Which immunosuppressive medications are typically used following cardiac transplantation?

Which immunosuppressive medications are typically used following cardiac transplantation?

Frequently, immunosuppressive regimens consist of selective T-cell inhibitors such as cyclosporine or tacrolimus; nonspecific purine antimetabolites, such as azathioprine; and corticosteroids, such as prednisone. Characteristics of these medications are summarized in Table 12.1. Classic regimens based on high-dose steroids and multiple immunosuppressive agents are falling out of favor, and may soon be replaced by regimens based on rap-idly tapered steroids and tacrolimus. Other agents, includ-ing mycophenolate mofetil (CellCept) and sirolimus (Rapamune), are approved for use following cardiac trans-plantation, and are becoming part of typical immunosup-pressive maintenance regimens.

While immunosuppressive agents are the key to survival following cardiac transplantation, they also have detrimental side-effects. Cyclosporine and tacrolimus tend to cause renal insufficiency, hepatotoxicity, hypertension, and neu-rotoxicity. Neurotoxicity manifests as seizures, which result from lowering the seizure threshold. Azathioprine primarily causes hematologic toxicity, producing thrombocytopenia and anemia, but also causes hepatotoxicity. Steroids can cause hypertension, diabetes mellitus, adrenal insuffi-ciency, pancreatitis, and psychiatric disturbances.

While side-effects such as those listed in Table 12.1 may require medical management, some others mandate surgi-cal management. These side-effects will constitute some of the most frequent indications for non-cardiac surgery in the post-transplantation period.

Steroids predispose to peptic ulceration, aseptic bone necrosis, and cataracts. Consequently, patients receiving chronic high-dose steroids may present for drainage of abscesses; orthopedic procedures on the hips, knees, elbows, or shoulders; bowel resection for perforated viscus and diverticulitis; as well as ophthalmologic procedures related to cataracts and retinal detachments.

Cyclosporine, tacrolimus, and azathioprine tend to cause biliary stasis, so patients on these agents often pres-ent for cholecystectomy. Their nonspecific gastrointestinal toxicities can also cause severe symptoms (e.g., nausea, vomiting, diarrhea, anorexia, and abdominal pain) mim-icking an intra-abdominal process that occasionally prompts exploratory laparotomy.

Immunosuppression predisposes to malignancies. Some of these patients may present for lymphoma staging, node sampling, and resection of gynecologic or skin malignancies.