66 Immunosuppressants

Some patients can be on “triple immunosuppression”, e.g. prednisone, MMF, tacro

# On Chronic Immunosuppression
# s/p *** (OHT?) *** (year)
- *** complications?
- Immunosuppression regimen: ***
- Tacro level in AM

# Sepsis
- If pt is septic, hold MMF and consider stress dose steroids if pt on prednisone > 6 mos
- Consider ID consult
- Consider screen for atypical infections: EBV, CMV, BK
- If recurrent infection, consider if reduction in immunosuppression appropriate

Figure source: (n.d.)

66.1 Calcineurin Inhibitors

Side effects
- Nephrotoxicity
- HTN (CSA > Tacro)
- Post-transplant DM (Tacrolimus > CSA)
- Neurological (Tacrolimus)
- Hirsutism (CSA) / Alopecia (Tacrolimus)
- HLD ( CSA> Tacrolimus)
Medication interactions
- Drugs that ↑ levels
  - Ca channel blockers Diltiazem, Verapamil, Amlodipine, Nicardipine (40% dose reduction)
  - Antifungal agents: Ketoconazole, Fluconazole, Itraconazole, Voriconazole (80% dose reduction)
  - Antibiotics: Macrolide (Clarithromycin), Chloramphenicol Tacrolimus), Erythromycin
  - mTOR inhibitors: increase CNI level
- Drugs that ↓ levels
  - Antituberculosis drugs: Rifampn, Rifabun, Isoniazid
  - Anticonvulsant: Barbiturates, Phenytoin, Carbamazepine
  - Herbal preparation: St. John’s wort
  - Cholestiramine (decreased absorption)

66.1.1 Tacrolimus

Diarrhea as a cause of ↑ tacro levels?

66.1.2 Cyclosporine

66.2 Antimetabolite

Side effects
- Bone marrow toxicity (AZA >MMF)
- MMF-related birth defects
- MMF dose related nausea, gastritis and diarrhea
Medication interactions
- Drugs that ↑ levels
- Drugs that ↓ levels

66.2.1 Mycophenolate mofetil (MMF)

66.2.2 Azathioprine (AZA)

66.3 mTOR Inhibitors

Sirolimus (rapamycin)
Everolimus
Side effects
- Acne/rash
- Mouth ulcers
- HLD
- anemia/thrombocytopenia
- Proteinuria (rare) : Bx: FSGS, podocyte injury
- Pneumonitis (4-11%) Sirolimus > Everolimus
- Sirolimus: anemia, NODAT
Medication interactions
- Drugs that ↑ levels
- Drugs that ↓ levels