Immunosuppressants

Question 1

Anti-thymocyte globulin
Basiliximab (Simulect)
Alemtuzumab (Campath)
Methylprednisolone

Answer 1

Induction immunosuppressants

Question 2

Which induction immunosuppressant is T cell depleting?

Answer 2

Anti-thymocyte globulin

Question 3

The two anti-thymocyte formulations are:

Answer 3

thymoglobulin, atgam

Question 4

What are the premedications that must be given with anti-thymocyte globulin to prevent cytokine release syndrome?

Answer 4

steroids, acetaminophen, diphenhydramine

Question 5

Which induction immunosuppressant is non-depleting of T cells?

Answer 5

Basiliximab

Question 6

Anti-thymocyte globulin vs. Basiliximab - which immunosuppressant has a duration of T-cell inhibition for 6-12 months and which one for 1 month?

Answer 6

Anti-thymocyte globulin - 6-12 months

Basiliximab - 1 month

Question 7

Basiliximab requires premedications (T/F)

Answer 7

False, no cytokine release syndrome is present

Question 8

Which induction immunosuppressant depletes both B and T cells?

Answer 8

Alemtuzumab

Question 9

Which induction immunosuppressant has a BBW for bone marrow suppression, infusion reactions, and infections?

Answer 9

Alemtuzumab

Question 10

What adverse effect do you have to watch for alemtuzumab?

Answer 10

Very resistant infections

Question 11

Which induction immunosuppressant serves for both induction and a pre-medication agent?

Answer 11

Methylprednisolone

Question 12

Which induction immunosuppressants can also be used for rejection treatment?

Answer 12

anti-thymocyte globulin, methylprednisolone

Question 13

Tacrolimus

Cyclosporine

Answer 13

Calcineurin inhibitors (maintenance suppression)

Question 14

Which CI has lots of DDIs?

Answer 14

Tacrolimus

Question 15

Tacrolimus dosing

Answer 15

0.075-0.2 mg/kg/day (either BID or Qday)

Question 16

Which two formulations are modified cyclosporines?

Answer 16

Gengraf, Neoral

Question 17

Which formulation is non-modified cyclosporine?

Answer 17

Sandimmune

Question 18

Cyclosporine dosing

Answer 18

3-10 mg/kg/day BID

Question 19

The modified cyclosporine formulations have increased absorption compared to non-modified formulation, are less dependent on food, bile acids, etc. (T/F)

Answer 19

True

Question 20

Which CI is 50% more potent?

Answer 20

Tacrolimus

Question 21

Food increases tacrolimus absorption (T/F)

Answer 21

False, decreases absorption

Question 22

Mycophenolate

Azathioprine (Imuran)

Answer 22

Anti-proliferative agents (maintenance suppression)

Question 23

Mycophenolate mofetil vs. mycophenolic acid - which is a prodrug that theoretically decreases GI side effects?

Answer 23

mycophenolic acid

Question 24

Mycophenolate decreases the effectiveness of oral contraceptives (T/F)

Answer 24

True

Question 25

Are mycophenolate mofetil and mychophenolic acid interchangeable?

Answer 25

False

Question 26

Mycophenolate levels need to be monitored

Answer 26

False

Question 27

Mycophenolate is teratogenic (T/F)

Answer 27

True

Question 28

Prenisone

Answer 28

Steroid (maintenance suppression)

Question 29

Prednisone has long-term adverse effects such as poor wound healing, adrenal suppression, and osteoporosis (T/F)

Answer 29

True

Question 30

mTOR inhibitors are considered 2nd line agents if the first line agents produce undesirable nephrotoxic effects (T/F)

Answer 30

True

Question 31

mTOR inhibitors have anti-____ properies

Answer 31

anti-cancer properties

Question 32

Sirolimus | Everolimus

Answer 32

mTOR inhibitors

Question 33

Which mTOR inhibitor is once daily dosing and which is twice daily?

Answer 33

Sirolimus - once daily | Everolimus - twice daily

Question 34

mTOR inhibitors are not given right after transplant but ____ months after surgery

Answer 34

1-3 months post surgery

Question 35

You need to wait to give mTOR inhibitors because of their BBW of...

Answer 35

poor wound healing

Question 36

mTOR inhibitors are also known for causing ___ ulcers

Answer 36

oral, recommended to put in applesauce to try and prevent mouth ulcers

Question 37

mTOR inhibitors need daily trough levels because of their long half-lives (T/F)

Answer 37

False, they do NOT need daily trough levels because of their long half-lives (take 4-5 days after initiation and/or dose adjustment)

Question 38

mTOR inhibitors can be combined with CI. If a high risk of rejection, tacrolimus is best but it pt is not able to tolerate dose, can lower tacrolimus dose/goal and add mTOR inhibitos (T/F)

Answer 38

True, lowers nephrotoxic risk and other side effects

Question 39

This immunosuppressive agent is a selective t-cell co-stimulation blocker that is only approved in kidney transplants

Answer 39

belatacept

Question 40

Belatacept's BBW is the increased risk of post-transplant lymphoproliferative disorder (PTLD) (T/F)

Answer 40

True

Question 41

Patients about to take belatacept need to be EBV negative(T/F)

Answer 41

False, they must be EBV positive because negative increases the risk of post-transplant lymphoproliferative disorder (PTLD)

Question 42

Belatacept is very well-tolerated (T/F)

Answer 42

True

Question 43

Standard maintenance immunosuppression regimen is ____ + _____ +/- ______

Answer 43

CNI (tacrolimus) + antimetabolite (mycophenolate) +/- prednisone

Question 44

Alternative maintenance immunosuppression regimen is ___ +/- ____ + _____ + _____

Answer 44

CNI (tacrolimus or cyclosporine) +/- antimetabolite (mycophenolate or azathioprine) + mTORin (sirolimus or everolimus) + prednisone

Question 45

Azole antifungals are CYP3A4/PGP inhibitors that increase CNI concentrations (T/F)

Answer 45

True

Question 46

Possible post-transplant complications include:

Answer 46

- Infections - due to immunosuppression, threshold for bring pts in for work-up is lower - New Onset Diabetes After Transplant (NODA) - most commonly from tacrolimus - Cardiovascular complications - risk of metabolic syndrome due to anti-rejection medication - Cancer - due to immunosuppression

Question 47

What is more difficult to treat: cellular rejection or antibody mediated rejection?

Answer 47

antibody mediated rejection

Question 48

``` Treatment for cellular rejection: Pulse-dose _____ Thymoglobulin Increase ______ immunosuppression Consider "restarting" ____ rophylaxis ```

Answer 48

Pulse-dose corticosteroids Thymoglobulin Increase maintenance immunosuppression Consider "restarting" infection prophylaxis

Question 49

Treatment for antibody mediated rejection: Plasmaphersis IVIG Rituximab

Answer 49

Plasmaphersis IVIG Rituximab

Question 50

Infection prophylaxis includes

Answer 50

Valganciclovir - CMV Bactrim - Pneumocystic Jiroveci Pneumonia + Toxoplasmosis Fluconazole - "Valley Fever"

Question 51

When should infection prophylaxis be started?

Answer 51

Immediately post transplant