Transplant rejection prophylaxis
Long-term pharmacotherapy after organ transplant (kidney, liver, heart, lung) to prevent immune attack on donor tissue.
ICD-10 Z946 drugs
Also known as: Post-transplant immunosuppression
Drugs used for this condition
- ACiclosporinFirst line · Immunosuppressants. Calcineurin inhibitorsCyclosporine is one of the cornerstone maintenance immunosuppressants after kidney, liver, heart, lung and bone marrow transplantation. Standard regimens combine it with an antimetabolite (mycophenolate mofetil, azathioprine) and a glucocorticoid. In recent years tacrolimus has gradually replaced cyclosporine in most protocols due to better graft survival, but cyclosporine remains an alternative when tacrolimus is not tolerated or specific adverse effects develop.
- AEverolimusSecond line · mTOR kinase inhibitor – immunosuppressant and antineoplasticEverolimus is a second-line mTOR inhibitor for rejection prophylaxis after kidney, liver and heart transplantation. Combined with tacrolimus or ciclosporin at reduced doses to limit calcineurin nephrotoxicity. KDIGO 2024 recommends everolimus as an option in patients with prior malignancy due to its anticancer activity.
- AMycophenolate mofetilFirst line · Immunosuppressant, selective inosine monophosphate dehydrogenase inhibitorMycophenolate mofetil is first-line for rejection prophylaxis after kidney, heart and liver transplantation, usually combined with tacrolimus or ciclosporin and a glucocorticoid. EMA and AEMPS approved. Requires CBC monitoring (myelosuppression risk) and strict contraception in women of childbearing age due to high teratogenic risk.
- ASirolimusSecond line · Selective immunosuppressant, mTOR inhibitormTOR inhibitor for maintenance immunosuppression after organ transplantation. AEMPS positions sirolimus as an alternative or adjunct to calcineurin inhibitors to reduce nephrotoxicity.
- ATacrolimusFirst line · Calcineurin inhibitor (immunosuppressant)Tacrolimus is a first-line calcineurin inhibitor for rejection prophylaxis after kidney, liver, heart, lung and pancreas transplantation. Combined with mycophenolate mofetil and a glucocorticoid. KDIGO 2024 and AEMPS prefer tacrolimus over ciclosporin because of lower acute rejection rates. Dose is titrated by trough blood concentration (target 5–10 ng/mL first 3 months, 3–7 ng/mL thereafter).
- BAzathioprineSecond line · Immunosuppressants, thiopurinesAzathioprine is a thiopurine antimetabolite that was part of maintenance immunosuppression after kidney transplantation for decades (indication no. 1 in the AEMPS ficha). Mycophenolate has since displaced it: on Cochrane review, mycophenolate mofetil produces less acute rejection, so azathioprine moved to reserve, used when mycophenolate is not tolerated and as the preferred antimetabolite in pregnant recipients because mycophenolate is teratogenic (KDIGO). Its role is reserve, prescribed and monitored by a transplant specialist. TPMT activity (and where possible NUDT15) must be tested before start, with blood-count monitoring for myelosuppression; the increased risk of lymphoma and skin cancer persists.
How to read tiers A–F
Evidence tiers belong to the drug-indication pair, not to the drug as a whole: the same substance can be A for one condition and F for another.
- AStrong evidence – first or second line in international guidelines
- BRecommended in selected cases
- CStudy data contradict each other
- DBenefit not proven, no documented harm
- FDocumented harm, or risk without benefit