Should prednisone be held in a transplant patient with an infection?

From the Guidelines

Prednisone should not be held in transplant patients with infection, but rather continued at a potentially reduced dose, as complete withdrawal can trigger acute rejection and adrenal crisis, especially in patients on long-term therapy. For most transplant patients on maintenance immunosuppression who develop an infection, prednisone should be continued, potentially at a reduced dose (e.g., reducing from 10mg to 5mg daily) while treating the infection appropriately 1. However, for severe, life-threatening infections such as severe sepsis or invasive fungal infections, temporary reduction of overall immunosuppression may be necessary, which could include lowering prednisone to the minimum tolerated dose, as recommended by the 2016 Infectious Diseases Society of America (IDSA) clinical practice guideline for the treatment of coccidioidomycosis 1.

Key Considerations

• The type of infection, time since transplantation, history of rejection episodes, current immunosuppressive regimen, and the patient's overall clinical status all influence this decision 1.
• The balance between preventing rejection and controlling infection is critical, as both outcomes can be life-threatening.
• A personalized approach to tapering immunosuppressive medications, including prednisone, should be considered in patients with a failing allograft, with the goal of minimizing the risk of infection and rejection 1.

Management Approach

• For patients with severe or rapidly progressing infections, reduction of immunosuppression, including prednisone, may be necessary until the infection has begun to improve 1.
• In patients with a failing allograft, tapering of prednisone to the minimal dose necessary over the first 6 months after graft failure may be considered, with a personalized approach based on individual patient needs 1.
• The decision to reduce or withdraw prednisone should be made in consultation with the transplant team, infectious disease specialists, and the primary team managing the patient.

From the FDA Drug Label

Corticosteroids, including prednisone tablets, suppress the immune system and increase the risk of infection with any pathogen, including viral, bacterial, fungal, protozoan, or helminthic pathogens Corticosteroids can: • Reduce resistance to new infections • Exacerbate existing infections • Increase the risk of disseminated infections • Increase the risk of reactivation or exacerbation of latent infections • Mask some signs of infection Monitor for the development of infection and consider prednisone tablets withdrawal or dosage reduction as needed.

The patient is a transplant patient with an infection. Holding prednisone is a consideration due to the increased risk of infection.

• The immunosuppressive effects of prednisone may worsen the infection.
• Dosage reduction or withdrawal of prednisone may be necessary to prevent further immunosuppression 2.

From the Research

Holding Prednisone in Transplant Patients with Infection

• The decision to hold prednisone in transplant patients with infection is complex and depends on various factors, including the type and severity of the infection, the patient's overall health, and the immunosuppressive regimen 3, 4.
• Studies have shown that infections are a significant cause of morbidity and mortality in transplant patients, and that the use of immunosuppressive agents such as prednisone can increase the risk of infection 4, 5.
• However, prednisone is also an important component of the immunosuppressive regimen, and withholding it can increase the risk of rejection 3, 6.
• In general, the approach to managing infections in transplant patients involves a balance between preventing and treating rejection, and preventing and treating infection 3, 4.
• Some studies suggest that higher doses of prednisone may be associated with an increased risk of infection, and that reducing or withholding prednisone may be necessary in certain situations 5.
• The use of alternative immunosuppressive agents, such as tacrolimus or ruxolitinib, may also be considered in patients with infections or other complications 6, 7.

Factors to Consider

• The type and severity of the infection
• The patient's overall health and immune status
• The immunosuppressive regimen and the potential risks and benefits of withholding or reducing prednisone
• The availability of alternative immunosuppressive agents and their potential risks and benefits
• The need for close monitoring and adjustment of the immunosuppressive regimen as needed 3, 4, 6, 5, 7