corticosteroids may increase or decrease cyclosporine concentrations. Also, cyclosporine may increase the plasma concentrations of the corticosteroids. Monitor for changes in cyclosporine concentrations and for toxicities of corticosteroids and/or cyclosporine.

            • prednisone

              cyclosporine, prednisone. Either increases levels of the other by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              cyclosporine, prednisone. Either increases levels of the other by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              prednisone, cyclosporine. Other (see comment). Use Caution/Monitor. Comment: Corticosteroids may increase or decrease cyclosporine concentrations. Also, cyclosporine may increase the plasma concentrations of the corticosteroids. Monitor for changes in cyclosporine concentrations and for toxicities of corticosteroids and/or cyclosporine.

            • primidone

              primidone will decrease the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • pyrazinamide

              pyrazinamide decreases levels of cyclosporine by unknown mechanism. Use Caution/Monitor. A case reported demonstrated a decrease in cyclosporine plasma levels after pyrazinamide was added onto a renal transplant patient's therapy.

            • quercetin

              quercetin will decrease the level or effect of cyclosporine by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • quetiapine

              cyclosporine will increase the level or effect of quetiapine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • quinapril

              quinapril, cyclosporine. Either increases toxicity of the other by nephrotoxicity and/or ototoxicity. Use Caution/Monitor. Risk of acute renal failure.

            • quinidine

              quinidine will increase the level or effect of cyclosporine by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              cyclosporine will increase the level or effect of quinidine by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • quinine

              cyclosporine will increase the level or effect of quinine by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • quinupristin/dalfopristin

              quinupristin/dalfopristin will increase the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • rabeprazole

              cyclosporine, rabeprazole. Either increases toxicity of the other by Other (see comment). Use Caution/Monitor. Comment: When used for prolonged periods of time PPIs may cause hypomagnesemia and the risk is further increased when used concomitantly with drugs that also have the same effects.

            • rabies vaccine

              cyclosporine decreases effects of rabies vaccine by pharmacodynamic antagonism. Modify Therapy/Monitor Closely. If possible, complete all age-appropriate vaccinations at least 2 weeks before initiating immunosuppressant therapy. Patients vaccinated <14 days before starting immunosuppressive therapy or during immunosuppressive therapy should be revaccinated at least 3 months after therapy is discontinued if immune competence has been restored. Longer waiting periods may be required for drugs that maintain their immunosuppressive effects for more than 3 months after discontinuation (eg, ocrelizumab). .

            • rabies vaccine chick embryo cell derived

              cyclosporine decreases effects of rabies vaccine chick embryo cell derived by pharmacodynamic antagonism. Modify Therapy/Monitor Closely. If possible, complete all age-appropriate vaccinations at least 2 weeks before initiating immunosuppressant therapy. Patients vaccinated <14 days before starting immunosuppressive therapy or during immunosuppressive therapy should be revaccinated at least 3 months after therapy is discontinued if immune competence has been restored. Longer waiting periods may be required for drugs that maintain their immunosuppressive effects for more than 3 months after discontinuation (eg, ocrelizumab). .

            • ramipril

              ramipril, cyclosporine. Either increases toxicity of the other by nephrotoxicity and/or ototoxicity. Use Caution/Monitor. Risk of acute renal failure.

            • ranolazine

              ranolazine will increase the level or effect of cyclosporine by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • repaglinide

              cyclosporine will increase the level or effect of repaglinide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Cyclosporine increases low dose repaglinide exposures by 2.5 fold. Do not exceed 6 mg/day of repaglinide. Consider increasing frequency of glucose monitoring if coadministered.

            • ribociclib

              ribociclib will increase the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Caution if ribociclib is coadministered with sensitive CYP3A4 substrates that have a narrow therapeutic index. Dose reduction for sensitive CYP3A4 substrates may be needed.

            • rifabutin

              rifabutin will decrease the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • rifampin

              rifampin will decrease the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely.

              rifampin will decrease the level or effect of cyclosporine by P-glycoprotein (MDR1) efflux transporter. Modify Therapy/Monitor Closely.

            • rifapentine

              rifapentine will decrease the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • rifaximin

              cyclosporine increases levels of rifaximin by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor. Coadministration of cyclosporine with rifaximin resulted in 83-fold and 124-fold increases in rifaximin mean Cmax and AUC in healthy subjects.

            • risperidone

              cyclosporine will increase the level or effect of risperidone by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • ritonavir

              ritonavir will increase the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              ritonavir will increase the level or effect of cyclosporine by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • rivaroxaban

              cyclosporine increases levels of rivaroxaban by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Cyclosporine, a moderate dual inhibitors of CYP3A4 and P-gp may increase the plasma concentrations of rivaroxaban, a P-gp and CYP3A4 substrate. This interaction is clinically significant in patients with with renal impairment based on simulated pharmacokinetic data.

            • rolapitant

              rolapitant will increase the level or effect of cyclosporine by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor. Oral rolapitant (P-gp inhibitor) may increase plasma concentrations of P-gp substrates and may result in potential adverse reactions. Monitor possible adverse reactions if concomitant use of P-gp substrates and rolapitant can not be avoided.

            • romidepsin

              cyclosporine will increase the level or effect of romidepsin by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              cyclosporine will increase the level or effect of romidepsin by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • ropeginterferon alfa 2b

              ropeginterferon alfa 2b will increase the level or effect of cyclosporine by Other (see comment). Use Caution/Monitor. Certain proinflammatory cytokines, including interferons, can suppress CYP450 enzymes resulting in increased exposures of some CYP substrates. Therefore, monitor patients who are receiving concomitant drugs that are CYP450 substrates with a narrow therapeutic index from toxicities to such drugs.

            • rucaparib

              rucaparib will increase the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Adjust dosage of CYP3A4 substrates, if clinically indicated.

            • ruxolitinib

              cyclosporine will increase the level or effect of ruxolitinib by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • sacubitril/valsartan

              cyclosporine, sacubitril/valsartan. Either increases toxicity of the other by Other (see comment). Use Caution/Monitor. Comment: Coadministration may potentiate the hyperkalemic effects of cyclosporine or valsartan.

            • salicylates (non-asa)

              salicylates (non-asa) increases toxicity of cyclosporine by nephrotoxicity and/or ototoxicity. Use Caution/Monitor. NSAIDs decrease prostaglandin synthesis, increasing the risk of nephrotoxicity.

            • saquinavir

              saquinavir increases levels of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • sarecycline

              sarecycline will increase the level or effect of cyclosporine by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor. Monitor for toxicities of P-gp substrates that may require dosage reduction when coadministered with P-gp inhibitors.

            • sarilumab

              sarilumab, cyclosporine. Other (see comment). Use Caution/Monitor. Comment: Formation of CYP450 enzymes can be altered by increased levels of certain cytokines during chronic inflammation; thus, sarilumab could normalize the formation of CYP450 enzymes thus decrease levels of CYP substrates. Upon initiation or discontinuation of sarilumab in patients who are receiving concomitant CYP450 substrates with a narrow therapeutic index, monitor therapeutic effect.

            • schisandra

              schisandra will increase the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • secobarbital

              secobarbital will decrease the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • secukinumab

              secukinumab, cyclosporine. Other (see comment). Use Caution/Monitor. Comment: Formation of CYP450 enzymes can be altered by increased levels of certain cytokines during chronic inflammation; thus, secukinumab could normalize the formation of CYP450 enzymes. Upon initiation or discontinuation of secukinumab in patients who are receiving concomitant CYP450 substrates, particularly those with a narrow therapeutic index, consider monitoring for therapeutic effect.

            • selexipag

              cyclosporine will increase the level or effect of selexipag by Other (see comment). Use Caution/Monitor. Selexipag is a ABCG2 (BCRP) substrate. Monitor selexipag for increased pharmacologic or adverse effects when coadministered with ABCG2 (BCRP) inhibitors.

            • sildenafil

              cyclosporine will increase the level or effect of sildenafil by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • siltuximab

              siltuximab, cyclosporine. Other (see comment). Use Caution/Monitor. Comment: CYP450 activity in the liver is down regulated by infection and inflammation stimuli including cytokines (eg, IL-6); inhibition of IL-6 by siltuximab may restore CYP450 enzymatic activity; caution if coadministered with CYP substrates that have a narrow therapeutic index.

            • siponimod

              siponimod, cyclosporine. Either increases effects of the other by immunosuppressive effects; risk of infection. Use Caution/Monitor. Caution if coadministered because of additive immunosuppressive effects during such therapy and in the weeks following administration. When switching from drugs with prolonged immune effects, consider the half-life and mode of action of these drugs to avoid unintended additive immunosuppressive effects.

            • sipuleucel-T

              cyclosporine decreases effects of sipuleucel-T by pharmacodynamic antagonism. Modify Therapy/Monitor Closely.

            • sirolimus

              cyclosporine will increase the level or effect of sirolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Simultaneous coadministration significantly increases sirolimus levels; this is minimized by administering sirolimus 4 hr after cyclosporine

              cyclosporine will increase the level or effect of sirolimus by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor. Simultaneous coadministration significantly increases sirolimus levels; this is minimized by administering sirolimus 4 hr after cyclosporine

              cyclosporine, sirolimus. Either increases effects of the other by immunosuppressive effects; risk of infection. Use Caution/Monitor.

              sirolimus increases toxicity of cyclosporine by nephrotoxicity and/or ototoxicity. Use Caution/Monitor. Elevations in serum creatinine, hemolytic uremic syndrome, TTP, and microangiopathy were observed when sirolimus used in combination with cyclosporine. Administer oral doses of sirolimus 4 hr after doses of cyclosporine.

            • solifenacin

              cyclosporine will increase the level or effect of solifenacin by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • stiripentol

              stiripentol, cyclosporine. affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Stiripentol is a CYP3A4 inhibitor and inducer. Monitor CYP3A4 substrates coadministered with stiripentol for increased or decreased effects. CYP3A4 substrates may require dosage adjustment.

              stiripentol will increase the level or effect of cyclosporine by P-glycoprotein (MDR1) efflux transporter. Modify Therapy/Monitor Closely. Consider reducing the dose of P-glycoprotein (P-gp) substrates, if adverse reactions are experienced when administered concomitantly with stiripentol.

            • streptomycin

              cyclosporine and streptomycin both increase nephrotoxicity and/or ototoxicity. Use Caution/Monitor.

            • streptozocin

              cyclosporine and streptozocin both increase nephrotoxicity and/or ototoxicity. Use Caution/Monitor.

            • sufentanil

              cyclosporine will increase the level or effect of sufentanil by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Coadministration of sufentanil with any CYP3A4 inhibitor may increase sufentanil plasma concentration, and, thereby increase or prolonged adverse effects, including potentially fatal respiratory depression.

            • sufentanil SL

              cyclosporine will increase the level or effect of sufentanil SL by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Coadministration of sufentanil SL with any CYP3A4 inhibitor may increase sufentanil plasma concentration, and, thereby increase or prolonged adverse effects, including potentially fatal respiratory depression.

            • sulfadiazine

              sulfadiazine decreases effects of cyclosporine by unknown mechanism. Use Caution/Monitor. Increased nephrotoxicity with this combination.

              sulfadiazine, cyclosporine. Either increases toxicity of the other by nephrotoxicity and/or ototoxicity. Use Caution/Monitor.

            • sulfamethoxazole

              sulfamethoxazole, cyclosporine. Either increases effects of the other by nephrotoxicity and/or ototoxicity. Use Caution/Monitor.

            • sulfasalazine

              cyclosporine will increase the level or effect of sulfasalazine by Other (see comment). Use Caution/Monitor. Cyclosporine, a BCRP inhibitor, may increase levels of sulfasalazine (a BCRP substrate) when combined.

            • sulfisoxazole

              sulfisoxazole will decrease the level or effect of cyclosporine by unknown mechanism. Use Caution/Monitor.

            • sulindac

              sulindac, cyclosporine. Either increases toxicity of the other by nephrotoxicity and/or ototoxicity. Modify Therapy/Monitor Closely.

            • sunitinib

              cyclosporine will increase the level or effect of sunitinib by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • suvorexant

              cyclosporine will increase the level or effect of suvorexant by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Decrease suvorexant starting dose to 5 mg HS if coadministered with moderate CYP3A4 inhibitors

            • tadalafil

              cyclosporine will increase the level or effect of tadalafil by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • tamsulosin

              cyclosporine increases levels of tamsulosin by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Dose reduction may be needed for coadministered drugs that are predominantly metabolized by CYP3A.

            • tecovirimat

              tecovirimat will decrease the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Tecovirimat is a weak CYP3A4 inducer. Monitor sensitive CYP3A4 substrates for effectiveness if coadministered.

            • teduglutide

              teduglutide increases levels of cyclosporine by Other (see comment). Use Caution/Monitor. Comment: Teduglutide may increase absorption of concomitant PO medications; caution with with drugs requiring titration or those with a narrow therapeutic index; dose adjustment may be necessary.

            • telotristat ethyl

              telotristat ethyl will decrease the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Telotristat ethyl induces CYP3A4 and may reduce systemic exposure of sensitive CYP3A4 substrates. Monitor for suboptimal efficacy and consider increasing the dose of the CYP3A4 substrate.

            • temsirolimus

              cyclosporine will increase the level or effect of temsirolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • teniposide

              cyclosporine will increase the level or effect of teniposide by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • tetanus toxoid adsorbed or fluid

              cyclosporine decreases effects of tetanus toxoid adsorbed or fluid by pharmacodynamic antagonism. Modify Therapy/Monitor Closely. If possible, complete all age-appropriate vaccinations at least 2 weeks before initiating immunosuppressant therapy. Patients vaccinated <14 days before starting immunosuppressive therapy or during immunosuppressive therapy should be revaccinated at least 3 months after therapy is discontinued if immune competence has been restored. Longer waiting periods may be required for drugs that maintain their immunosuppressive effects for more than 3 months after discontinuation (eg, ocrelizumab). .

            • tezacaftor

              cyclosporine will increase the level or effect of tezacaftor by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Adjust tezacaftor dosage regimen if coadministered with a moderate CYP3A inhibitor.

            • tick-borne encephalitis vaccine

              cyclosporine decreases effects of tick-borne encephalitis vaccine by pharmacodynamic antagonism. Modify Therapy/Monitor Closely. Immunosuppressants also increase risk of infection with concomitant live vaccines.

            • ticlopidine

              ticlopidine decreases levels of cyclosporine by unspecified interaction mechanism. Use Caution/Monitor.

            • tinidazole

              tinidazole will increase the level or effect of cyclosporine by unknown mechanism. Use Caution/Monitor. Monitored for signs of calcineurin-inhibitor associated toxicities (eg, nephrotoxicity, cholestasis, paresthesias).

            • tipranavir

              cyclosporine will increase the level or effect of tipranavir by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              tipranavir, cyclosporine. Other (see comment). Use Caution/Monitor. Comment: Cyclosporine levels may incr or decr, due to contradictory effects of tipranavir on hepatic CYP3A4 and P glycoprotein.

            • tobramycin

              cyclosporine and tobramycin both increase nephrotoxicity and/or ototoxicity. Modify Therapy/Monitor Closely.

            • tocilizumab

              tocilizumab and cyclosporine both increase immunosuppressive effects; risk of infection. Use Caution/Monitor.

            • tofacitinib

              cyclosporine increases levels of tofacitinib by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. No specific dose adjustment recommended when tofacitinib coadministered with moderate CYP3A4 inhibitors; decrease tofacitinib dose if coadministered with both moderate CYP3A4 and potent CYP2C19 inhibitors.

            • tolazamide

              tolazamide, cyclosporine. unknown mechanism. Use Caution/Monitor. Cyclosporine may decrease the effects of sulfonylureas. Sulfonylureas may increase the effects of cyclosporine.

            • tolbutamide

              tolbutamide increases levels of cyclosporine by unknown mechanism. Use Caution/Monitor. Coadministration of tolbutamide and cyclosporine may increase cyclosporine levels and reduce therapeutic effects of tolbutamide.

            • tolmetin

              tolmetin, cyclosporine. Either increases toxicity of the other by nephrotoxicity and/or ototoxicity. Modify Therapy/Monitor Closely.

            • tolterodine

              cyclosporine will increase the level or effect of tolterodine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • tolvaptan

              cyclosporine will increase the level or effect of tolvaptan by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              tolvaptan will increase the level or effect of cyclosporine by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • topiramate

              topiramate will decrease the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • trabectedin

              cyclosporine will increase the level or effect of trabectedin by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • trastuzumab

              trastuzumab, cyclosporine. Either increases toxicity of the other by immunosuppressive effects; risk of infection. Use Caution/Monitor. Neutropenia or febrile neutropenia incidence were increased when trastuzumab was coadministered with myelosuppressive chemotherapy. .

            • trastuzumab deruxtecan

              trastuzumab deruxtecan, cyclosporine. Either increases toxicity of the other by immunosuppressive effects; risk of infection. Use Caution/Monitor. Neutropenia or febrile neutropenia incidence were increased when trastuzumab was coadministered with myelosuppressive chemotherapy. .

            • travelers diarrhea and cholera vaccine inactivated

              cyclosporine decreases effects of travelers diarrhea and cholera vaccine inactivated by pharmacodynamic antagonism. Modify Therapy/Monitor Closely. Immunosuppressants also increase risk of infection with concomitant live vaccines.

            • trazodone

              cyclosporine will increase the level or effect of trazodone by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • triamcinolone acetonide extended-release injectable suspension

              triamcinolone acetonide extended-release injectable suspension, cyclosporine. Other (see comment). Use Caution/Monitor. Comment: Corticosteroids may increase or decrease cyclosporine concentrations. Also, cyclosporine may increase the plasma concentrations of the corticosteroids. Monitor for changes in cyclosporine concentrations and for toxicities of corticosteroids and/or cyclosporine.

            • triamcinolone acetonide injectable suspension

              cyclosporine will increase the level or effect of triamcinolone acetonide injectable suspension by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              triamcinolone acetonide injectable suspension, cyclosporine. Other (see comment). Use Caution/Monitor. Comment: Corticosteroids may increase or decrease cyclosporine concentrations. Also, cyclosporine may increase the plasma concentrations of the corticosteroids. Monitor for changes in cyclosporine concentrations and for toxicities of corticosteroids and/or cyclosporine.

            • triazolam

              cyclosporine will increase the level or effect of triazolam by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • trimethoprim

              trimethoprim and cyclosporine both increase serum potassium. Use Caution/Monitor. Trimethoprim decreases urinary potassium excretion. May cause hyperkalemia, particularly with high doses, renal insufficiency, or when combined with other drugs that cause hyperkalemia.

            • ustekinumab

              ustekinumab, cyclosporine. Other (see comment). Use Caution/Monitor. Comment: Formation of CYP450 enzymes can be altered by increased levels of certain cytokines during chronic inflammation; thus, normalizing the formation of CYP450 enzymes. Upon initiation or discontinuation of ustekinumab in patients who are receiving concomitant CYP450 substrates, particularly those with a narrow therapeutic index, consider monitoring for therapeutic effect.

            • valsartan

              cyclosporine and valsartan both increase Other (see comment). Use Caution/Monitor. Cyclosporine and valsartan both increase the risk of hyperkalemia and nephrotoxicity.

            • vancomycin

              cyclosporine and vancomycin both increase nephrotoxicity and/or ototoxicity. Use Caution/Monitor.

            • vardenafil

              cyclosporine will increase the level or effect of vardenafil by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • vemurafenib

              cyclosporine increases levels of vemurafenib by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              vemurafenib increases levels of cyclosporine by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • verapamil

              verapamil, cyclosporine. affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Verapamil and cyclosporine may inhibit CYP3A4 metabolism. Coadministration of verapamil and cyclosporine may increase plasma concentrations of either drugs.

            • vinblastine

              cyclosporine will increase the level or effect of vinblastine by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • vincristine

              cyclosporine will increase the level or effect of vincristine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              cyclosporine will increase the level or effect of vincristine by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • vincristine liposomal

              cyclosporine will increase the level or effect of vincristine liposomal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              cyclosporine will increase the level or effect of vincristine liposomal by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • vinorelbine

              cyclosporine will increase the level or effect of vinorelbine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              cyclosporine will increase the level or effect of vinorelbine by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • voclosporin

              cyclosporine will increase the level or effect of voclosporin by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Reduce voclosporin daily dosage to 15.8 mg PO in AM and 7.9 mg PO in PM.

              voclosporin and cyclosporine both increase serum potassium. Use Caution/Monitor.

            • voriconazole

              voriconazole will increase the level or effect of cyclosporine by altering metabolism. Modify Therapy/Monitor Closely. voriconazole may inrease blood levels of cyclosporine; monitor closely and adjust cyclosporine therapy as needed

            • warfarin

              cyclosporine will increase the level or effect of warfarin by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • zanubrutinib

              cyclosporine will increase the level or effect of zanubrutinib by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Reduce zanubrutinib dose when coadministered with a moderate CYP3A4 inhibitor. Interrupt dose as recommended for adverse reactions. After discontinuing the CYP3A4 inhibitor, resume previous dose of zanubrutinib. See zanubrutinib Dosage Modifications for precise recommendation.

            • zoster vaccine recombinant

              cyclosporine decreases effects of zoster vaccine recombinant by pharmacodynamic antagonism. Modify Therapy/Monitor Closely. If possible, complete all age-appropriate vaccinations at least 2 weeks before initiating immunosuppressant therapy. Patients vaccinated <14 days before starting immunosuppressive therapy or during immunosuppressive therapy should be revaccinated at least 3 months after therapy is discontinued if immune competence has been restored. Longer waiting periods may be required for drugs that maintain their immunosuppressive effects for more than 3 months after discontinuation (eg, ocrelizumab). .

            Minor (41)

            • alfentanil

              cyclosporine will increase the level or effect of alfentanil by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Minor/Significance Unknown.

            • alfuzosin

              cyclosporine will increase the level or effect of alfuzosin by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Minor/Significance Unknown.

            • allopurinol

              allopurinol increases levels of cyclosporine by unknown mechanism. Minor/Significance Unknown.

            • alosetron

              cyclosporine will increase the level or effect of alosetron by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Minor/Significance Unknown.

            • alvimopan

              cyclosporine will increase the level or effect of alvimopan by P-glycoprotein (MDR1) efflux transporter. Minor/Significance Unknown.

            • amiodarone

              amiodarone increases levels of cyclosporine by decreasing renal clearance. Minor/Significance Unknown.

            • armodafinil

              cyclosporine will increase the level or effect of armodafinil by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Minor/Significance Unknown.

              cyclosporine will increase the level or effect of armodafinil by P-glycoprotein (MDR1) efflux transporter. Minor/Significance Unknown.

            • atazanavir

              cyclosporine will increase the level or effect of atazanavir by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Minor/Significance Unknown.

            • budesonide

              budesonide, cyclosporine. Either increases levels of the other by decreasing metabolism. Minor/Significance Unknown.

            • cevimeline

              cyclosporine will increase the level or effect of cevimeline by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Minor/Significance Unknown.

            • clarithromycin

              cyclosporine will increase the level or effect of clarithromycin by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Minor/Significance Unknown.

            • clonidine

              clonidine increases levels of cyclosporine by unknown mechanism. Minor/Significance Unknown.

            • clotrimazole

              clotrimazole increases levels of cyclosporine by decreasing metabolism. Minor/Significance Unknown.

            • cordyceps

              cordyceps decreases toxicity of cyclosporine by unspecified interaction mechanism. Minor/Significance Unknown.

            • creatine

              creatine, cyclosporine. Mechanism: pharmacodynamic synergism. Minor/Significance Unknown. (Theoretical interaction) Combination may have additive nephrotoxic effects.

            • dapsone

              cyclosporine will increase the level or effect of dapsone by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Minor/Significance Unknown.

            • disopyramide

              cyclosporine will increase the level or effect of disopyramide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Minor/Significance Unknown.

            • docetaxel

              cyclosporine will increase the level or effect of docetaxel by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Minor/Significance Unknown.

            • donepezil

              cyclosporine will increase the level or effect of donepezil by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Minor/Significance Unknown.

            • dutasteride

              cyclosporine will increase the level or effect of dutasteride by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Minor/Significance Unknown.

            • efavirenz

              cyclosporine will increase the level or effect of efavirenz by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Minor/Significance Unknown.

            • enalapril

              cyclosporine will increase the level or effect of enalapril by Other (see comment). Minor/Significance Unknown. may increase plasma concentrations of OATP substrates

            • entecavir

              cyclosporine, entecavir. Either increases effects of the other by decreasing renal clearance. Minor/Significance Unknown. Coadministration with drugs that reduce renal function or compete for active tubular secretion may increase serum concentrations of either entecavir or the coadministered drug.

            • eplerenone

              cyclosporine will increase the level or effect of eplerenone by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Minor/Significance Unknown.

            • estradiol vaginal

              cyclosporine will increase the level or effect of estradiol vaginal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Minor/Significance Unknown.

            • eucalyptus

              cyclosporine will increase the level or effect of eucalyptus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Minor/Significance Unknown.

            • fenofibric acid

              fenofibric acid increases levels of cyclosporine by unspecified interaction mechanism. Minor/Significance Unknown.

            • fexofenadine

              cyclosporine will increase the level or effect of fexofenadine by P-glycoprotein (MDR1) efflux transporter. Minor/Significance Unknown.

            • hydrocortisone

              hydrocortisone, cyclosporine. Either increases levels of the other by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Minor/Significance Unknown.

            • imatinib

              cyclosporine will increase the level or effect of imatinib by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Minor/Significance Unknown.

            • isradipine

              cyclosporine, isradipine. Either increases levels of the other by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Minor/Significance Unknown.

            • magnesium chloride

              cyclosporine decreases levels of magnesium chloride by increasing renal clearance. Minor/Significance Unknown.

            • montelukast

              cyclosporine will increase the level or effect of montelukast by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Minor/Significance Unknown.

            • nifedipine

              cyclosporine will increase the level or effect of nifedipine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Minor/Significance Unknown.

            • oritavancin

              oritavancin will decrease the level or effect of cyclosporine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Minor/Significance Unknown. Oritavancin is a weak CYP3A4 inducer; caution if coadministered with CYP3A4 substrates that have a narrow therapeutic index

            • propafenone

              cyclosporine will increase the level or effect of propafenone by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Minor/Significance Unknown.

            • roxithromycin

              cyclosporine increases levels of roxithromycin by decreasing elimination. Minor/Significance Unknown.

            • saxagliptin

              cyclosporine will increase the level or effect of saxagliptin by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Minor/Significance Unknown.

            • vinblastine

              cyclosporine will increase the level or effect of vinblastine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Minor/Significance Unknown.

            • zaleplon

              cyclosporine will increase the level or effect of zaleplon by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Minor/Significance Unknown.

            • ziprasidone

              cyclosporine will increase the level or effect of ziprasidone by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Minor/Significance Unknown.

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            Adverse Effects

            >10%

            Tremor (12-55%)

            Nephrotoxicity (32%)

            Hypertension (26%)

            Infection (3-25%)

            Headache (2-25%)

            Nausea (23%)

            Hirsutism (21%)

            Hypertrichosis (5-19%)

            Female reproductive disorder (5-19%)

            Gum hyperplasia (2-16%)

            Triglycerides increased (15%)

            Abdominal discomfort (1-15%)

            URI (1-14%)

            Diarrhea (3-13%)

            Dyspepsia (2-12%)

            Leg cramps (2-12%)

            Parathesia (1-11%)

            1-10%

            Acne

            Convulsions

            Pruitus

            Hyperkalemia, hypomagnesemia

            Pancreatitis

            Hepatotoxicity

            Flu-like syndrome

            Frequency Not Defined

            Leukopenia

            Thrombocytopenia

            Anaphylaxis

            Glomerular capillary thrombosis

            Hypomagnesemia

            Migraine

            Hyponatremia

            Postmarketing Reports

            Pain in lower extremities

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            Warnings

            Black Box Warnings

            Should be prescribed only by physicians who have experience with immunosuppression in solid organ transplant recipients and can provide necessary follow-up and appropriate monitoring

            Coadministration with other immunosuppressants in kidney, liver, and heart transplant recipients, but risk of infection and neoplasia may be increased

            Increased risk for development of lymphomas and other malignancies, particularly those of the skin; avoid excess UV light exposure

            Increased risk appears related to the intensity and duration of immunosuppression rather than to the use of specific agents; oversuppression of the immune system may result in infection or malignancy; caution with regimens containing multiple immunosuppressants

            Sandimmune and Neoral are not bioequivalent and should not be interchanged without physician approval; Neoral (capsules and oral solution) has increased bioavailability compared with Sandimmune (capsules and oral solution)

            For a given trough concentration, cyclosporine exposure will be greater with Neoral than with Sandimmune

            Sandimmune has decreased bioavailability compared with Neoral and erratic absorption; requires careful monitoring of blood levels and subsequent dosage adjustments

            Patients with psoriasis who have been treated with PUVA, methotrexate or immunosuppressants, UVB, coal tar, or radiation are at increased risk for skin malignancies, hypertension, and renal dysfunction

            Contraindications

            Hypersensitivity

            Breastfeeding

            (RA/Psoriasis use): Abnormal renal function, uncontrolled HTN, malignancies

            (Psoriasis use) Concomitant PUVA, UVB radiation, coal tar, methotrexate, other immunosuppressants

            Cautions

            Injection: monitor closely for at least 30 min

            Risk of hepatotoxicity and nephrotoxicity

            Myelosuppression may be severe and prolonged; monitor complete blood and platelet counts

            Potential increase risk for optic disk edema and infusion-related anaphylactic reactions

            Some malignancies caused by cyclosporine immunosuppression may be fatal (eg, lymphoma)

            Serious and fatal cerebral, gastrointestinal and pulmonary hemorrhage; monitor platelets and coagulation parameters and treat accordingly

            Anticipate and monitor for signs and symptoms of tumor lysis syndrome occur; treat promptly

            Monitor for and discontinue promptly if systemic inflammatory response or capillary leak syndrome suspected

            Monitor for signs and symptoms of infection; severe and fatal sepsis as a result of bone marrow suppression; discontinue therapy promptly if infection occur

            Monitor for and discontinue if venous occlusive disease of the liver suspected

            Monitor liver enzymes and discontinue therapy at first signs of severe hepatotoxicity; fatal hepatotoxicity may occur

            Monitor renal function and interrupt or discontinue if creatinine levels increase or acute renal failure occur

            Increased risk for serious infection with fatal outcome because of immunosuppression, including activation of latent viruses, eg, BK virus-induced nephropathy

            Patients with psoriasis who received coal tar, PUVA, methotrexate, or other immunosuppressants have higher risk of skin cancer with Neoral

            Discontinue therapy if exfoliative or bullous rash suspected or if Stevens-Johnson syndrome or toxic epidermal necrolysis suspected

            Monitor for signs and symptoms of enterocolitis and treat promptly

            Extensively metabolized by CYP3A isoenzymes, in particular CYP3A4, and is a substrate of the multidrug efflux transporter P-glycoprotein (P-gp); various agents are known to either increase or decrease plasma or whole blood of cyclosporine levels usually by inhibition or induction of CYP3A4 or P-gp or both

            Occasionally, patients develop a syndrome of thrombocytopenia and thrombotic microangiopathic hemolytic anemia may result in graft failure

            Significant hyperkalemia and hyperuricemia may occur

            Neurotoxicity may occur, particularly with high dose methylprednisolone; caution with other drugs that may cause neurotoxicity

            Mild or moderate hypertension and rarely severe hypertension may occur; incidence decreases over time; antihypertensive therapy may be required in recipients of kidney, liver, and heart allografts treated with cyclosporine; potassium-sparing diuretics should not be used to treat cyclosporine associated hypertension as cyclosporine may cause hyperkalemia; calcium antagonists can be effective but can interfere with cyclosporine metabolism

            Gingival hyperplasia may occur; avoid concomitant nifedipine administration in patients who develop gingival hyperplasia

            Seizures may occur when used in combination with high-dose corticosteroids

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            Pregnancy & Lactation

            Pregnancy Category: C; take into consideration alcohol content of various cyclosporine formulations

            Lactation: excreted in breast milk, do not nurse

            Pregnancy Categories

            A: Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.

            B: May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.

            C: Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.

            D: Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.

            X: Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.

            NA: Information not available.

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            Pharmacology

            Mechanism of Action

            Calcineurin inhibitor

            Suppresses cellular and humoral immunity (mainly T cells)

            Absorption

            Bioavailability: Neoral >Sandimmune

            Peak plasma time: Neoral 1.5-2 hr; Sandimmune 3.5 hr

            Onset: unknown

            Duration: unknown

            Distribution

            Protein Bound: 90%

            Vd: 13 L/kg

            Metabolism

            Via hepatic CYP3A4

            Metabolites: AM1, AM9, AM4N

            Enzymes inhibited: CYP3A4 and P-gp

            Elimination

            Half-Life: 8.4-27 hr

            Clearance: 5-7 mL/min/kg

            Excretion: Mainly bile and feces; 6% urine

            Pharmacogenomics

            Substrate of CYP3A4 and CYP3A5

            Genetic variant in CYP3A4 containing an A- to G- mutation (called CYP3A4-V or CYP3A4*1B) is associated with impaired enzyme activity

            Frequency of this mutation is 4% in the white population, but 67% in the black population

            This may be important in the early postsurgical phase when trying to establish adequate therapeutic serum levels

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            Administration

            IV Incompatibilities

            Additive: MgSO4

            Y-site: amphotericin B cholesteryl sulfate

            IV Compatibilities

            Solution: NS, D5W

            Additive: ciprofloxacin

            Y-site: gatifloxacin, linezolid, propofol, sargramostim

            IV Preparation

            Dilute 1 mL (50 mg) of concentrated inj soln in 20-100 mL of D5W or NS

            Stability of injection of parenteral admixture at room temp (25°C) is 6 hr in PVC; 24 hr in Excel, PAB containers, or glass

            Polyoxyethylated castor oil surfactant in cyclosporine injection may leach phthalate from PVC containers such as bags and tubing

            Actual amount of DEHP plasticizer leached from PVC containers and administration sets may vary in clinical situations, depending on surfactant concentration, bag size, & contact time

            IV Administration

            Following dilution, infuse over 2-6 hr

            Continuously monitor for at least the first 30 min of the infusion, and then frequently thereafter

            Anaphylaxis possible with IV use; reserve only for patients unable to take oral form

            Maintain airway; other supportive measures & agents for treating anaphylaxis should be present

            Oral Administration

            Neoral and Sandimmune are NOT bioequivalent, exercise caution if switching between brands/generics

            Storage

            Store ampules at controlled room temp; do not refrigerate

            Protect ampules from light

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            Images

            BRAND FORM. UNIT PRICE PILL IMAGE
            Sandimmune intravenous
            -
            250 mg/5 mL solution
            Restasis ophthalmic (eye)
            -
            0.05 % liquid
            Restasis ophthalmic (eye)
            -
            0.05 % liquid
            Sandimmune oral
            -
            100 mg capsule
            Sandimmune oral
            -
            25 mg capsule
            Sandimmune oral
            -
            100 mg/mL solution
            Restasis MultiDose ophthalmic (eye)
            -
            0.05 % drops
            cyclosporine oral
            -
            100 mg capsule
            cyclosporine oral
            -
            25 mg capsule
            cyclosporine intravenous
            -
            250 mg/5 mL solution
            cyclosporine intravenous
            -
            250 mg/5 mL solution
            cyclosporine intravenous
            -
            250 mg/5 mL solution

            Copyright © 2010 First DataBank, Inc.

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            Patient Handout

            Select a drug:
            Patient Education
            cyclosporine ophthalmic (eye)

            CYCLOSPORINE - OPHTHALMIC

            (SYE-kloe-SPOR-in)

            COMMON BRAND NAME(S): Cequa, Restasis

            USES: Cyclosporine eye drops are used to treat a certain type of dry eyes. They work by increasing the amount of tears you make.

            HOW TO USE: Read the Instructions for Use if available from your pharmacist before you start using cyclosporine and each time you get a refill. If you have any questions, ask your doctor or pharmacist.Use this medication in the affected eye(s) as directed by your doctor, usually twice a day (about 12 hours apart).To apply eye drops, wash hands first. To avoid contamination, do not touch the dropper tip or let it touch your eye or any other surface.There are different brands of this medication available. Some brands should be mixed before use. If your brand does not need to be mixed before use, the liquid is clear and colorless. If your brand should be mixed, evenly mix the eye drops by turning the vial upside down a few times before using your dose. The mixed drops should look milky and white. Ask your doctor or pharmacist if you have any questions about your brand.If you have dry eyes, contact lens wear is usually not recommended. If you are wearing contact lenses, remove them before using eye drops. Wait at least 15 minutes before replacing your contact lenses. Tilt your head back, look upward, and pull down the lower eyelid to make a pouch. Hold the dropper directly over your eye and place one drop into the pouch. Look downward, gently close your eyes, and place one finger at the corner of your eye (near the nose). Apply gentle pressure for 1 to 2 minutes before opening your eyes. This will prevent the medication from draining out. Try not to blink or rub your eye. If directed to use this medication in both eyes, repeat these steps for your other eye. Do not rinse the dropper. Replace the dropper cap after each use.If you are using another kind of eye medication (such as drops or ointments), wait at least 15 minutes before applying other medications. Use eye drops before eye ointments to allow the drops to enter the eye.Wait several minutes for your vision to clear before driving or operating machinery.Use this medication regularly to get the most benefit from it. To help you remember, use it at the same times each day.If you are using the single-use form of this medication, throw away the opened vial after use. Do not save for later use.Tell your doctor if your condition gets worse.

            SIDE EFFECTS: Eye discomfort/redness/itching, feeling as if something is in the eye, or temporary blurred vision may occur. If any of these effects last or get worse, tell your doctor or pharmacist promptly.Remember that this medication has been prescribed because your doctor has judged that the benefit to you is greater than the risk of side effects. Many people using this medication do not have serious side effects.A very serious allergic reaction to this drug is rare. However, get medical help right away if you notice any symptoms of a serious allergic reaction, including: rash, itching/swelling (especially of the face/tongue/throat), severe dizziness, trouble breathing.This is not a complete list of possible side effects. If you notice other effects not listed above, contact your doctor or pharmacist.In the US -Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088 or at www.fda.gov/medwatch.In Canada - Call your doctor for medical advice about side effects. You may report side effects to Health Canada at 1-866-234-2345.

            PRECAUTIONS: Before using this medication, tell your doctor or pharmacist if you are allergic to it; or if you have any other allergies. This product may contain inactive ingredients, which can cause allergic reactions or other problems. Talk to your pharmacist for more details.Before using this medication, tell your doctor or pharmacist your medical history, especially of: current/recent eye infection.After you apply this drug, your vision may become temporarily blurred. Do not drive, use machinery, or do any activity that requires clear vision until you are sure you can perform such activities safely.During pregnancy, this medication should be used only when clearly needed. Discuss the risks and benefits with your doctor.It is unknown if this drug passes into breast milk. Consult your doctor before breast-feeding.

            DRUG INTERACTIONS: Drug interactions may change how your medications work or increase your risk for serious side effects. This document does not contain all possible drug interactions. Keep a list of all the products you use (including prescription/nonprescription drugs and herbal products) and share it with your doctor and pharmacist. Do not start, stop, or change the dosage of any medicines without your doctor's approval.

            OVERDOSE: This medicine may be harmful if swallowed. If someone has overdosed and has serious symptoms such as passing out or trouble breathing, call 911. Otherwise, call a poison control center right away. US residents can call their local poison control center at 1-800-222-1222. Canada residents can call a provincial poison control center.

            NOTES: Do not share this medication with others.

            MISSED DOSE: If you miss a dose, use it as soon as you remember. If it is near the time of the next dose, skip the missed dose. Use your next dose at the regular time. Do not double the dose to catch up.

            STORAGE: Store at room temperature away from light and moisture. Do not store in the bathroom. Keep all medications away from children and pets.Do not flush medications down the toilet or pour them into a drain unless instructed to do so. Properly discard this product when it is expired or no longer needed. Consult your pharmacist or local waste disposal company.

            Information last revised August 2021. Copyright(c) 2021 First Databank, Inc.

            IMPORTANT: HOW TO USE THIS INFORMATION: This is a summary and does NOT have all possible information about this product. This information does not assure that this product is safe, effective, or appropriate for you. This information is not individual medical advice and does not substitute for the advice of your health care professional. Always ask your health care professional for complete information about this product and your specific health needs.

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            Formulary

            FormularyPatient Discounts

            Adding plans allows you to compare formulary status to other drugs in the same class.

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            The above information is provided for general informational and educational purposes only. Individual plans may vary and formulary information changes. Contact the applicable plan provider for the most current information.

            Tier Description
            1 This drug is available at the lowest co-pay. Most commonly, these are generic drugs.
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            5 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            6 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            NC NOT COVERED – Drugs that are not covered by the plan.
            Code Definition
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            Drugs that require prior authorization. This restriction requires that specific clinical criteria be met prior to the approval of the prescription.
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            Drugs that have step therapy associated with each prescription. This restriction typically requires that certain criteria be met prior to approval for the prescription.
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            Medscape prescription drug monographs are based on FDA-approved labeling information, unless otherwise noted, combined with additional data derived from primary medical literature.