Heart transplantation immunosuppressive therapy

Editor(s)-in-Chief: C. Michael Gibson, M.S., M.D.; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [1]Ifrah Fatima, M.B.B.S[2]

Post cardiac transplantation, medical therapy with immunosuppressive drugs is essential to prevent both acute and chronic rejection. Immunosuppressive therapy is given in two phases- Induction therapy and Maintenance therapy. The drugs used include different combinations of drugs like IL-2 Receptor antagonists, Anti-thymocyte antibodies, calcineurin inhibitor, anti-metabolite, glucocorticoids, mammalian target of rapamycin [m-TOR] inhibitors, proliferation signal inhibitors and monoclonal Antibody OKT3.

• Immunosuppressive medical therapy is recommended in patients after undergoing cardiac transplantation.
• Pharmacologic medical therapies or Post-transplantation immunosuppressive therapy includes two stages-
  • Induction- Intense therapy for the first 2-3 months to prevent acute graft rejection
  • Maintenance- Throughout the life of the patient to combat both acute and chronic rejection. ^[1]

Even though regimens vary from center to center and case to case, most regimens consist of 2-3 drugs, usually including- ^{[2] [3]}

• IL-2 Receptor antagonists– Basiliximab ^[4]
• Anti-thymocyte antibodies– Associated with severe serum sickness like reaction ^[5]

• Calcineurin inhibitor– Tacrolimus or Cyclosporin; known to cause nephrotoxicity, hypertension, dyslipidemia. Gingival hyperplasia and hirsutism are associated with Cyclosporin alone.
• Anti-metabolite– Mycophenolate mofetil, Azathioprine
• Glucocorticoids– tapering dose
• Mammalian target of rapamycin [m-TOR] inhibitors and other strategies are aimed at minimizing the use of calcineurin inhibitors and corticosteroids.^[6]

• Proliferation signal inhibitors (sirolimus and everolimus)– In the case of cardiac allograft vasculopathy (CAV) or renal insufficiency
• Monoclonal Antibody OKT3– Associated with an increase in the incidence of post-transplantation lymphoproliferative disorder^[7]

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