Neoral/cyclosporine-based immunosuppression.

The introduction of cyclosporine (CsA) has been a major advance. Its use paved the way for successful programs in heart, lung, liver, kidney, and kidney-pancreas transplantation. The recent introduction of Neoral has overcome many of the problems associated with the use of Sandimmune (Novartis, Basel, Switzerland), including poor bioavailability, dependence on bile for absorption, and need for intravenous CsA early in the postoperative period. The use of Neoral has resulted in (1) a marked reduction in the incidence of acute cellular rejection, (2) ability to discontinue steroid therapy in the early posttransplantation period, and (3) low toxicity profiles. In direct comparison with tacrolimus, Neoral was equally efficacious and less toxic. This is even more impressive when one now realizes the monitoring of Neoral has been inadequate, and with more sensitive monitoring tools, including peak CsA level; a surrogate marker for C(max), CsA blood concentrations 2 hours after drug intake; or area under the CsA time-concentration curve, rejection rates may be improved, with improvement in toxicity profiles.