📋 Key Information Summary
- Heart transplant recipients require lifelong triple-drug immunosuppression: a calcineurin inhibitor (CNI), an antiproliferative agent, and corticosteroids — with rapid taper of steroids where feasible.
- Tacrolimus is the preferred CNI in Australian heart transplant programmes; target trough levels are highest in the first 3 months (10–15 ng/mL) and lower at 12 months and beyond (5–10 ng/mL).
- Mycophenolate mofetil (MMF) 1 g BD is the standard antiproliferative; dose-limiting GI toxicity and cytopenias are common — monitor FBC fortnightly for the first 3 months.
- Induction therapy with basiliximab (anti-CD25) is standard at most Australian centres; ATG (thymoglobulin) is reserved for high-immunological-risk recipients.
- CNI trough levels must be checked 2–3 times weekly during dose changes and at every clinic visit; trough timing is 12 hours post-dose for tacrolimus and 12 hours post-dose for ciclosporin (C2 levels also used).
- CNI nephrotoxicity is the leading cause of chronic renal failure post-transplant — minimise concurrent nephrotoxins and consider switching to an mTOR inhibitor (everolimus/sirolimus) with reduced CNI.
- Clinically significant drug interactions are pervasive: azole antifungals, macrolide antibiotics, calcium-channel blockers, grapefruit juice, and St John's wort all alter CNI levels — review all medications at every visit.
- mTOR inhibitors (everolimus, sirolimus) provide an alternative or CNI-sparing strategy, particularly for cardiac allograft vasculopathy (CAV) or malignancy — everolimus is PBS-listed (Authority Required).
- Infection prophylaxis is mandatory: trimethoprim-sulfamethoxazole (Pneumocystis jirovecii, first 6–12 months), valganciclovir (CMV, 3–6 months based on donor/recipient serostatus), and nystatin/amphotericin (oral candidiasis, first 3 months).
- Adherence to immunosuppression is the single greatest modifiable factor for long-term graft survival; non-adherence rates in adolescents and young adults reach 30–50%.
- All heart transplant recipients must have annual influenza, pneumococcal, and COVID-19 vaccinations; live vaccines (MMR, varicella, yellow fever) are contraindicated while immunosuppressed.
- Aboriginal and Torres Strait Islander patients face additional barriers including remote access to transplant centres, specialist pharmacy services, and therapeutic drug monitoring — coordinate with local AMS and Telehealth.
- Corticosteroid-related complications (diabetes, osteoporosis, obesity) are common — implement early bone protection (calcium, vitamin D, bisphosphonates if indicated) and glycaemic monitoring.
Introduction & Australian Epidemiology
Heart transplantation remains the definitive treatment for end-stage heart failure refractory to optimal medical and device therapy. Australia performs approximately 100–120 heart transplants annually across five adult centres (St Vincent's Hospital Sydney, Alfred Hospital Melbourne, Prince Charles Hospital Brisbane, Royal Adelaide Hospital, and Fiona Stanley Hospital Perth) and two paediatric centres. Post-transplant immunosuppression is essential to prevent acute and chronic rejection, yet it simultaneously increases the risks of infection, malignancy, nephrotoxicity, and metabolic disease.
The modern immunosuppressive regimen for heart transplant recipients is built on a triple-drug backbone: a calcineurin inhibitor (CNI — tacrolimus or ciclosporin), an antiproliferative agent (mycophenolate mofetil or mycophenolic acid), and corticosteroids (prednisolone). This triple therapy targets distinct nodes of T-cell activation and proliferation, enabling lower doses of each agent and reduced individual drug toxicity. In the first 1–3 months post-transplant — the period of highest rejection risk — induction therapy with a biological agent (basiliximab or anti-thymocyte globulin) provides additional immunosuppressive intensity.
Over the past two decades, one-year survival following heart transplantation in Australia has improved to 85–90%, and five-year survival to approximately 70–75%. However, long-term outcomes are limited by cardiac allograft vasculopathy (CAV), chronic kidney disease (largely CNI-mediated), malignancy (particularly skin cancers in the Australian UV environment), and infection. Optimising the balance between adequate immunosuppression and minimisation of these complications is the central challenge of transplant pharmacotherapy.
This guideline provides a comprehensive, Australian-focused overview of the immunosuppressive and adjunctive medications used following heart transplantation, including drug-specific dosing, therapeutic drug monitoring, drug interactions, adverse-effect management, and considerations for special populations.
Lifelong therapy: Immunosuppression following heart transplantation is lifelong. Abrupt cessation or non-adherence, even briefly, can precipitate acute rejection and graft loss. All dose changes should be guided by the transplant team.
Induction & Maintenance Immunosuppression
Induction Therapy
Induction therapy provides intense immunosuppression in the perioperative period to reduce early acute rejection episodes and allow delayed introduction of nephrotoxic agents. Australian centres typically use one of two strategies:
Basiliximab
Simulect® · Anti-CD25 monoclonal antibody (IL-2 receptor antagonist)
Adult dose
20 mg IV on Day 0 (before or during surgery) and Day 4 (post-transplant)
Paediatric dose
<35 kg: 10 mg IV × 2 doses; ≥35 kg: 20 mg IV × 2 doses
Route
Intravenous infusion over 20–30 minutes
Renal adjustment
Not required
PBS status
⚠ Authority Required
Anti-thymocyte globulin (rabbit)
Thymoglobulin® · ATG · Polyclonal T-cell depleting antibody
Adult dose
1–1.5 mg/kg IV daily for 3–5 days (total 3–7 mg/kg); first dose intraoperatively or Day 1
Indications for use
High immunological risk (PRA >10%, retransplant, sensitised recipient, donor-specific antibodies), or need for delayed CNI initiation (renal impairment)
Key monitoring
FBC (lymphocyte count), platelet count before each infusion; premedicate with paracetamol, antihistamine, corticosteroids
PBS status
⚠ Authority Required
Standard Maintenance Triple Therapy
Following induction, maintenance immunosuppression is commenced with a calcineurin inhibitor (tacrolimus preferred), mycophenolate mofetil, and prednisolone. The typical timeline is:
Day 0–1
Commence tacrolimus PO/NG 0.05–0.1 mg/kg/day in 2 divided doses. If renal impairment present, delay CNI and use ATG induction to cover.
Day 0–3
Commence MMF 1 g BD (or 750 mg BD if GI intolerance anticipated). In paediatrics: 600 mg/m² BD.
Day 0
Methylprednisolone 500–1000 mg IV intraoperatively; taper to oral prednisolone 1 mg/kg/day (max 50 mg) over first week.
Month 1–3
Prednisolone taper: reduce by 5 mg every 1–2 weeks to 10 mg/day, then slower taper. Target 5 mg/day or withdrawal by 3–6 months if no rejection.
Month 3–6
Tacrolimus target trough 8–12 ng/mL. MMF target trough mycophenolic acid (MPA) 1.5–4.0 mg/L if available. Prednisolone 5–7.5 mg/day.
Month 6–12+
Tacrolimus target trough 5–10 ng/mL. MMF continued at 500 mg–1 g BD. Prednisolone ≤5 mg/day or weaned off in selected patients.
Steroid withdrawal: Complete steroid withdrawal (by 6–12 months) is increasingly attempted in low-risk patients to reduce metabolic complications. It requires close surveillance with protocol biopsies and should only be undertaken by the transplant team. Rejection rates increase modestly with steroid withdrawal.
Target Trough Levels — Summary
| Time Period | Tacrolimus (ng/mL) | Ciclosporin (C0 ng/mL) | Everolimus (ng/mL) | Sirolimus (ng/mL) |
|---|---|---|---|---|
| 0–3 months | 10–15 | 200–350 | 3–8 (with reduced CNI) | 5–15 |
| 3–6 months | 8–12 | 150–250 | 3–8 | 5–15 |
| 6–12 months | 5–10 | 100–200 | 3–8 | 5–12 |
| >12 months | 5–8 | 75–150 | 3–8 | 5–12 |
Calcineurin Inhibitors (Tacrolimus, Ciclosporin) & Side Effects
Calcineurin inhibitors (CNIs) are the cornerstone of maintenance immunosuppression. They block calcineurin phosphatase, preventing nuclear translocation of NFAT and thereby inhibiting IL-2 transcription and T-cell activation. Tacrolimus is the preferred CNI in Australian heart transplant programmes due to superior efficacy in preventing acute rejection.
Tacrolimus
Prograf® · Advagraf® (MR) · Generic · Calcineurin inhibitor
Adult dose
0.05–0.1 mg/kg/day PO in 2 divided doses (immediate-release). Modified-release (Advagraf): same total daily dose, once daily.
Paediatric dose
0.1–0.2 mg/kg/day PO in 2 divided doses (children require higher mg/kg doses)
Trough monitoring
12-hour post-dose trough; target varies by time post-transplant (see table above)
Renal adjustment
Reduce dose if eGFR declining; no fixed formula — guided by trough levels and clinical response. Consider CNI minimisation strategy.
Hepatic adjustment
Reduce dose by 50% in severe hepatic impairment (Child-Pugh C)
PBS status
✔ PBS General Benefit
Ciclosporin
Neoral® · Sandimmun® · Calcineurin inhibitor
Adult dose
4–6 mg/kg/day PO in 2 divided doses (microemulsion formulation). Titrate to trough or C2 level.
Paediatric dose
5–10 mg/kg/day PO in 2 divided doses
Monitoring
C0 (trough) 12-h post-dose or C2 (2-h post-dose) — C2 more closely correlates with AUC; C2 target 1000–1500 ng/mL (early), 600–800 ng/mL (late)
Renal adjustment
As per tacrolimus — CNI nephrotoxicity is class effect
PBS status
✔ PBS General Benefit
Side Effects of Calcineurin Inhibitors
| System | Tacrolimus | Ciclosporin | Management |
|---|---|---|---|
| Renal | Nephrotoxicity (acute & chronic); dose-dependent | Nephrotoxicity — often more pronounced | Minimise dose; avoid concurrent nephrotoxins (NSAIDs, aminoglycosides, IV contrast); consider mTOR switch |
| Neurological | Tremor, headache, paraesthesia, rarely PRES | Tremor, headache (less common) | Dose reduction; PRES requires urgent MRI and ICU admission |
| Metabolic | New-onset diabetes (NODAT) — 15–30%; hyperkalaemia; hypomagnesaemia | Dyslipidaemia, hyperuricaemia/gout, hyperkalaemia | HbA1c 3-monthly; Mg²⁺ and K⁺ monitoring; gout: colchicine (dose-adjusted), avoid allopurinol + azathioprine combination |
| Cardiovascular | Hypertension (less than ciclosporin) | Hypertension (marked, endothelin-mediated) | CCBs (amlodipine preferred — see interactions); ACEi/ARB |
| GI | Diarrhoea, nausea, abdominal pain | Gingival hyperplasia, hirsutism | Dose adjustment; gingival hygiene; ciclosporin → tacrolimus switch if intolerable |
| Haematological | TMA (thrombotic microangiopathy) — rare | TMA — more common than tacrolimus | Consider switching CNI or to mTOR inhibitor; plasmapheresis if severe |
| Malignancy | Increased risk (skin cancer, PTLD) — immunosuppression class effect | Similar risk; may have more direct tumour-promoting effect via TGF-β | Annual dermatology screening; minimise immunosuppression; consider mTOR inhibitor switch (anti-tumour properties) |
Nephrotoxicity is the most important long-term limitation. By 10 years post-transplant, 10–15% of heart transplant recipients develop stage 4–5 CKD, with CNIs as the predominant contributor. Regular eGFR monitoring (at least monthly for first year, then 3-monthly) and early CNI minimisation strategies are essential.
CNI Nephroprotection Strategies
- CNI minimisation: Reduce tacrolimus target trough to 3–5 ng/mL (after 12 months) with addition of an mTOR inhibitor (everolimus 1.5–3 mg/day)
- CNI withdrawal: Complete CNI cessation and switch to mTOR inhibitor-based regimen — higher rejection risk; only in selected patients with protocol biopsy surveillance
- Avoid concurrent nephrotoxins: NSAIDs, aminoglycosides, amphotericin B, high-dose trimethoprim, IV iodinated contrast (hydrate pre/post)
- Maintain adequate hydration: Dehydration precipitates acute CNI toxicity
Antiproliferative Agents & mTOR Inhibitors
Antiproliferative Agents
Antiproliferative agents inhibit lymphocyte proliferation by blocking DNA synthesis. Mycophenolate mofetil (MMF) is the first-line agent in Australian heart transplant programmes.
Mycophenolate mofetil (MMF)
CellCept® · Generic · Inosine monophosphate dehydrogenase (IMPDH) inhibitor
Adult dose
1 g PO/NG BD (2 g/day total); reduce to 500 mg BD if intolerant
Paediatric dose
600 mg/m² PO BD (max 1 g BD); oral suspension available
Common adverse effects
Diarrhoea (dose-limiting in 15–20%), nausea, vomiting; leucopenia, anaemia, thrombocytopenia
Monitoring
FBC fortnightly × 3 months, then monthly; MPA trough (if available) target 1.5–4.0 mg/L
Renal adjustment
No dose adjustment required; active metabolite (MPA) not removed by haemodialysis
PBS status
✔ PBS General Benefit
Mycophenolate sodium (enteric-coated)
Myfortic® · Enteric-coated MPA
Adult dose
720 mg PO BD (equivalent to MMF 1 g BD)
Advantage
May reduce upper GI side effects compared to MMF; bioequivalent MPA exposure
PBS status
✔ PBS General Benefit
MMF and pregnancy: MMF is teratogenic (Category D). It must be discontinued at least 6 weeks before conception and replaced with azathioprine. All women of childbearing age must use reliable contraception while taking MMF.
mTOR Inhibitors
Mechanistic target of rapamycin (mTOR) inhibitors — everolimus and sirolimus — inhibit T- and B-cell proliferation via a different mechanism to CNIs and antiproliferatives. They also possess antiproliferative effects on smooth muscle cells and fibroblasts, providing anti-fibrotic and anti-atherosclerotic properties relevant to cardiac allograft vasculopathy (CAV).
Everolimus
Certican® · Afinitor® · mTOR inhibitor
Adult dose
0.75 mg PO BD initially; target trough 3–8 ng/mL. Used with reduced-dose CNI (tacrolimus trough 3–5 ng/mL)
Indications
CNI nephrotoxicity (CNI-sparing regimen); CAV progression; malignancy (skin cancer prophylaxis); post-transplant malignancy history
Common adverse effects
Dyslipidaemia (hypercholesterolaemia, hypertriglyceridaemia), oral ulcers, peripheral oedema, impaired wound healing, proteinuria, cytopenias
Renal adjustment
No dose adjustment; however, proteinuria must be monitored (hold if >1 g/day)
PBS status
⚠ Authority Required — heart transplant (Certican®)
Sirolimus
Rapamune® · mTOR inhibitor
Adult dose
Loading dose 3–5 mg PO Day 1; then 1–2 mg PO daily. Target trough 5–15 ng/mL. Long half-life (~62 hours).
Key difference from everolimus
Longer half-life (less predictable kinetics); not PBS-listed for heart transplant; less data in cardiac transplantation compared to everolimus
PBS status
⚠ Authority Required (renal transplant only on PBS — cardiac use is off-PBS)
Azathioprine
Imuran® · Generic · Purine synthesis inhibitor
Adult dose
1.5–2.5 mg/kg/day PO (typically 100–150 mg/day)
Role
Alternative to MMF when MMF is contraindicated (pregnancy, severe GI intolerance unresponsive to dose reduction); less potent than MMF
Key monitoring
FBC weekly × 4 weeks, then fortnightly; TPMT/NUDT15 genotyping recommended before initiation (risk of severe myelosuppression with poor metaboliser phenotype)
PBS status
✔ PBS General Benefit
Azathioprine — TPMT/NUDT15 Pharmacogenomic Testing
Before commencing azathioprine, TPMT (thiopurine methyltransferase) and NUDT15 genotyping is recommended (MBS item available). Patients who are homozygous deficient (approximately 1 in 300 for TPMT) are at risk of life-threatening myelosuppression and require dose reduction to 10% of standard or alternative therapy.
MBS item for TPMT testing: TPMT genotyping (MBS item 73311) is available on the Medicare Benefits Schedule. NUDT15 testing may also be accessed through specialist pharmacogenomic services.
Drug Interactions & Monitoring
Calcineurin inhibitors (especially tacrolimus) are substrates of CYP3A4 and P-glycoprotein (P-gp), making them highly susceptible to drug interactions. Clinically significant interactions can result in supra-therapeutic levels (toxicity) or sub-therapeutic levels (rejection). A systematic approach to interaction checking at every prescription is essential.
Major CNI Drug Interactions
| Interacting Drug | Effect on CNI Levels | Mechanism | Clinical Action |
|---|---|---|---|
| Fluconazole | ↑↑↑ (2–5× increase) | Potent CYP3A4 inhibition | Reduce CNI dose by 50%; check level 48–72 h after starting; recheck when stopping |
| Itraconazole, voriconazole, posaconazole | ↑↑↑ (3–10× increase) | Potent CYP3A4 inhibition | Reduce CNI dose by 66–75%; mandatory level monitoring. Avoid if possible — use alternative antifungal. |
| Erythromycin, clarithromycin | ↑↑ (2–3× increase) | CYP3A4 inhibition | Reduce CNI dose by 50%; azithromycin has minimal interaction (preferred macrolide) |
| Rifampicin | ↓↓↓ (profound decrease) | Potent CYP3A4 induction | Increase CNI dose 3–5× or consider alternative anti-TB regimen; daily level monitoring essential |
| Carbamazepine, phenytoin, phenobarbital | ↓↓ (significant decrease) | CYP3A4 induction | Avoid if possible; use levetiracetam, gabapentin, or valproate (minimal CYP3A4 interaction) as anticonvulsant alternatives |
| Amlodipine, diltiazem, verapamil | ↑ (moderate increase) | CYP3A4 inhibition (diltiazem, verapamil) or P-gp effect | Amlodipine: minimal interaction (preferred CCB). Diltiazem/verapamil: can be used therapeutically to reduce CNI dose requirement — monitor closely. |
| Grapefruit juice | ↑ (variable increase) | CYP3A4 and P-gp inhibition in gut wall | AVOID completely — advise all patients at every visit |
| St John's wort | ↓↓ (significant decrease) | Potent CYP3A4 and P-gp induction | CONTRAINDICATED — educate patients regarding herbal/complementary medicine interactions |
| Metoclopramide | ↓ (moderate decrease) | Increased GI motility reduces absorption | Separate dosing by ≥2 hours; consider domperidone as antiemetic alternative |
| Norfloxacin, ciprofloxacin | ↑ (moderate increase — ciclosporin) | CYP3A4 inhibition | Monitor CNI levels if initiating; amoxicillin/clavulanate or cephalexin preferred for empiric UTI |
Azole antifungal–CNI interactions are the most common cause of drug-related toxicity in heart transplant patients. Whenever an azole antifungal is prescribed (orally or IV), the CNI dose must be empirically reduced and trough levels monitored within 48–72 hours. Failure to do so can result in severe nephrotoxicity or neurotoxicity.
Therapeutic Drug Monitoring Schedule
Consistent and timely therapeutic drug monitoring (TDM) is critical to safe CNI dosing. The following schedule is recommended for tacrolimus:
| Time Post-Transplant | Monitoring Frequency | Target Trough (ng/mL) |
|---|---|---|
| Week 1–2 (inpatient) | Daily | 10–15 |
| Week 2–4 (outpatient) | 2–3 times per week | 10–15 |
| Month 1–3 | Weekly | 10–15 |
| Month 3–6 | Fortnightly | 8–12 |
| Month 6–12 | Monthly | 5–10 |
| >12 months (stable) | Every 3 months | 5–8 |
| After any dose change or interacting drug | 48–72 hours post-change | Within target range |
Practical Tips for CNI Trough Level Collection
- Collect blood exactly 12 hours (±30 minutes) post-dose for both tacrolimus and ciclosporin trough levels
- Ensure the patient has taken their dose before the blood draw — document timing
- EDTA (purple top) tube is preferred for tacrolimus assays; lithium heparin also acceptable
- Whole blood levels (not serum) should be measured for CNIs
- Food intake, particularly high-fat meals, can affect tacrolimus absorption — advise consistent timing relative to meals
- Brand switching (generic ↔ branded tacrolimus) may alter bioavailability — recheck levels 5–7 days after any brand change
Additional Monitoring for All Immunosuppressed Patients
| Investigation | Frequency | Purpose |
|---|---|---|
| FBC + differential | Fortnightly × 3 months, then monthly | MMF/AZA-induced cytopenias; viral infection screening |
| U&E, creatinine, eGFR | Fortnightly × 3 months, then monthly → 3-monthly | CNI nephrotoxicity monitoring |
| LFTs | Monthly × 6 months, then 3-monthly | Drug-induced hepatotoxicity |
| Fasting lipids | 3-monthly (especially if on mTOR inhibitor or ciclosporin) | Post-transplant dyslipidaemia; statin therapy response |
| HbA1c / fasting glucose | 3-monthly | New-onset diabetes after transplantation (NODAT) — prevalence 15–30% |
| Magnesium, potassium, phosphate | Monthly (more frequently in first 3 months) | CNI-induced hypomagnesaemia, hyperkalaemia |
| CMV viral load (PCR) | Weekly during prophylaxis; fortnightly × 3 months after stopping | CMV reactivation/disease |
| EBV viral load | 3-monthly (especially in paediatric recipients) | PTLD risk stratification |
| Endomyocardial biopsy | Per protocol (varies by centre: weeks 1, 4, 8, 12, 26, 52; or as clinically indicated) | Acute cellular rejection surveillance (gold standard) |
| Donor-specific antibodies (DSA) | 3-monthly, or if rejection suspected | Antibody-mediated rejection (AMR) surveillance |
| Coronary angiography / CT coronary | Annual | Cardiac allograft vasculopathy (CAV) surveillance |
| Dermatology review | Annual (more frequent if history of skin cancer) | Skin cancer screening (Australian UV risk) |
Special Populations
Pregnancy
Tacrolimus
Continue during pregnancy — Category C. Doses usually need to increase (expanded plasma volume, increased clearance). Monitor levels more frequently (every 2 weeks). No major teratogenic risk established.
Ciclosporin
Continue if already established — Category C. Similar pharmacokinetic changes as tacrolimus. Risk of pre-eclampsia and prematurity increased.
Mycophenolate mofetil
CONTRAINDICATED — Category D. Discontinue ≥6 weeks before planned conception. Replace with azathioprine 1.5–2 mg/kg/day. Ensure reliable contraception while on MMF.
Azathioprine
Safe in pregnancy (Category D in system but widely used with safety data). TPMT testing essential before use.
Prednisolone
Continue at lowest effective dose — Category A (low dose). Risk of gestational diabetes, pre-eclampsia. Neonatal adrenal suppression possible at higher doses.
Everolimus / Sirolimus
CONTRAINDICATED — Category D. Discontinue ≥12 weeks before conception (long half-life for sirolimus).
Paediatrics
Dosing differences
Children have higher weight-adjusted CNI clearance — typically require higher mg/kg doses than adults. Therapeutic drug monitoring is even more critical. Paediatric cardiologists manage dosing.
MMF formulation
Oral suspension (CellCept® 200 mg/mL) available for children unable to swallow capsules. Dose: 600 mg/m² BD. Note suspension has shorter shelf-life (70 days after opening).
Adherence
Non-adherence rates highest in adolescents (30–50%). Consider supervised dosing, pill counts, and electronic adherence monitoring. Transition programmes essential from paediatric to adult services.
EBV / PTLD
Children are more frequently EBV-naïve; if transplanted from EBV-positive donor, PTLD risk is highest. Monitor EBV viral load 3-monthly for first 2–3 years.
Elderly
CNI dosing
Reduced hepatic CYP3A4 activity and lower lean body mass may require lower initial doses. Aim for lower end of target trough range.
Infection risk
Significantly higher infection risk — consider lower overall immunosuppression intensity. Extended PJP and CMV prophylaxis may be warranted.
Polypharmacy
Increased interaction risk. Perform medication reconciliation at every visit. Deprescribe non-essential medications.
Renal Impairment
CNI nephrotoxicity
The most common cause of post-transplant CKD. If eGFR <30 mL/min or declining rapidly, reduce CNI dose and consider adding mTOR inhibitor (CNI-sparing strategy). Avoid NSAIDs, IV contrast, aminoglycosides.
MMF
No dose adjustment required for renal impairment. MPA is not removed by haemodialysis.
Allopurinol + azathioprine
CONTRAINDICATED combination. Allopurinol inhibits xanthine oxidase, dramatically increasing 6-mercaptopurine levels → fatal pancytopenia risk. Use febuxostat or colchicine for gout instead.
Hepatic Impairment
Tacrolimus
Reduce dose by 50% in Child-Pugh C cirrhosis (decreased CYP3A4 metabolism). Trough levels may not accurately reflect free-drug exposure — clinical assessment essential.
Azathioprine
Use with caution in hepatic impairment — hepatotoxicity risk. Monitor LFTs closely. Consider MMF as alternative.
Immunocompromised Considerations
Infection prophylaxis
PJP: Trimethoprim-sulfamethoxazole 480 mg PO daily or 960 mg PO 3 times/week for 6–12 months (first line). Alternatives: dapsone 100 mg PO daily, atovaquone 1500 mg PO daily. CMV: Valganciclovir 900 mg PO daily for 3–6 months based on D/R serostatus (highest risk: D+/R−). Oral candidiasis: Nystatin suspension or fluconazole 100 mg PO daily for 3 months.
Vaccination
Annual influenza (inactivated), pneumococcal (PCV20 or PCV15+PPV23), COVID-19 (per ATAGI schedule), hepatitis B (if non-immune). Live vaccines (MMR, varicella, yellow fever, oral polio) are CONTRAINDICATED.
Aboriginal and Torres Strait Islander Health Considerations
Aboriginal and Torres Strait Islander Health
📚 References
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