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Cyclosporin administration designed to achievetarget peak, rather than trough, concentrations is nowroutine practice for many transplant programmes. Thepeak cyclosporin concentration exhibits some degreeof inter-subject variability. However, the concentrationattained2hfollowingtheadministrationofcyclosporinmicro-emulsion (CsA-ME), referred to as C2, is themost consistent peak [1]. Recent trial data have demon-strated the effectiveness of CsA-ME dose adjustmentaccordingtoC2targets,achievingexcellenttolerability,safety and freedom from rejection after kidney [2]and liver transplantation [3].Reliance upon C2 as the sole guide to CSA-MEdosing for an individual patient assumes that thepeak CsA concentration consistently occurs at 2hfollowing ingestion for that individual. Signicantintra-patient variability in time to CsA peak concen-tration may theoretically reduce the reliability of C2monitoring as a surrogate for overall CsA exposure,and hence for clinical outcomes. We present two illus-trativecaseswheretimetopeakCsAconcentrationwasdelayed by intercurrent clinical events, temporarilyrendering C2 an underestimate of overall CsAexposure.

Two cases of delayed cyclosporin absorption leading to CsA exposure higher than that predicted by C2 monitoring alone