From the Guidelines
Sirolimus-induced Posterior Reversible Encephalopathy Syndrome (PRES) is rare, not common. While sirolimus (also known as rapamycin) is an immunosuppressant medication commonly used after organ transplantation, PRES is an uncommon neurological complication associated with its use. The exact incidence is difficult to determine precisely, but it represents an infrequent adverse effect compared to more common side effects like hyperlipidemia, mouth ulcers, or impaired wound healing, as noted in studies such as 1. When sirolimus-induced PRES does occur, patients typically present with headache, altered mental status, seizures, visual disturbances, and hypertension. The condition is usually reversible with prompt discontinuation or dose reduction of sirolimus and management of associated hypertension.
The mechanism likely involves endothelial cell injury and disruption of the blood-brain barrier, leading to vasogenic edema primarily affecting the posterior cerebral regions. Healthcare providers should maintain vigilance for neurological symptoms in patients on sirolimus therapy, especially those with additional risk factors such as hypertension or concurrent use of other medications associated with PRES, as recommended by guidelines such as those outlined in 1 and 1. Monitoring of drug concentration is also recommended for patients undergoing sirolimus therapy, as stated in 1 and further detailed in 1, to minimize the risk of adverse effects, including PRES.
Key considerations for the management and monitoring of patients on sirolimus include:
- Monitoring for hyperlipidemia, as recommended in 1
- Regular assessment of CBC counts, creatinine, and BP, as suggested in 1
- Avoidance of sirolimus in patients with certain conditions, such as high fasting triglyceride levels, as indicated in 1
- Consideration of dose adjustments or alternative therapies in patients at risk for poor wound healing or other complications, as noted in 1 and 1.
By prioritizing these considerations and maintaining awareness of the potential for sirolimus-induced PRES, healthcare providers can optimize patient outcomes and minimize the risk of morbidity and mortality associated with this condition.
From the Research
Sirolimus-Induced PRESS
- Sirolimus-induced Posterior Reversible Encephalopathy Syndrome (PRES) is a rare condition, with limited reports in the literature 2.
- One study reported a case of an adult multivisceral transplant recipient who experienced recurrent PRES, initially associated with tacrolimus and subsequently with sirolimus 2.
- The study suggests that sirolimus may be associated with PRES after solid organ transplantation, in addition to calcineurin inhibitors 2.
Incidence of Sirolimus-Induced PRES
- The exact incidence of sirolimus-induced PRES is not well-established, but it is considered a rare complication 2.
- The study reported an incidence of PRES in 0.5-5% of solid organ transplant recipients, most commonly associated with tacrolimus 2.
- However, the association of sirolimus with PRES is less common, and more research is needed to determine the exact incidence 2.
Comparison with Other Sirolimus-Induced Toxicities
- Sirolimus has been associated with other toxicities, such as pulmonary toxicity, which has been reported in several studies 3, 4, 5, 6.
- The incidence of sirolimus-induced pulmonary toxicity is higher than that of PRES, with reports ranging from 2-4% of patients 3, 4, 6.
- However, the clinical presentation and outcomes of sirolimus-induced pulmonary toxicity and PRES may differ, and more research is needed to understand the relationship between these conditions 2, 3, 4, 5, 6.