Key Concepts
- Vital in managing autoimmune conditions, transplant recipients, and inflammatory disorders
- Require careful monitoring due to significant side effects
- Different classes target various aspects of immune response
- Often used in combination for synergistic effects
General Principles
- Individualize therapy based on disease severity and patient factors
- Regular monitoring of drug levels and side effects
- Vaccination considerations in immunosuppressed patients
- Infection prevention strategies essential
Corticosteroids
Common Agents
- Prednisone: 1-2 mg/kg/day (max 60mg)
- Methylprednisolone: 1-30 mg/kg/day IV
- Dexamethasone: 0.15-0.3 mg/kg/day
Clinical Applications
- Acute inflammation and autoimmune flares
- Induction therapy in various conditions
- Maintenance in select cases
- Transplant rejection prevention
Monitoring Parameters
- Growth velocity
- Blood pressure
- Blood glucose
- Bone density
- Adrenal function
Major Side Effects
- Growth suppression
- Cushingoid features
- Osteoporosis
- Metabolic derangements
- Increased infection risk
Calcineurin Inhibitors
Tacrolimus
- Initial dose: 0.1-0.3 mg/kg/day divided BID
- Target trough levels vary by indication
- Monitor: Renal function, electrolytes, drug levels
- Side effects: Nephrotoxicity, hypertension, tremors
Cyclosporine
- Starting dose: 5-10 mg/kg/day divided BID
- Regular therapeutic drug monitoring required
- Common uses: Transplant, severe autoimmune conditions
- Major concerns: Nephrotoxicity, hypertension, gingival hyperplasia
Antimetabolites
Mycophenolate Mofetil (MMF)
- Dosing: 600-1200 mg/m²/day divided BID
- Uses: Transplant, autoimmune conditions
- Monitoring: CBC, liver function
- Side effects: GI upset, myelosuppression
Azathioprine
- Typical dose: 1-3 mg/kg/day
- TPMT testing before initiation
- Monitor: CBC, liver function
- Major concerns: Bone marrow suppression, hepatotoxicity
Methotrexate
- Dosing varies by indication:
- - Rheumatic: 10-15 mg/m²/week
- - Oncologic: Protocol-specific
- Requires folate supplementation
- Monitor: CBC, liver function, renal function
Biologic Agents
TNF Inhibitors
- Adalimumab: Weight-based dosing
- Infliximab: 5-10 mg/kg/dose
- Screen for TB before initiation
- Monitor for infections, malignancy
Rituximab
- 375 mg/m² weekly for specified duration
- Monitor CD19/20 counts
- Screen for hepatitis B
- Premedication protocol important
IL-6 Inhibitors
- Tocilizumab: Weight-based dosing
- Monitor lipids, liver function
- Screen for infections before starting
- Risk of GI perforation
Special Considerations
- Live vaccines contraindicated
- Infection risk management
- Regular screening for complications
- Coordination with subspecialists
Further Reading
