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Low Intraindividual Variability of Cyclosporin A Exposure Reduces Chronic Rejection Incidence and Health Care Costs

BARRY D. KAHAN^*, MARIA WELSH^*, DIANA L. URBAUER, MELINDA B. MOSHEIM^*, KATHLEEN M. BEUSTERIEN, MARTHA R. WOOD, LINDA P. SCHOENBERG^*, JOSEPH DICESARE^§, STEPHEN M. KATZ^* and CHARLES T. VAN BUREN^*

^* Division of Immunology and Organ Transplantation, Department of Surgery, University of Texas Houston Health Science Center - Medical School, Houston, Texas
Biometrics Consulting, Houston, Texas
Covance Health Economics and Outcomes Services, Inc., Washington, DC
^§ Novartis Pharmaceuticals Corporation, East Hanover, New Jersey.

Correspondence to Dr. Barry D. Kahan, Division of Immunology and Organ Transplantation, Department of Surgery, University of Texas Houston Health Science Center - Medical School, 6431 Fannin, Suite 6.240, Houston, TX 77030. Phone: 713-500-7400; Fax: 713-500-0785; E-mail bkahan{at}orgtx71.med.uth.tmc.edu

Abstract. The present study applied a receiver operating characteristic (ROC) analysis to assess the role of intraindividual variability of cyclosporin A (CsA) drug exposure in predisposing renal transplant recipients to the occurrence of chronic rejection, as well as to increased health care costs using a resource-based economic analysis. Two hundred and four adult renal transplant recipients were treated with tapering doses of prednisone (Pred) and with a concentration-controlled strategy that selected doses of the olive oil-based formulations of CsA (Sandimmune®) that achieved target concentrations based on serial pharmacokinetic profiles. The ROC analysis revealed an inflection point of plots of the coefficient of variation (%CV) of CsA exposure versus the risk of chronic rejection at 28.4% for the average concentration (C_av), i.e., the dosing interval-corrected area under the concentration-time curves, and 36% for the trough concentration (C₀). The incidence of chronic rejection over a period of 5 yr was 24% among the less variable (LV) versus 40% among the variable (V) cohort. The economic analysis revealed that the total mean facility and physician costs per patient were $48,789 versus $60,998, respectively (P < 0.01). The degree of variability displayed by any individual could only be predicted by serial measurements of CsA concentrations, and not by demographic features, laboratory determinations, clinical characteristics, individual or mean values of any observed CsA concentration, or other pharmacokinetic parameters calculated following a single drug exposure. Thus, strategies that reduce intrapatient variability of CsA exposure over time may lead to reductions in chronic allograft loss and in treatment costs.

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Copyright © 2008 by the American Society of Nephrology. Online ISSN: 1533-3450 Print ISSN: 1046-6673