Calcineurin Inhibitors. CsA and TAC are CNIs by virtue of their shared property of binding to their specific immunophilin, which leads to inhibition of calcineurin activity. The routine application of CNIs to OLT has dramatically reduced rejection, morbidity associated with treatment of rejection and graft loss, and death caused by rejection. The dosage of CsA or TAC is based on blood levels and is tailored based on time after OLT, presence or absence of renal dysfunction, or other side effects. The usual acceptable trough levels early after OLT are 8 to 12 ng/mL for TAC and 200 to 300 ng/mL for CsA. The side effects of TAC and CsA overlap and include nephrotoxicity, neurotoxicity, diabetogenicity, increased susceptibility to opportunistic infections, and certain de novo malignancies.
Over 90 percent of patients with systemic lupus erythematosus eventually have a cutaneous manifestation of the disease, including malar rash, discoid lupus erythematosus, alopecia or aphthous stomatitis. The usual therapy for cutaneous lupus erythematosus is strict use of sun block, judicious use of topical steroids (although fluorinated topical steroids should not be used on the face) and antimalarial therapy ( Table 4 ) . Some patients with very severe cases of discoid lupus erythematosus may not respond adequately to the usual dosage of hydroxychloroquine, which is 400 mg per day for a normal-sized adult. Quinacrine, in a dosage of 100 mg per day, can be added without increasing the risk of retinopathy, or the patient can be switched to chloroquine HCl (Aralen), in a dosage of 250 mg per day.