Experiences with the enzyme-multiplied immunoassay cyclosporine specific assay in a therapeutic drug monitoring laboratory

Reducing the cost of cyclosporin assays: modification of the EMIT 2000 method

Cyclosporin is the leading immunosuppressant agent in organ transplantation, and therapeutic drug monitoring forms an integral part of patient management in most institutions. In the authors' laboratory, the cost of cyclosporin assays represents a major fraction of total consumable expenditure. At present, an average of 4,300 patient cyclosporin assays are performed annually using the EMIT 2000 method (Behring-Syva) on the Cobas Mira analyser (Roche), at a cost of AUD$50,000 in kits alone. As a means of reducing laboratory costs, the manufacturer's recommended method was modified by decreasing all of the reagent and sample volumes in the "Analytical" section of the Cobas Mira cyclosporin programme by 33%. Assay performance was monitored over a 10-month period and compared to that of the unmodified method. Calibration curves were stable, requiring a one-point correction on average of once every 12 days, and a full calibration once ever 1.7 months. Interassay variability was not different to that previously reported for the unchanged method, with mean (SD, CV) concentrations for trilevel quality control specimens of 86.5 micrograms/L (10.2, 11.9%), 185.9 micrograms/L (11.4, 6.2%) and 408.5 micrograms/l (28.9, 7.1%). From 24 specimens assayed in an international quality assurance programme, the results of 23 were within 1.2 SD of the group mean for the EMIT method, with an average bias of 0.8%. With the current modifications, we were able to perform an average of 105 patient assays per kit compared to the previous 71, equating to an annual saving the AUD$16,600.

Noninterchangeability of specific radioimmunoassay and monoclonal antibody fluorescent polarization immunoassay in cyclosporine measurements

This study compares cyclosporine (CsA) concentrations in whole blood from patients receiving bone marrow (n = 10), renal (n = 48), heart (n = 50) or liver (n = 50) transplants, as measured by monoclonal antibody flurorescence polarization immunoassay (FPIA) and specific 125I-radioimmunoassay (RIA). The FPIA overestimated CsA by an average of 25%. Results were higher for all indications: FPIA/RIA ratios were 1.17 for bone marrow, 1.23 for renal and 1.27 for both heart and liver transplants, and these values were significantly different from 1.0. The percentage of overestimation was higher at low CsA concentrations (< or = 100 micrograms/L) than at high CsA concentrations (> or = 400 micrograms/L). In all indications, results by both methods correlated well (r > 0.96) but slopes and intercepts were different from 1.0 and 0.0, respectively, and these parameters varied greatly between the grafted populations. These findings obtained with the two methods could not be attributed to matrix effect because the mean FPIA/RIA ratio for spiked control samples was 1.0. The discrepancy between the FPIA and RIA could be explained by the lower specificity of the monoclonal antibody contained in the FPIA kit. These results suggest that FPIA is not as accurate as RIA and that the two methods are not interchangeable in CsA level measurement.

The use of therapeutic drug monitoring to optimise immunosuppressive therapy

Most experience of the therapeutic drug monitoring of immunosuppressive agents has been acquired in the field of solid organ transplantation; however, agents such as cyclosporin (cyclosporin A) are being increasingly utilised for the management of autoimmune diseases. Cyclosporin is the most widely studied immunosuppressant, but in spite of this many controversies still exist as to the optimum strategy for monitoring this drug. Owing to its widely variable pharmacokinetics and metabolism, and the absence of a simple method to measure therapeutic effectiveness, many factors should be considered. In most circumstances, measuring whole blood through concentrations of cyclosporin with a specific assay methodology is warranted. In addition, knowledge of other factors that may alter the pharmacokinetics (such as liver function, concomitant food or medications, gastrointestinal status, and time since transplantation) should be taken into account so that therapy can be appropriately adjusted. Other methods of monitoring have been investigated, such as AUC (area under the concentration-time curve) monitoring and immunological monitoring. However, further refinement of these techniques and greater experience with their efficacy must be accumulated before their role in the monitoring of cyclosporin can be defined. Tacrolimus, like cyclosporin, shares many of the difficulties in monitoring for efficacy and toxicity due largely to the variable pharmacokinetics; similarly to cyclosporin, whole blood through concentration monitoring should be utilised in combination with knowledge of the factors that may affect the pharmacokinetics. Muromonab CD3 (OKT3) is a monoclonal antibody used for the treatment and prophylaxis of acute allograft rejection. Several immunological monitoring techniques have been investigated for this agent. Monitoring CD3+ levels can assist clinicians in determining therapeutic efficacy, while measuring antimuromonab CD3 antibody titres can help determine if xenosensitisation has occurred, causing therapeutic ineffectiveness. The clinical monitoring of azathioprine, one of the first immunosuppressive agents used in transplantation, has historically been limited to monitoring complete blood counts for bone marrow suppression. However, newer techniques measuring intracellular DNA nucleotides appear to be promising. The new immunosuppressants on the horizon include mycophenolate mofetil and rapamycin. The clinical experience with therapeutic drug monitoring of these 2 compounds is scant in the literature; however, both agents have demonstrated efficacy in preventing or treating allograft rejection while maintaining a relatively well tolerated toxicity profile in recent clinical trials. Routine monitoring does not appear to be warranted for immunosuppressive therapy in autoimmune diseases.