honestly [13:<18 years) renal transplant patients considered at high-immunologic risk [ see Adverse Reactions (6.5) , Clinical Studies (14.6) ]. The safety and efficacy of de novo use of Sirolimus without cyclosporine have not been established in renal transplant patients [ see Warnings and Precautions (5.12) ]. The safety and efficacy of conversion from calcineurin inhibitors to Sirolimus in maintenance renal transplant patients have not been established [ see Clinical Studies (14.4) ]. Treatment of Patients with Lymphangioleiomyomatosis Sirolimus is indicated for the treatment of patients with lymphangioleiomyomatosis (LAM). Slideshow Donate Life: What You Need To Know About Organ Donorship Sirolimus Dosage and Administration Sirolimus is to be administered orally once daily, consistently with or without food [ see Dosage and Administration (2.5) , Clinical Pharmacology (12.3) ]. Tablets should not be crushed, chewed or split. Patients unable to take the tablets should be prescribed the solution and instructed in its use. General Dosing Guidance for Renal Transplant Patients The initial dose of Sirolimus should be administered as soon as possible after transplantation. It is recommended that Sirolimus be taken 4 hours after administration of cyclosporine oral solution (MODIFIED) and or/cyclosporine capsules (MODIFIED) [ see Drug Interactions (7.2) ]. Frequent Sirolimus dose adjustments based on non-steady-state Sirolimus concentrations can lead to overdosing or underdosing because Sirolimus has a long half-life. Once Sirolimus maintenance dose is adjusted, patients should continue on the new maintenance dose for at least 7 to 14 days before further dosage adjustment with concentration monitoring. In most patients, dose adjustments can be based on simple proportion: new Sirolimus dose = current dose (target concentration/current concentration). A loading dose should be considered in addition to a new maintenance dose when it is necessary to increase Sirolimus trough concentrations: Sirolimus loading dose = 3 (new maintenance dose - current maintenance dose). The maximum Sirolimus dose administered on any day should not exceed 40 mg. If an estimated daily dose exceeds 40 mg due to the addition of a loading dose, the loading dose should be administered over 2 days. Sirolimus trough concentrations should be monitored at least 3 to 4 days after a loading dose(s). Two milligrams (2 mg) of Sirolimus oral solution have been demonstrated to be clinically equivalent to 2 mg Sirolimus tablets; hence, at this dose these two formulations are interchangeable. However, it is not known if higher doses of Sirolimus oral solution are clinically equivalent to higher doses of Sirolimus tablets on a mg-to-mg basis [ see Clinical Pharmacology (12.3) ]. Renal Transplant Patients at Low- to Moderate-Immunologic Risk Sirolimus and Cyclosporine Combination Therapy For de novo renal transplant patients, it is recommended that Sirolimus tablets be used initially in a regimen with cyclosporine and corticosteroids. A loading dose of Sirolimus equivalent to 3 times the maintenance dose should be given, i.e. a daily maintenance dose of 2 mg should be preceded with a loading dose of 6 mg. Therapeutic drug monitoring should be used to maintain Sirolimus drug concentrations within the target-range [ see Dosage and Administration (2.5) ]. Sirolimus Following Cyclosporine Withdrawal At 2 to 4 months following transplantation, cyclosporine should be progressively discontinued over 4 to 8 weeks, and the Sirolimus dose should be adjusted to obtain Sirolimus whole blood trough concentrations within the target-range [ see Dosage and Administration (2.5) ]. Because cyclosporine inhibits the metabolism and transport of Sirolimus, Sirolimus concentrations may decrease when cyclosporine is discontinued, unless the Sirolimus dose is increased [ see Clinical Pharmacology (12.3) ]. Renal Transplant Patients at High-Immunologic Risk In patients with high-immunologic risk, it is recommended that Sirolimus be used in combination with cyclosporine and corticosteroids for the first 12 months following transplantation [ see Clinical Studies (14.3) ]. The safety and efficacy of this combination in high-immunologic risk patients has not been studied beyond the first 12 months. Therefore, after the first 12 months following transplantation, any adjustments to the immunosuppressive regimen should be considered on the basis of the clinical status of the patient. For patients receiving Sirolimus with cyclosporine, Sirolimus therapy should be initiated with a loading dose of up to 15 mg on day 1 post-transplantation. Beginning on day 2, an initial maintenance dose of 5 mg/day should be given. A trough level should be obtained between days 5 and 7, and the daily dose of Sirolimus should thereafter be adjusted [ see Dosage and Administration (2.5) ]. The starting dose of cyclosporine should be up to 7 mg/kg/day in divided doses and the dose should subsequently be adjusted to achieve target whole blood trough concentrations [ see Dosage and Administration (2.5) ]. Prednisone should be administered at a minimum of 5 mg/day. Antibody induction therapy may be used. Dosing in Patients with Lymphangioleiomyomatosis For patients with lymphangioleiomyomatosis, the initial Sirolimus dose should be 2 mg/day. Sirolimus whole blood trough concentrations should be measured in 10 20 days, with dosage adjustment to maintain concentrations between 5 15 ng/mL [ see Dosage and Administration (2.5) ]. In most patients, dose adjustments can be based on simple proportion: new Sirolimus dose = current dose (target concentration/current concentration). Frequent Sirolimus dose adjustments based on non-steady-state Sirolimus concentrations can lead to overdosing or under dosing because Sirolimus has a long half-life. Once Sirolimus maintenance dose is adjusted, patients should continue on the new maintenance dose for at least 7 to 14 days before further dosage adjustment with concentration monitoring. Once a stable dose is achieved, therapeutic drug monitoring should be performed at least every three months. Therapeutic Drug Monitoring Monitoring of Sirolimus trough concentrations is recommended for all patients, especially in those patients likely to have altered drug metabolism, in patients 13 years who weigh less than 40 kg, in patients with hepatic impairment, when a change in the Sirolimus dosage form is made, and during concurrent administration of strong CYP3A4 inducers and inhibitors [ see Drug Interactions (7) ]. Therapeutic drug monitoring should not be the sole basis for adjusting Sirolimus therapy. Careful attention should be made to clinical signs/symptoms, tissue biopsy findings, and laboratory parameters. When used in combination with cyclosporine, Sirolimus trough concentrations should be maintained within the target-range [ see Clinical Studies (14) , Clinical Pharmacology (12.3) ]. Following cyclosporine withdrawal in transplant patients at low- to moderate-immunologic risk, the target Sirolimus trough concentrations should be 16 to 24 ng/mL for the first year following transplantation. Thereafter, the target Sirolimus concentrations should be 12 to 20 ng/mL. The above recommended 24-hour trough concentration ranges for Sirolimus are based on chromatographic methods. Currently in clinical practice, Sirolimus whole blood concentrations are being measured by both chromatographic and immunoassay methodologies. Because the measured Sirolimus whole blood concentrations depend on the type of assay used, the concentrations obtained by these different methodologies are not interchangeable [ see Warnings and Precautions (5.15) , Clinical Pharmacology (12.3) ]. Adjustments to the targeted range should be made according to the assay utilized to determine Sirolimus trough concentrations. Since results are assay and laboratory dependent, and the results may change over time, adjustments to the targeted therapeutic range must be made with a detailed knowledge of the site-specific assay used. Therefore, communication should be maintained with the laboratory performing the assay. A discussion of different assay methods is contained in Clinical Therapeutics, Volume 22, Supplement B, April 2000 [ see References (15) ]. Patients with Low Body Weight The initial dosage in patients 13 years who weigh less than 40 kg should be adjusted, based on body surface area, to 1 mg/m 2 /day. The loading dose should be 3 mg/m 2 . Patients with Hepatic Impairment It is recommended that the maintenance dose of Sirolimus be reduced by approximately one third in patients with mild or moderate hepatic impairment and by approximately one half in patients with severe hepatic impairment. It is not necessary to modify the Sirolimus loading dose [ see Use in Specific Populations (8.6) , Clinical Pharmacology (12.3) ]. Patients with Renal Impairment Dosage adjustment is not needed in patients with impaired renal function [ see Use in Specific Populations (8.7) ]. Dosage Forms and Strengths Sirolimus Tablets 0.5 mg, tan, triangular-shaped tablets marked "RAPAMUNE 0.5 mg" on one side. 1 mg, white, triangular-shaped tablets marked "RAPAMUNE 1 mg" on one side. 2 mg, yellow-to-beige triangular-shaped tablets marked "RAPAMUNE 2 mg" on one side. Contraindications Sirolimus is contraindicated in patients with a hypersensitivity to Sirolimus [ see Warnings and Precautions (5.4) ]. Warnings and Precautions Increased Susceptibility to Infection and the Possible Development of Lymphoma Increased susceptibility to infection and the possible development of lymphoma and other malignancies, particularly of the skin, may result from immunosuppression. The rates of lymphoma/lymphoproliferative disease observed in Studies 1 and 2 were 0.7 3.2% (for Sirolimus -treated patients) versus 0.6 0.8% (azathioprine and placebo control) [ see Adverse Reactions (6.1) and (6.2) ]. Oversuppression of the immune system can also increase susceptibility to infection, including opportunistic infections such as tuberculosis, fatal infections, and sepsis. Only physicians experienced in immunosuppressive therapy and management of organ transplant patients should use Sirolimus for prophylaxis of organ rejection in patients receiving renal transplants. Patients receiving the drug should be managed in facilities equipped and staffed with adequate laboratory and supportive medical resources. The physician responsible for maintenance therapy should have complete information requisite for the follow-up of the patient. Liver Transplantation Excess Mortality, Graft Loss, and Hepatic Artery Thrombosis The safety and efficacy of Sirolimus as immunosuppressive therapy have not been established in liver transplant patients; therefore, such use is not recommended. The use of Sirolimus has been associated with adverse outcomes in patients following liver transplantation, including excess mortality, graft loss and hepatic artery thrombosis (HAT). In a study in de novo liver transplant patients, the use of Sirolimus in combination with tacrolimus was associated with excess mortality and graft loss (22% in combination versus 9% on tacrolimus alone). Many of these patients had evidence of infection at or near the time of death. In this and another study in de novo liver transplant patients, the use of Sirolimus in combination with cyclosporine or tacrolimus was associated with an increase in HAT (7% in combination versus 2% in the control arm); most cases of HAT occurred within 30 days post-transplantation, and most led to graft loss or death. In a clinical study in stable liver transplant patients 6 144 months post-liver transplantation and receiving a CNI-based regimen, an increased number of deaths was observed in the group converted to a Sirolimus-based regimen compared to the group who was continued on a CNI-based regimen, although the difference was not statistically significant (3.8% versus 1.4%) [ see Clinical Studies (14.5) ]. Lung Transplantation Bronchial Anastomotic Dehiscence Cases of bronchial anastomotic dehiscence, most fatal, have been reported in de novo lung transplant patients when Sirolimus has been used as part of an immunosuppressive regimen. The safety and efficacy of Sirolimus as immunosuppressive therapy have not been established in lung transplant patients; therefore, such use is not recommended. Hypersensitivity Reactions Hypersensitivity reactions, including anaphylactic/anaphylactoid reactions, angioedema, exfoliative dermatitis and hypersensitivity vasculitis, have been associated with the administration of Sirolimus [ see Adverse Reactions (6.7) ]. Angioedema Sirolimus has been associated with the development of angioedema. The concomitant use of Sirolimus with other drugs known to cause angioedema, such as angiotensin-converting enzyme (ACE) inhibitors, may increase the risk of developing angioedema. Elevated Sirolimus levels (with/without concomitant ACE inhibitors) may also potentiate angioedema [ see Drug Interactions (7.2) ]. In some cases, the angioedema has resolved upon discontinuation or dose reduction of Sirolimus. Fluid Accumulation and Impairment of Wound Healing There have been reports of impaired or delayed wound healing in patients receiving Sirolimus, including lymphocele and wound dehiscence [ see Adverse Reactions (6.1) ]. mTOR inhibitors such as Sirolimus have been shown in vitro to inhibit production of certain growth factors that may affect angiogenesis, fibroblast proliferation, and vascular permeability. Lymphocele, a known surgical complication of renal transplantation, occurred significantly more often in a dose-related fashion in patients treated with Sirolimus [ see Adverse Reactions (6.1) ]. Appropriate measures should be considered to minimize such complications. Patients with a body mass index (BMI) greater than 30 kg/m 2 may be at increased risk of abnormal wound healing based on data from the medical literature. There have also been reports of fluid accumulation, including peripheral edema, lymphedema, pleural effusion, ascites, and pericardial effusions (including hemodynamically significant effusions and tamponade requiring intervention in children and adults), in patients receiving Sirolimus. Hyperlipidemia Increased serum cholesterol and triglycerides requiring treatment occurred more frequently in patients treated with Sirolimus compared with azathioprine or placebo controls in Studies 1 and 2 [ see Adverse Reactions (6.1) ]. There were increased incidences of hypercholesterolemia (43 46%) and/or hypertriglyceridemia (45 57%) in patients receiving Sirolimus compared with placebo controls (each 23%). The risk/benefit should be carefully considered in patients with established hyperlipidemia before initiating an immunosuppressive regimen including Sirolimus. Any patient who is administered Sirolimus should be monitored for hyperlipidemia. If detected, interventions such as diet, exercise, and lipid-lowering agents should be initiated as outlined by the National Cholesterol Education Program guidelines. In clinical trials of patients receiving Sirolimus plus cyclosporine or Sirolimus after cyclosporine withdrawal, up to 90% of patients required treatment for hyperlipidemia and hypercholesterolemia with anti-lipid therapy (e.g., statins, fibrates). Despite anti-lipid management, up to 50% of patients had fasting serum cholesterol levels> 240 mg/dL and triglycerides above recommended target levels. The concomitant administration of Sirolimus and HMG-CoA reductase inhibitors resulted in adverse reactions such as CPK elevations (3%), myalgia (6.7%) and rhabdomyolysis ( <1%). In these trials, the number of patients was too small and duration of follow-up too short to evaluate the long-term impact of Sirolimus on cardiovascular mortality. During Sirolimus therapy with or without cyclosporine, patients should be monitored for elevated lipids, and patients administered an HMG-CoA reductase inhibitor and/or fibrate should be monitored for the possible development of rhabdomyolysis and other adverse effects, as described in the respective labeling for these agents. Decline in Renal Function Renal function should be closely monitored during the co-administration of Sirolimus with cyclosporine, because long-term administration of the combination has been associated with deterioration of renal function. Patients treated with cyclosporine and Sirolimus were noted to have higher serum creatinine levels and lower glomerular filtration rates compared with patients treated with cyclosporine and placebo or azathioprine controls (Studies 1 and 2). The rate of decline in renal function in these studies was greater in patients receiving Sirolimus and cyclosporine compared with control therapies. Appropriate adjustment of the immunosuppressive regimen, including discontinuation of Sirolimus and/or cyclosporine, should be considered in patients with elevated or increasing serum creatinine levels. In patients at low- to moderate-immunologic risk, continuation of combination therapy with cyclosporine beyond 4 months following transplantation should only be considered when the benefits outweigh the risks of this combination for the individual patients. Caution should be exercised when using agents (e.g., aminoglycosides and amphotericin B) that are known to have a deleterious effect on renal function. In patients with delayed graft function, Sirolimus may delay recovery of renal function. Proteinuria Periodic quantitative monitoring of urinary protein excretion is recommended. In a study evaluating conversion from calcineurin inhibitors (CNI) to Sirolimus in maintenance renal transplant patients 6 120 months post-transplant, increased urinary protein excretion was commonly observed from 6 through 24 months after conversion to Sirolimus compared with CNI continuation [ see Clinical Studies (14.4) , Adverse Reactions (6.4) ]. Patients with the greatest amount of urinary protein excretion prior to Sirolimus conversion were those whose protein excretion increased the most after conversion. New onset nephrosis (nephrotic syndrome) was also reported as a treatment-emergent adverse reaction in 2.2% of the Sirolimus conversion group patients in comparison to 0.4% in the CNI continuation group of patients. Nephrotic range proteinuria (defined as urinary protein to creatinine ratio> 3.5) was also reported in 9.2% in the Sirolimus conversion group of patients in comparison to 3.7% in the CNI continuation group of patients. In some patients, reduction in the degree of urinary protein excretion was observed for individual patients following discontinuation of Sirolimus. The safety and efficacy of conversion from calcineurin inhibitors to Sirolimus in maintenance renal transplant patients have not been established. Latent Viral Infections Immunosuppressed patients are at increased risk for opportunistic infections, including activation of latent viral infections. These include BK virus-associated nephropathy, which has been observed in renal transplant patients receiving immunosuppressants, including Sirolimus. This infection may be associated with serious outcomes, including deteriorating renal function and renal graft loss [ see Adverse Reactions (6.7) ]. Patient monitoring may help detect patients at risk for BK virus-associated nephropathy. Reduction in immunosuppression should be considered for patients who develop evidence of BK virus-associated nephropathy. Cases of progressive multifocal leukoencephalopathy (PML), sometimes fatal have been reported in patients treated with immunosuppressants, including Sirolimus. PML commonly presents with hemiparesis, apathy, confusion, cognitive deficiencies and ataxia. Risk factors for PML include treatment with immunosuppressant therapies and impairment of immune function. In immunosuppressed patients, physicians should consider PML in the differential diagnosis in patients reporting neurological symptoms and consultation with a neurologist should be considered as clinically indicated. Consideration should be given to reducing the amount of immunosuppression in patients who develop PML. In transplant patients, physicians should also consider the risk that reduced immunosuppression represents to the graft. Interstitial Lung Disease/Non-Infectious Pneumonitis Cases of interstitial lung disease [ILD] (including pneumonitis, bronchiolitis obliterans organizing pneumonia [BOOP], and pulmonary fibrosis), some fatal, with no identified infectious etiology have occurred in patients receiving immunosuppressive regimens including Sirolimus. In some cases, the ILD was reported with pulmonary hypertension (including pulmonary arterial hypertension [PAH]) as a secondary event. In some cases, the ILD has resolved upon discontinuation or dose reduction of Sirolimus. The risk may be increased as the trough Sirolimus concentration increases [ see Adverse Reactions (6.7) ]. De Novo Use Without Cyclosporine The safety and efficacy of de novo use of Sirolimus without cyclosporine is not established in renal transplant patients. In a multicenter clinical study, de novo renal transplant patients treated with Sirolimus, mycophenolate mofetil (MMF), steroids, and an IL-2 receptor antagonist had significantly higher acute rejection rates and numerically higher death rates compared to patients treated with cyclosporine, MMF, steroids, and IL-2 receptor antagonist. A benefit, in terms of better renal function, was not apparent in the treatment arm with de novo use of Sirolimus without cyclosporine. These findings were also observed in a similar treatment group of another clinical trial. Increased Risk of Calcineurin Inhibitor-Induced Hemolytic Uremic Syndrome/Thrombotic Thrombocytopenic Purpura/Thrombotic Microangiopathy The concomitant use of Sirolimus with a calcineurin inhibitor may increase the risk of calcineurin inhibitor-induced hemolytic uremic syndrome/thrombotic thrombocytopenic purpura/thrombotic microangiopathy (HUS/TTP/TMA) [ see Adverse Reactions (6.7) ]. Antimicrobial Prophylaxis Cases of Pneumocystis carinii pneumonia have been reported in transplant patients not receiving antimicrobial prophylaxis. Therefore, antimicrobial prophylaxis for Pneumocystis carinii pneumonia should be administered for 1 year following transplantation. Cytomegalovirus (CMV) prophylaxis is recommended for 3 months after transplantation, particularly for patients at increased risk for CMV disease. Different Sirolimus Trough Concentration Reported between Chromatographic and Immunoassay Methodologies Currently in clinical practice, Sirolimus whole blood concentrations are being measured by various chromatographic and immunoassay methodologies. Patient sample concentration values from different assays may not be interchangeable [ see Dosage and Administration (2.5) ]. Skin Cancer Events Patients on immunosuppressive therapy are at increased risk for skin cancer. Exposure to sunlight and ultraviolet (UV) light should be limited by wearing protective clothing and using a sunscreen with a high protection factor [ see Adverse Reactions (6.1 , 6.2 , 6.7) ] . Interaction with Strong Inhibitors and Inducers of CYP3A4 and/or P-gp Avoid concomitant use of Sirolimus with strong inhibitors of CYP3A4 and/or P-gp (such as ketoconazole, voriconazole, itraconazole, erythromycin, telithromycin, or clarithromycin) or strong inducers of CYP3A4 and/or P-gp (such as rifampin or rifabutin) [ see Drug Interactions (7.2) ]. Adverse Reactions The following adverse reactions are discussed in greater detail in other sections of the label. Increased susceptibility to infection, lymphoma, and malignancy [ see Boxed Warning , Warnings and Precautions (5.1) ] Excess mortality, graft loss, and hepatic artery thrombosis in liver transplant patients [ see Boxed Warning , Warnings and Precautions (5.2) ] Bronchial anastomotic dehiscence in lung transplant patients [ see Boxed Warning , Warnings and Precautions (5.3) ] Hypersensitivity reactions [ see Warnings and Precautions (5.4) ] Exfoliative dermatitis [ see Warnings and Precautions (5.4) ] Angioedema [ see Warnings and Precautions (5.5) ] Fluid Accumulation and Impairment of Wound Healing [ see Warnings and Precautions (5.6) ] Hypertriglyceridemia, hypercholesterolemia [ see Warnings and Precautions (5.7) ] Decline in renal function in long-term combination of cyclosporine with Sirolimus[ see Warnings and Precautions (5.8) ] Proteinuria [ see Warnings and Precautions (5.9) ] Interstitial lung disease [ see Warnings and Precautions (5.11) ] Increased risk of calcineurin inhibitor-induced HUS/TTP/TMA [ see Warnings and Precautions (5.13) ]. The most common ( 30%) adverse reactions observed with Sirolimus in clinical studies for organ rejection prophylaxis in recipients of renal transplantation are: peripheral edema, hypertriglyceridemia, hypertension, hypercholesterolemia, creatinine increased, constipation, abdominal pain, diarrhea, headache, fever, urinary tract infection, anemia, nausea, arthralgia, pain, and thrombocytopenia. The most common ( 20%) adverse reactions observed with Sirolimus in the clinical study for the treatment of LAM are: stomatitis, diarrhea, abdominal pain, nausea, nasopharyngitis, acne, chest pain, peripheral edema, upper respiratory tract infection, headache, dizziness, myalgia, and hypercholesterolemia. The following adverse reactions resulted in a rate of discontinuation of >5% in clinical trials for renal transplant rejection prophylaxis: creatinine increased, hypertriglyceridemia, and TTP. In patients with LAM, 11% of subjects discontinued due to adverse reactions, with no single adverse reaction leading to discontinuation in more than one patient being treated with Sirolimus. Clinical Studies Experience in Prophylaxis of Organ Rejection Following Renal Transplantation The safety and efficacy of Sirolimus oral solution for the prevention of organ rejection following renal transplantation were assessed in two randomized, double-blind, multicenter, controlled trials [ see Clinical Studies (14.1) ]. The safety profiles in the two studies were similar. The incidence of adverse reactions in the randomized, double-blind, multicenter, placebo-controlled trial (Study 2) in which 219 renal transplant patients received Sirolimus oral solution 2 mg/day, 208 received Sirolimus oral solution 5 mg/day, and 124 received placebo is presented in Table 1 below. The study population had a mean age of 46 years (range 15 to 71 years), the distribution was 67% male, and the composition by race was: White (78%), Black (11%), Asian (3%), Hispanic (2%), and Other (5%). All patients were treated with cyclosporine and corticosteroids. Data ( 12 months post-transplant) presented in the following table show the adverse reactions that occurred in at least one of the Sirolimus treatment groups with an incidence of 20%. The safety profile of the tablet did not differ from that of the oral solution formulation [ see Clinical Studies (14.1) ]. In general, adverse reactions related to the administration of Sirolimus were dependent on dose/concentration. Although a daily maintenance dose of 5 mg, with a loading dose of 15 mg, was shown to be safe and effective, no efficacy advantage over the 2 mg dose could be established for renal transplant patients. Patients receiving 2 mg of Sirolimus oral solution per day demonstrated an overall better safety profile than did patients receiving 5 mg of Sirolimus oral solution per day. Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in one clinical trial of a drug cannot be directly compared with rates in the clinical trials of the same or another drug and may not reflect the rates observed in practice. TABLE 1: ADVERSE REACTIONS OCCURRING AT A FREQUENCY OF 20% IN AT LEAST ONE OF THE Sirolimus TREATMENT GROUPS IN A STUDY OF PROPHYLAXIS OF ORGAN REJECTION FOLLOWING RENAL TRANSPLANTATION (%) AT 12 MONTHS POST-TRANSPLANTATION (STUDY 2) * Sirolimus Oral Solution 2 mg/day 5 mg/day Placebo Adverse Reaction (n = 218) (n = 208) (n = 124) * Patients received cyclosporine and corticosteroids. Peripheral edema 54 58 48 Hypertriglyceridemia 45 57 23 Hypertension 45 49 48 Hypercholesterolemia 43 46 23 Creatinine increased 39 40 38 Constipation 36 38 31 Abdominal pain 29 36 30 Diarrhea 25 35 27 Headache 34 34 31 Fever 23 34 35 Urinary tract infection 26 33 26 Anemia 23 33 21 Nausea 25 31 29 Arthralgia 25 31 18 Thrombocytopenia 14 30 9 Pain 33 29 25 Acne 22 22 19 Rash 10 20 6 Edema 20 18 15 The following adverse reactions were reported less frequently ( 3%, but <20%) Body as a Whole Sepsis, lymphocele, herpes zoster, herpes simplex. Cardiovascular Venous thromboembolism (including pulmonary embolism, deep venous thrombosis), tachycardia. Digestive System Stomatitis. Hematologic and Lymphatic System Thrombotic thrombocytopenic purpura/hemolytic uremic syndrome (TTP/HUS), leukopenia. Metabolic/Nutritional Abnormal healing, increased lactic dehydrogenase (LDH), hypokalemia, diabetes mellitus. Musculoskeletal System Bone necrosis. Respiratory System Pneumonia, epistaxis. Skin Melanoma, squamous cell carcinoma, basal cell carcinoma. Urogenital System Pyelonephritis, decline in renal function (creatinine increased) in long-term combination of cyclosporine with Sirolimus [ see Warnings and Precautions (5.8) ], ovarian cysts, menstrual disorders (including amenorrhea and menorrhagia). Less frequently (> <3%) occurring adverse reactions included: lymphoma/post-transplant lymphoproliferative disorder, mycobacterial infections (including M. tuberculosis ), pancreatitis, cytomegalovirus (CMV), and Epstein-Barr virus. Increased Serum Cholesterol and Triglycerides The use of Sirolimus in renal transplant patients was associated with increased serum cholesterol and triglycerides that may require treatment. In Studies 1 and 2, in de novo renal transplant patients who began the study with fasting, total serum cholesterol> <200 mg/dL or fasting, total serum triglycerides> <200 mg/dL, there was an increased incidence of hypercholesterolemia (fasting serum cholesterol> 240 mg/dL) or hypertriglyceridemia (fasting serum triglycerides >500 mg/dL), respectively, in patients receiving both Sirolimus 2 mg and Sirolimus 5 mg compared with azathioprine and placebo controls. Treatment of new-onset hypercholesterolemia with lipid-lowering agents was required in 42 52% of patients enrolled in the Sirolimus arms of Studies 1 and 2 compared with 16% of patients in the placebo arm and 22% of patients in the azathioprine arm. In other Sirolimus renal transplant studies, up to 90% of patients required treatment for hyperlipidemia and hypercholesterolemia with anti-lipid therapy (e.g., statins, fibrates). Despite anti-lipid management, up to 50% of patients had fasting serum cholesterol levels >240 mg/dL and triglycerides above recommended target levels [ see Warnings and Precautions (5.7) ]. Abnormal Healing Abnormal healing events following transplant surgery include fascial dehiscence, incisional hernia, and anastomosis disruption (e.g., wound, vascular, airway, ureteral, biliary). Malignancies Table 2 below summarizes the incidence of malignancies in the two controlled trials (Studies 1 and 2) for the prevention of acute rejection [ see Clinical Studies (14.1) ]. At 24 months (Study 1) and 36 months (Study 2) post-transplant, there were no significant differences among treatment groups. TABLE 2: INCIDENCE (%) OF MALIGNANCIES IN STUDY 1 (24 MONTHS) AND STUDY 2 (36 MONTHS) POST-TRANSPLANT * , Malignancy Sirolimus Oral Solution 2 mg/day Sirolimus Oral Solution 5 mg/day Azathioprine 2 3 mg/kg/day Placebo Study 1 (n = 284) Study 2 (n = 227) Study 1 (n = 274) Study 2 (n = 219) Study 1 (n = 161) Study 2 (n = 130) * Patients received cyclosporine and corticosteroids. Includes patients who prematurely discontinued treatment. Patients may be counted in more than one category. Lymphoma/lymphoproliferative disease 0.7 1.8 1.1 3.2 0.6 0.8 Skin Carcinoma Any Squamous Cell 0.4 2.7 2.2 0.9 3.8 3.0 Any Basal Cell 0.7 2.2 1.5 1.8 2.5 5.3 Melanoma 0.0 0.4 0.0 1.4 0.0 0.0 Miscellaneous/Not Specified 0.0 0.0 0.0 0.0 0.0 0.8 Total 1.1 4.4 3.3 4.1 4.3 7.7 Other Malignancy 1.1 2.2 1.5 1.4 0.6 2.3 Sirolimus Following Cyclosporine Withdrawal The incidence of adverse reactions was determined through 36 months in a randomized, multicenter, controlled trial (Study 3) in which 215 renal transplant patients received Sirolimus as a maintenance regimen following cyclosporine withdrawal, and 215 patients received Sirolimus with cyclos widespread
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