Switching from Tacrolimus to Cyclosporine in Transplant Patients

Clinical Context and Recommendations

The European Respiratory Society recommends converting from cyclosporine to tacrolimus in lung transplant patients with bronchiolitis obliterans syndrome, as it slows or reverses lung function decline 1, 2, 3, 4, 5, 6
The European Respiratory Society strongly recommends against switching from tacrolimus to cyclosporine in lung transplant patients 1, 2, 3
The American transplant society is not mentioned, however, the Journal of Hepatology notes that tacrolimus demonstrates superior rejection prevention and is associated with better patient and graft survival in liver transplant patients 7

The European Respiratory Journal recommends a corticosteroid bridge during the conversion period, with transiently increased maintenance corticosteroid dosing until cyclosporine blood levels reach the desired target range 1, 2, 3
Praxis Medical Insights recommends monitoring drug levels frequently after conversion until stable therapeutic targets are achieved, and avoiding conversion during high-risk periods such as acute rejection episodes or the early post-transplant period 8

Praxis Medical Insights notes that close monitoring is required when adding or removing CYP3A4 inhibitors or inducers, as both tacrolimus and cyclosporine are metabolized by CYP3A4 9

The Journal of Hepatology notes that no specific immunosuppressive regimen is recommended to prevent primary sclerosing cholangitis recurrence in liver transplant patients 7
Praxis Medical Insights recommends tacrolimus as the first-line calcineurin inhibitor in kidney transplant patients, with conversion from cyclosporine to tacrolimus improving outcomes 8

The National Kidney Foundation recommends starting cyclosporine at an initial dose, typically 3-5 mg/kg/day in 2 divided doses, targeting trough levels of 100-175 ng/mL, when converting from tacrolimus to cyclosporine in kidney transplant recipients 10, 11

The American Society of Transplantation suggests monitoring cyclosporine blood trough concentrations every 4-7 days initially until stabilization within the desired range, with a strength of evidence level of B, based on a single study with a small sample size 10, 11