The Massachusetts General Hospital Handbook of Neurology

Authors: Flaherty, Alice W.; Rost, Natalia S.

Title: Massachusetts General Hospital Handbook of Neurology, The, 2nd Edition

Copyright 2007 Lippincott Williams & Wilkins

> Table of Contents > Drugs > Immunosuppressants

Immunosuppressants

A. Side effects

Immunosuppressants of all types increase the risk of opportunistic infections and malignancy, especially lymphoma.

B. Azathioprine

An antimetabolite. Coadministration with allopurinol will increase its toxicity. Marrow and liver side effects.

C. Corticosteroids

• Indications: For brain tumors, MS, other autoimmune dz, pre-op neurosurgery.

• Stress-dose steroids: For pts. on chronic steroids or with adrenal insufficiency, who are exposed to trauma, severe illness, or surgery, give hydrocortisone 100 mg IV q8h 2-3 d. Unless insult is prolonged, you do not need to taper.

• Adrenal insufficiency after withdrawal: Taper steroids over several weeks to avoid insufficiency.

• Side effects:

  • Endocrine: Glucose intolerance, adrenal insufficiency after withdrawal of steroids, hirsutism, growth retardation.

  • Electrolytes: Na and water retention, low K. Give KCl supplements.

  • Musculoskeletal: Osteoporosis, myopathy. Give calcium + vitamin D between steroid courses (risk of kidney stones when given together).

  • Connective tissue: Centripetal obesity, striae, poor wound healing.

  • Immune: Increased infections, decreased allergic reactions, increased WBC count.

  • GI: Ulcers. Give ulcer prophylaxis.

  • CNS: Insomnia, agitation, psychosis. Olanzapine 2.5-10 mg or lithium 300 mg qhs.

D. Cyclophosphamide (Cytoxan)

An alkylating agent. See Chemotherapy, p. 166.

E. Cyclosporine

Inhibits T cells. Major side effects are renal. Some pts. get cyclosporine headaches that are dose dependent; may benefit from propranolol or gabapentin.

F. FK506 (Tacrolimus)

Inhibits T cells. Major side effects are renal. Some pts. get FK506 encephalopathy, with MRI showing white-matter dz. This is sometimes reversible with stopping FK506.

G. Interferon

Cytokines with immunosuppressive and antiviral effects. -interferon is used in multiple sclerosis. Side effects include a flu-like syndrome, marrow suppression, and rare confusion or seizures.

H. Methotrexate

An antimetabolite; see Chemotherapy, p. 166.