Immunosuppressive Therapies Maintenance Therapy

The goals of maintenance immunosuppression are to prevent acute and chronic rejection episodes and to optimize patient and graft survival. Antirejection medications require careful selection and dosage titration to balance the risks of rejection with the risks of toxicities.

Common maintenance immunosuppressive agents can be divided into four basic medication classes:

• Calcineurin inhibitors (cyclosporine and tacrolimus);

• Antiproliferatives (azathioprine and the mycophenolic acid [MPA] derivatives);

• Target of Rapamycin (ToR) inhibitors (sirolimus); and

• Corticosteroids (prednisolone derivatives and dexamethasone).

Maintenance immunosuppression is generally achieved by combining two or more medications from the different classes to maximize efficacy by specifically targeting unique components of the immune response. Please refer to Figure 55-1 for a schematic representation of these different drug mechanisms and Figure 55-2 for an example protocol for administration of immunosuppressive medications post-transplant. This method of medication selection also helps to minimize toxicities by choosing agents with different adverse event profiles. Immunosuppressive regimens vary between organ types and transplant centers, but most often they include a calcineurin inhibitor with an adjuvant agent, plus or minus corticosteroids. Selection of appropriate immunosuppressive regimens should be patient-specific. In doing so, the transplant practitioner must take into account patients' pre-existing disease states, medication regimens, and preferences.

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