From the Guidelines
The best initial maintenance immunosuppressive medication regimen for kidney transplant recipients is a combination of a calcineurin inhibitor (CNI) and an antiproliferative agent, with or without corticosteroids, with tacrolimus as the first-line CNI and mycophenolate as the first-line antiproliferative agent. This recommendation is based on the KDIGO clinical practice guideline for the care of kidney transplant recipients, which suggests that tacrolimus or CsA be started before or at the time of transplantation, rather than delayed until the onset of graft function 1. The guideline also recommends using a combination of immunosuppressive medications as maintenance therapy, including a CNI and an antiproliferative agent, with or without corticosteroids.
Some key points to consider when choosing an immunosuppressive regimen include:
- The use of tacrolimus as the first-line CNI, due to its efficacy and safety profile 1
- The use of mycophenolate as the first-line antiproliferative agent, due to its ability to prevent rejection and minimize side effects 1
- The importance of starting immunosuppressive therapy before or at the time of transplantation, rather than delaying until the onset of graft function 1
- The need to individualize immunosuppressive regimens based on patient-specific factors, such as renal function and comorbidities
Other studies, such as the 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus, also support the use of immunosuppressive agents, including mycophenolate and azathioprine, in the treatment of autoimmune diseases 1. However, the KDIGO guideline provides the most specific and relevant recommendations for kidney transplant recipients. Additionally, a study on immunosuppressive treatment regimens in autoimmune hepatitis highlights the importance of choosing the right immunosuppressive regimen, but its findings are not directly applicable to kidney transplant recipients 1.
Overall, the choice of immunosuppressive regimen should be based on the individual patient's needs and medical history, with the goal of minimizing the risk of rejection and maximizing graft survival, while also considering the potential side effects and interactions of different immunosuppressive agents.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Immunosuppressive Therapies
- Immunosuppressive therapies are used to treat a wide range of diseases, including rheumatologic or autoimmune diseases, and to prevent rejection in solid organ transplantation (SOT) or hematopoietic stem cell transplantation (HSCT) 2.
- These therapies can target pathologic immune system over-activation, and can also be used to condition and prevent graft versus host disease (GVHD) 2.
Types of Immunosuppressive Medications
- Classes of immunosuppressive medications include polyclonal and monoclonal antibodies, calcineurin inhibitors, antiproliferative agents, mammalian target of rapamycin inhibitors, and corticosteroids 3.
- Specific medications mentioned in the studies include mycophenolic acid, azathioprine, tacrolimus, cyclosporin, sirolimus, and everolimus 4, 5.
Mechanisms and Indications
- Mycophenolate mofetil, azathioprine, and tacrolimus have been found to be useful in the treatment of various rheumatic diseases, including lupus nephritis and interstitial lung disease in systemic rheumatic diseases 5.
- Tacrolimus inhibits lymphocyte activation by inhibiting the calcineurin pathway, while mycophenolate mofetil and azathioprine inhibit the purine pathway and diminish cell proliferation 5.
Utilization and Costs
- The utilization of immunosuppressive medications such as tacrolimus, mycophenolic acid, and azathioprine has been increasing in recent years, with a corresponding decrease in price per defined daily dose (DDD) 4.
- Despite the reduction in price per DDD, the costs of these medications are still significant and contribute to a substantial percentage of the budget for medicines in each country 4.
Adverse Effects and Interactions
- Immunosuppressive medications can have potentially deleterious physical, mental, and biochemical side effects, and can also interact with other medications to cause alterations in serum levels 6.
- Knowledge of the pharmacokinetic properties of these drugs and the potential for serious drug-drug interactions is essential for the management of patients taking immunosuppressants 6.