Monitoring Of Nonsteroidal Immunosuppressive Drugs In Patients With Lung Disease And Lung Transplant Recipients

Publication Date: November 1, 2012
Last Updated: March 14, 2022

Recommendations

Anti-Tumor Necrosis Factor-α Agents

For patients who will undergo anti-TNF-α therapy, a chest radiograph is recommended prior to treatment. (1, C)
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For patients who will undergo anti-TNF- α therapy, a tuberculin skin test is recommended to screen for latent TB prior to treatment. (1, C)
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For patients who will undergo anti-TNF-α therapy and present with a chest x-ray consistent with prior TB or a positive tuberculin skin test and/or are high-risk individuals, active TB infection should be excluded prior to treatment with
  • adalimumab,
(1, C)
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  • etanercept
(1, B)
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  • infliximab.
(1, B)
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For patients with latent M tuberculosis , active prophylactic treatment following published guidelines before initiation of anti-TNF-α therapy is recommended. (1, B)
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For patients with latent M. tuberculosis who will undergo anti-TNF-α therapy, close monitoring for TB is recommended for up to 6 months after discontinuing therapy. (1, C)
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For patients who develop symptoms indicative of TB, prompt evaluation for active disease is recommended. (1, C)
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For patients with known grade III or IV New York Heart Association class heart failure, administration of
  • adalimumab,
(1, C)
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  • etanercept or
(1, C)
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  • and infliximab
(1, B)
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is not recommended.
For patients with a history of congestive heart failure who undergo anti-TNF-α therapy, close observation for congestive heart failure exacerbation is recommended. (1, C)
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For patients with a history of demyelinating disease,
  • administration of etanercept is not recommended,
(1, C)
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  • and administration of adalimumab and infliximab is not suggested.
(2, C)
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For patients with no history of demyelinating disease who undergo anti-TNF-α therapy and experience symptoms or display signs of a demyelinating process, discontinuation of therapy is suggested. (2, C)
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For patients who undergo anti-TNF-α therapy and develop symptoms of a lupus-like disorder, discontinuation of therapy is suggested. (2, C)
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For patients who will undergo anti-TNF-α therapy and who are at risk for viral hepatitis, serologic screening for hepatitis B is recommended prior to treatment. (1, C)
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For patients who have hepatitis B virus infection, anti-TNF-α therapy should not be administered.

(1, C)
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For patients who undergo anti-TNF-α therapy and develop unresolved infections, discontinuation of treatment until the infection is resolved is recommended. (1, B)
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For patients who are pregnant, administration of anti-TNF-α therapy is used only if alternatives are not able to be used. (2, C)
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Calcineurin Inhibitors

For patients who will undergo CNI therapy, the monitoring of drug concentrations, BP, glucose, potassium, magnesium, lipids, CBC count, and renal function is recommended. (1, B)
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For patients who undergo CNI therapy, monitoring of drug levels when CYP3A4 inducers or inhibitors are added or stopped and adjusting doses are recommended when using
  • cyclosporin A or
(1, A)
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  • tacrolimus
(1, B)
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For lung transplant recipients receiving CNI therapy who develop renal dysfunction, a reduction in the target dose concentration is suggested.

(2, C)
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Antilymphocyte Antibodies

For patients who undergo antilymphocyte antibody therapy, monitoring for infusion reactions is recommended. (1, B)
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For patients who undergo antithymocyte globulin or muromonab therapy, monitoring of CBC counts and liver function tests is recommended during therapy. (1, B)
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For patients with lung disease and lung transplant recipients who will undergo antithymocyte globulin or muromonab therapy, laboratory evaluation for host antibodies (where available) before reinstitution of therapy is suggested. (2, C)
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For patients who undergo muromonab therapy, monitoring for pulmonary edema and systemic infl ammatory response syndrome during therapy is recommended. (1, B)
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Receptor Antagonists

For patients who undergo IL-2 receptor antagonist therapy, monitoring for infusion reactions is recommended. (1, C)
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For patients who undergo IL-2 receptor antagonist therapy, monitoring of renal function, CBC counts, and infection is recommended. (1, C)
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For patients who undergo IL-2 receptor antagonist therapy, the simultaneous use of either
  • basiliximab or
(1, C)
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  • daclizumab
(1, B)
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with antilymphocyte antibodies is not recommended.

Cytotoxic Agents

For patients who will undergo concurrent therapy with azathioprine and allopurinol, a reduction in dose of azathioprine is recommended. (1, A)
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For patients who undergo azathioprine therapy, obtaining CBC counts and renal/hepatic profi les every 1 to 3 months is recommended. (1, B)
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For patients who will undergo cyclophosphamide therapy, monitoring of CBC count, renal profile, and urinalysis at least monthly for dose adjustment is recommended. (1, B)
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For patients who will undergo cyclophosphamide therapy, increased fluid intake (eg, 2 L in addition to normal intake in adults; additional volume given to children needs to be calculated on the basis of body weight) on the days of therapy. (1, C)
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For patients who undergo or have undergone cyclophosphamide therapy and develop hematuria, further evaluation is recommended. (1, B)
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For patients who will undergo leflunomide or methotrexate therapy, screening for the use of alcohol and chronic viral hepatitis prior to treatment is recommended. (2, C)
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For patients who undergo methotrexate or leflunomide therapy, performance of liver function tests and CBC counts is recommended. (1, C)
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For patients who undergo methotrexate therapy, folic acid supplementation is recommended. (1, A)
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For patients who undergo leflunomide therapy and develop neuropathic symptoms, prompt consideration of discontinuing therapy and washing out with cholestyramine is recommended. (1, C)
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For patients who undergo
  • methotrexate or
(1, B)
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  • leflunomide
(, )
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therapy and develop new or worsening signs or symptoms of lung disease, further evaluation is recommended.
For patients who undergo methotrexate therapy and develop persistently elevated liver transaminases above their own baseline, cessation of treatment or evaluation by liver biopsy is recommended. (1, B)
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For patients with renal insufficiency, ascites, or pleural effusions who undergo methotrexate therapy, decreased methotrexate clearance may be present, and dose reduction may be required. (2, C)
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For patients who undergo mycophenolic acid therapy and develop adverse GI affects, including diarrhea, interruption of therapy or reduction in dose is recommended. (1, B)
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For patients who undergo mycophenolic acid therapy and develop signs or symptoms of progressive multifocal leukoencephalopathy, cessation of treatment is suggested. (2, C)
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Mammalian Target of Rapamycin Inhibitors

For patients who will undergo mTOR inhibitor therapy, obtaining cholesterol and triglyceride levels prior to treatment is recommended. (1, B)
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For patients who present with an abnormal elevation of fasting triglycerides, avoidance of mTOR therapy or careful monitoring of triglycerides is recommended. (1, B)
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For patients who undergo mTOR therapy, monitoring for hyperlipidemia is recommended. (1, A)
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For patients who undergo mTOR therapy, monitoring of CBC counts, creatinine, and BP is recommended. (1, B)
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For patients who undergo sirolimus therapy, monitoring of drug concentration is recommended. (1, B)
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For lung transplant recipients scheduled to undergo sirolimus therapy, administration of sirolimus during the early perioperative period is contraindicated due to the risk of airway dehiscence. (1, A)
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For patients who undergo sirolimus therapy and are at risk for poor wound healing, consideration of dose adjustments or an alternative therapy to lower this risk is suggested. (2, C)
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For patients who undergo sirolimus therapy and develop new or worsening respiratory symptoms or signs, an evaluation for sirolimusinduced pulmonary toxicity is recommended. (1, B)
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Other Immunosuppressive Drugs

For patients receiving hydroxychloroquine and chloroquine, an eye examination at least once per year is suggested. (2, B)
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For patients who undergo imatinib mesylate therapy, monitoring of CBC and hepatic function is suggested. (2, C)
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Recommendation Grading

Disclaimer

Overview

Title

Monitoring Of Nonsteroidal Immunosuppressive Drugs In Patients With Lung Disease And Lung Transplant Recipients

Authoring Organization

Publication Month/Year

November 1, 2012

Last Updated Month/Year

May 16, 2023

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

Immunosuppressive pharmacologic agents prescribed to patients with diffuse interstitial and inflammatory lung disease and lung transplant recipients are associated with potential risks for adverse reactions. Strategies for minimizing such risks include administering these drugs according to established, safe protocols; monitoring to detect manifestations of toxicity; and patient education. Hence, an evidence-based guideline for physicians can improve safety and optimize the likelihood of a successful outcome. To maximize the likelihood that these agents will be used safely, the American College of Chest Physicians established a committee to examine the clinical evidence for the administration and monitoring of immunosuppressive drugs (with the exception of corticosteroids) to identify associated toxicities associated with each drug and appropriate protocols for monitoring these agents.

Target Patient Population

Patients receiving immunosuppressive agents for interstitial/inflammatory lung disease or lung transplant

Inclusion Criteria

Male, Female, Adolescent, Adult, Child, Older adult

Health Care Settings

Hospital, Long term care, Outpatient, Operating and recovery room

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Treatment, Management, Prevention

Diseases/Conditions (MeSH)

D017563 - Lung Diseases, Interstitial, D007165 - Immunosuppression, D007166 - Immunosuppressive Agents, D008171 - Lung Diseases, D016040 - Lung Transplantation

Keywords

interstitial lung disease, immunosuppression, immunosuppressant, lung transplant