Both glucocorticoids and cyclosporine can exacerbate glucose intolerance, worsen osteoporosis, and cause myopathy and systemic hypertension. Commonly, chronic cyclosporine use at the levels employed in lung transplant immunosuppression results in renal insufficiency by decreasing renal blood flow and by a direct effect on the renal tubules, causing in hyperkalemia and hypomagnesemia. Nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided, since these will act synergistically with cyclosporine to further reduce glomerular filtration. The major side effect of azathioprine is bone marrow suppression. Neutropenia may often result from either azathioprine or CMV infection.
Drugs that are metabolized by the P-450 system will interact with cyclosporine metabolism. Drugs that induce these enzymes (e.g., phenytoin, rifampin, and phenobarbital) may lower cyclosporine levels acutely, possibly precipitating rejection. Drugs that inhibit cyclosporine metabolism (e.g., erythromycin, ketoconazole, cimetidine, and the calcium-channel blockers) may lead to elevation of cyclosporine levels into the toxic range and should be avoided unless appropriate changes in cyclosporine dosing are made to compensate.
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