Sandimmun Neoral 100 mg/ml oral solution: detailed information

Package leaflet: Information for the user

Introduction

Package leaflet: Information for the patient

Sandimmun Neoral 100mg/ml oral solution

ciclosporin

Read all of this leaflet carefully before you start taking this medicine, because it contains important information for you.

Keep this leaflet. You may need to read it again.
If you have any questions, ask your doctor or pharmacist.
This medicine has been prescribed for you only, and you should not give it to other people, even if they have the same symptoms as you, because it may harm them.
If you experience any adverse effects, consult your doctor or pharmacist, even if they are adverse effects not listed in this leaflet. See section 4.

Contents of the leaflet:

What Sandimmun Neoral is and what it is used for
What you need to know before taking Sandimmun Neoral
How to take Sandimmun Neoral
Possible adverse effects
How to store Sandimmun Neoral
Contents of the pack and other information

1. What Sandimmun Neoral is and what it is used for

What Sandimmun Neoral is

The name of your medicine is Sandimmun Neoral. It contains the active substance ciclosporin. It belongs to a group of medicines known as immunosuppressants. These medicines are used to reduce immune responses in the body.

What Sandimmun Neoral is used for and how it works

If you have undergone an organ, bone marrow or stem cell transplant, the function of Sandimmun Neoral is to control your body's immune system. Sandimmun Neoral prevents rejection of transplanted organs by suppressing the development of certain cells that would normally attack the transplanted tissue.
If you have an autoimmune disease, in which your body's immune response attacks its own cells, Sandimmun Neoral suppresses this immune reaction. These diseases include eye disorders that may affect your vision (endogenous uveitis, including Behçet's uveitis), severe cases of certain skin diseases (atopic dermatitis, or eczema, and psoriasis), severe rheumatoid arthritis, and a kidney disease called nephrotic syndrome.

2. What you need to know before taking Sandimmun Neoral

If you are taking Sandimmun Neoral after a transplant, it must have been prescribed by a doctor experienced in transplantation and/or autoimmune diseases.

The recommendations in this leaflet may vary depending on whether you are taking the medicine for a transplant or for an autoimmune disease.

Follow your doctor's instructions carefully. They may differ from the general information contained in this leaflet.

Do not take Sandimmun Neoral:

if you are allergic to ciclosporin or to any of the other components of this medicine (listed in section 6).
with medicines containing Hypericum perforatum (St. John's wort).
with medicines containing dabigatran etexilate (used to prevent blood clots after surgery) or bosentan and aliskiren (used to lower high blood pressure).

If any of these apply to you, do not take Sandimmun Neoral and inform your doctor. If you are unsure, consult your doctor before taking Sandimmun Neoral.

Warnings and precautions

Before and during treatment with Sandimmun Neoral, inform your doctor immediately:

if you have any signs of infection, such as fever or sore throat. Sandimmun Neoral suppresses the immune system and may also affect your body's ability to fight infections.
if you have liver problems.
if you have kidney problems. Your doctor will perform regular blood tests and may adjust your dose if necessary.
if you have high blood pressure. Your doctor will monitor your blood pressure regularly and may prescribe a medicine to lower it if needed.
if you have low magnesium levels in your body. Your doctor may give you magnesium supplements, especially shortly after your transplant surgery.
if you have high potassium levels in your blood.
if you suffer from gout.
if you need to receive a vaccine.

If you experience any of the above conditions before or during treatment with Sandimmun Neoral, inform your doctor immediately.

Sun protection and sunlight exposure

Sandimmun Neoral suppresses your immune system. This may increase the risk of developing cancer, particularly of the skin and lymphatic system. Therefore, you should limit your exposure to sunlight and UV radiation by:

wearing appropriate protective clothing.
frequently applying a high-protection-factor sunscreen.

Consult your doctor before taking Sandimmun Neoral:

if you have or have had alcohol-related problems.
if you have epilepsy.
if you have any liver problems.
if you are pregnant.
if you are breastfeeding.
if this medicine is prescribed for a child.

If any of these situations apply to you (or you are unsure), inform your doctor before taking Sandimmun Neoral. This is because this medicine contains alcohol (see section "Sandimmun Neoral contains ethanol" below).

Monitoring during treatment with Sandimmun Neoral

Your doctor will monitor:

ciclosporin blood levels, especially if you have undergone a transplant,
your blood pressure before starting treatment and regularly during treatment,
the function of your liver and kidneys,
your blood lipid levels (fats).

If you have any questions about how Sandimmun Neoral works or why it has been prescribed for you, consult your doctor.

Additionally, if you are taking Sandimmun Neoral for a condition other than transplantation (intermediate or posterior uveitis and Behçet's uveitis, atopic dermatitis, severe rheumatoid arthritis, or nephrotic syndrome), do not take Sandimmun Neoral:

if you have kidney problems (except for nephrotic syndrome).
if you have an infection that is not controlled with medication.
if you have any type of cancer.
if you have high blood pressure (hypertension) that is not controlled with medication. If you develop high blood pressure during treatment that cannot be controlled, your doctor should discontinue treatment with Sandimmun Neoral.

If any of these situations apply to you, do not take Sandimmun Neoral. If you are unsure, consult your doctor or pharmacist before taking Sandimmun Neoral.

If you are being treated for Behçet's uveitis, your doctor will monitor you carefully, especially if you experience neurological symptoms (e.g., frequent forgetfulness, gradual personality changes, psychiatric or mood disorders, burning sensation in the limbs, reduced sensitivity in the limbs, tingling in the limbs, limb weakness, motor disturbances, headache with or without nausea and vomiting, visual disturbances including limited eye movement).

Your doctor will monitor you closely if you are elderly and being treated for psoriasis or atopic dermatitis. If Sandimmun Neoral has been prescribed for your psoriasis or atopic dermatitis, you must not be exposed to UVB radiation or photochemotherapy during treatment.

Children and adolescents

Sandimmun Neoral should not be administered to children for indications other than transplantation, except for the treatment of nephrotic syndrome.

Elderly population (aged 65 years and older)

Experience with Sandimmun Neoral in elderly patients is limited. Your doctor should monitor your kidney function. If you are over 65 years old and have psoriasis or atopic dermatitis, Sandimmun Neoral should only be used if your condition is particularly severe.

Other medicines and Sandimmun Neoral

Inform your doctor or pharmacist if you are taking, have recently taken, or might need to take any other medicines.

In particular, inform your doctor or pharmacist if you are taking any of the following medicines before or during treatment with Sandimmun Neoral:

Medicines that may affect your potassium levels. These include medicines containing potassium, potassium supplements, potassium-sparing diuretics, and some medicines that lower your blood pressure.
Methotrexate. It is used to treat tumors, severe psoriasis, and severe rheumatoid arthritis.
Medicines that may increase or decrease ciclosporin (the active substance in Sandimmun Neoral) levels in your blood. Your doctor may check your ciclosporin blood levels when starting or stopping other medicines.
Medicines that may increase ciclosporin levels in your blood include: antibiotics (such as erythromycin or azithromycin), antifungals (voriconazole, itraconazole), medicines used for heart disorders or high blood pressure (diltiazem, nicardipine, verapamil, amiodarone), metoclopramide (used to stop vomiting), oral contraceptives, danazol (used to treat menstrual disorders), medicines used to treat gout (allopurinol), cholic acid and derivatives (used to treat gallstones), protease inhibitors used to treat HIV, imatinib (used to treat leukemia or tumors), colchicine, telaprevir (used to treat hepatitis C), cannabidiol (used, among others, to treat epileptic seizures).
Medicines that may decrease ciclosporin levels in your blood include: barbiturates (used to help you sleep), certain anticonvulsants (such as carbamazepine or phenytoin), octreotide (used to treat acromegaly or neuroendocrine tumors in the intestine), antibacterial medicines used to treat tuberculosis, orlistat (used to help lose weight), herbal medicines containing St. John's wort, ticlopidine (used after stroke), certain medicines that lower blood pressure (bosentan), and terbinafine (an antifungal medicine used to treat foot and nail infections).
Medicines that may affect your kidneys. These include: antibacterial medicines (gentamicin, tobramycin, ciprofloxacin), antifungal medicines containing amphotericin B, medicines used for urinary tract infections containing trimethoprim, cancer medicines containing melphalan, medicines used to reduce stomach acid (acid secretion inhibitors such as H2-receptor antagonists), tacrolimus, analgesics (non-steroidal anti-inflammatory drugs such as diclofenac), fibric acid derivatives (used to reduce blood fat levels).
Nifedipine. It is used to treat high blood pressure and chest pain. You may experience swollen gums that grow over your teeth if you are taking nifedipine during ciclosporin treatment.
Digoxin (used to treat heart disorders), cholesterol-lowering medicines (HMG-CoA reductase inhibitors also known as statins), prednisolone, etoposide (used to treat cancer), repaglinide (an oral antidiabetic medicine), immunosuppressants (everolimus, sirolimus), ambrisentan, and specific anticancer medicines called anthracyclines (such as doxorubicin).
Sodium mycophenolate or mycophenolate mofetil (an immunosuppressant) and eltrombopag (used to treat bleeding disorders).

If any of these situations apply to you (or you are unsure), inform your doctor or pharmacist before taking Sandimmun Neoral.

Taking Sandimmun Neoral with food and drinks

Do not take Sandimmun Neoral with grapefruit or grapefruit juice. This is because it may affect how Sandimmun Neoral works.

Pregnancy and breastfeeding

Consult your doctor or pharmacist before taking this medicine.

Inform your doctor if you are pregnant or planning to become pregnant. Experience with Sandimmun Neoral in pregnant women is limited. In general, Sandimmun Neoral should not be administered during pregnancy. If it is necessary for you to take this medicine, your doctor will discuss the potential benefits and risks of taking it during pregnancy.
Inform your doctor if you are breastfeeding. Breastfeeding is not recommended during treatment with Sandimmun Neoral. This is because ciclosporin, the active substance, passes into breast milk and could affect your child.

Hepatitis C

Inform your doctor if you have hepatitis C. Your liver function may change with hepatitis C treatment, which could affect ciclosporin blood levels. Your doctor may need to closely monitor your ciclosporin blood levels and adjust the dose after starting hepatitis C treatment.

Driving and using machines

You may feel drowsy, disoriented, or have blurred vision after taking Sandimmun Neoral. Be cautious when driving or operating machinery while taking Sandimmun Neoral until you know how it affects you.

Sandimmun Neoral contains ethanol

Sandimmun Neoral contains 94.70 mg of alcohol (ethanol) per ml, corresponding to 12.0% v/v. A 500 mg dose of Sandimmun Neoral contains 500 mg of ethanol, equivalent to approximately 13 ml of beer or 5 ml of wine. The small amount of alcohol in this medicine will not have any noticeable effect.

Sandimmun Neoral contains castor oil

Sandimmun Neoral may cause stomach discomfort and diarrhea because it contains castor oil.

Sandimmun Neoral contains propylene glycol

This medicine contains 94.70 mg of propylene glycol in each ml of oral solution.

If the baby is less than 4 weeks old, consult your doctor or pharmacist, especially if the baby has been given other medicines containing propylene glycol or alcohol.

3. How to take Sandimmun Neoral

Follow exactly the instructions for administering this medicine as given by your doctor. If in doubt, consult your doctor again.

Do not take more than the recommended dose.

Your doctor will carefully adjust the dose of this medicine to your individual needs. Taking too much of this medicine may affect your kidneys. You will have regular blood tests and hospital visits, especially after transplantation. This will allow you to discuss your treatment and any problems you may experience with your doctor.

How much Sandimmun Neoral you should take

Your doctor will tell you the correct dose of Sandimmun Neoral for you. This depends on your body weight and the reason why you are taking this medicine. Your doctor will also inform you how often you should take your medicine.

In adults:

Organ, bone marrow, and stem cell transplantation

The total daily dose is usually between 2 mg and 15 mg per kilogram of body weight. This is divided into two doses.
Higher doses are usually used before and immediately after your transplant. Lower doses are used once your transplanted organ or bone marrow is stabilized.
Your doctor will adjust the dose to one that is ideal for you. To do this, your doctor may need to perform some blood tests.

Endogenous uveitis

The total daily dose is usually between 5 mg and 7 mg per kilogram of body weight. This is divided into two doses.

Nephrotic syndrome

The total daily dose for adults is usually 5 mg per kilogram of body weight. This is divided into two doses. In patients with renal impairment, the initial daily dose should not exceed 2.5 mg per kilogram of body weight.

Severe rheumatoid arthritis

The total daily dose is usually between 3 mg and 5 mg per kilogram of body weight. This is divided into two doses.

Psoriasis and atopic dermatitis

The total daily dose is usually between 2.5 mg and 5 mg per kilogram of body weight. This is divided into two doses.
In children:

Nephrotic syndrome

The total daily dose for children is usually 6 mg per kilogram of body weight. This is divided into two doses. In patients with renal impairment, the initial daily dose should not exceed 2.5 mg per kilogram of body weight.

Follow your doctor's instructions exactly and never change the dose yourself, even if you feel well.

Switching from Sandimmun to Sandimmun Neoral

You may have previously been taking another medicine called Sandimmun soft gelatin capsules or Sandimmun oral solution. Your doctor may decide to switch you to Sandimmun Neoral oral solution.

All these medicines contain ciclosporin as the active substance.
Sandimmun Neoral is a different and improved formulation of ciclosporin compared to Sandimmun. Ciclosporin is better absorbed into the blood with Sandimmun Neoral and is less likely to be affected by food intake. This means that ciclosporin blood levels remain more consistent with Sandimmun Neoral than with Sandimmun.

If your doctor switches you from Sandimmun to Sandimmun Neoral:

Do not take Sandimmun again unless your doctor tells you to.
After switching from Sandimmun to Sandimmun Neoral, your doctor will monitor you more closely for a short period of time. This is due to the change in how ciclosporin is absorbed into the blood. Your doctor will ensure you are taking the correct dose according to your individual needs.
You may experience some adverse effects. If this happens, inform your doctor or pharmacist. It may be necessary to reduce your dose. Never reduce your dose yourself unless instructed by a doctor.

If your doctor switches you from one oral ciclosporin formulation to another

After switching from one oral ciclosporin formulation to another:

Your doctor will monitor you more closely for a short period of time.
You may experience some adverse effects. If this happens, inform your doctor or pharmacist. It may be necessary to adjust your dose. Never adjust your dose yourself unless instructed by a doctor.

When to take Sandimmun Neoral

Take Sandimmun Neoral at the same time each day. This is very important if you have undergone a transplant.

How to take Sandimmun Neoral

Your daily dose should always be administered in two divided doses.

For initial use, follow steps 1 to 9.
For subsequent use, follow steps 5 to 9.

Instructions for starting a new bottle of Sandimmun Neoral oral solution

1.	Lift the center tab of the metal closure ring.
2.	Completely remove the closure ring.
3.	Remove the gray stopper and discard it.
4.	Firmly insert and press the tube with the white stopper into the neck of the vial.
Dose Measurement
5.	Select the syringe depending on the amount of medication to be measured: For volumes less than or equal to 1 ml of medication, use the 1 ml syringe. For volumes greater than 1 ml of medication, use the 4 ml syringe. Insert the tip of the syringe into the white stopper.
6.	Pull back the plunger until the correct amount of medication is drawn up. The bottom edge of the plunger ring should align with the marking on the syringe indicating the amount of medication.
7.	Push down and pull up the plunger several times. This will help eliminate large air bubbles. The presence of a few small bubbles in the syringe is not significant and will not affect the dose in any way. Ensure that the correct amount of medication is contained in the syringe. Then, remove the syringe from the vial.
8.	Empty the medication from the syringe into a glass containing some liquid, preferably apple juice. Ensure that the syringe does not come into contact with the liquid in the glass. Stir and drink the entire contents of the glass immediately.
9.	After use, clean only the outside of the syringe with a dry cloth. Then, return the syringe to its packaging. Keep the white stopper and tube inside the vial. Close the vial with the included cap.

How long to take Sandimmun Neoral

Your doctor will advise you how long you need to take Sandimmun Neoral. This depends on whether you are taking it after an organ transplant or for the treatment of severe skin disorders, rheumatoid arthritis, uveitis, or nephrotic syndrome. In the case of severe skin rash, treatment usually lasts 8 weeks.

Continue taking Sandimmun Neoral for as long as your doctor prescribes it.

If you have any doubts about how long you should take Sandimmun Neoral, consult your doctor or pharmacist.

If you take more Sandimmun Neoral than you should

If you accidentally take too much of the medicine, inform your doctor immediately or go to the nearest hospital emergency department. You may require medical attention.

You may also call the Toxicology Information Service at telephone number 91 562 04 20, stating the medication and the amount taken.

If you forget to take Sandimmun Neoral

If you forget a dose, take it as soon as you remember. However, if it is almost time for your next dose, skip the missed dose and take the next dose at your regular time.
Do not take a double dose to make up for a missed dose.

If you stop taking Sandimmun Neoral

Do not stop treatment with Sandimmun Neoral unless your doctor tells you to do so.

Continue taking Sandimmun Neoral even if you feel well. Stopping treatment with Sandimmun Neoral may increase the risk of rejection of your transplanted organ.

If you have any further questions about the use of this medicine, ask your doctor or pharmacist.

4. Possible adverse effects

Like all medicines, this medicine can cause adverse effects, although not everyone will experience them.

Some adverse effects can be serious

Tell your doctor immediately if you notice any of the following serious adverse effects:

Like other medicines that affect the immune system, cyclosporine can influence your body's ability to fight certain infections and may cause tumors or other malignant diseases, especially of the skin. Signs of infection may include fever or sore throat.
Vision disturbances, lack of coordination, clumsiness, memory loss, difficulty speaking or understanding what others say, and muscle weakness. These could be signs of a brain infection called progressive multifocal leukoencephalopathy.
Brain problems with signs such as seizures, confusion, disorientation, reduced sensation, personality changes, agitation, insomnia, vision disturbances, blindness, coma, paralysis of part or all of the body, torticollis, lack of coordination with or without abnormal speech or eye movements.
Inflammation at the back of the eye that may be associated with blurred vision. It may also affect your vision due to increased pressure inside the head (benign intracranial hypertension).
Liver injury and dysfunction, with or without yellowing of the eyes or skin, nausea, vision loss, and dark urine.
Kidney problems, which may greatly reduce the amount of urine you produce.
Decrease in the number of red blood cells or platelets. These signs include pale skin, fatigue, shortness of breath, dark urine (a sign of red blood cell breakdown), bleeding or bruising without apparent reason, confusion, disorientation, inattention, and kidney problems.

Other adverse effects include:

Very common: may affect more than 1 in 10 people

Kidney problems.
High blood pressure.
Headache.
Uncontrollable body tremors.
Excessive growth of facial and body hair.
Increased blood lipids.