Treatment of Bronchiolitis Obliterans Syndrome in Lung Transplant Recipients Receiving Cyclosporine-Based Maintenance Immunosuppression
Clinical Scenario
This protocol applies to lung transplant recipients who develop bronchiolitis obliterans syndrome (BOS) while on chronic maintenance immunosuppression with a regimen that includes cyclosporine.
Treatment Approach
The recommended approach involves a structured modification to the calcineurin inhibitor component of the maintenance immunosuppressive regimen, with careful management of overall immunosuppressive coverage during the transition period.
Full sequencing, monitoring requirements, and therapeutic targets are detailed in the complete protocol.
For lung transplant recipients who develop BOS while receiving chronic immunosuppression with a regimen that includes cyclosporine, we suggest switching the cyclosporine to tacrolimus (conditional recommendation, very low quality evidence).
The conversion of cyclosporine to tacrolimus is generally performed by stopping cyclosporine and initiating tacrolimus while transiently increasing maintenance corticosteroid dosing until tacrolimus blood levels are ascertained to have reached the desired target range.
The target for therapeutic trough blood levels of tacrolimus is generally considered to range from 5 to 15 ng/mL for patients who are ≥18 years of age once a steady state has been attained.