Pharmacotherapeutic considerations in solid organ transplant patients with COVID-19

ABSTRACT

Introduction

Coronavirus disease 2019 (COVID-19) has spread rapidly worldwide. While there are presently a few case reports/series on COVID-19 amongst solid organ transplant (SOT) patients, there is no official guideline for the management of SOT patients.

Areas covered

The authors discuss the pharmacotherapeutic management of SOT patients during the COVID-19 outbreak and provide their expert perspectives.

Expert opinion

Prophylactic reduction of immunosuppression because of fear of COVID-19 is not suggested in SOT patients. With maintenance immunosuppressive regimens, corticosteroids can be continued during COVID-19. Continuing other immunosuppressive drugs with lowest effective dose/blood concentration is suggested for patients with mild to moderate COVID-19. Discontinuation of antimetabolites and perhaps inhibitors of mammalian target of rapamycin (mTOR) is suggested in moderate to severe COVID-19. Calcineurin inhibitors (CNIs) may be continued or substituted for mTOR inhibitors with lowest therapeutic concentrations in moderate to severe COVID-19. If continued in patients with COVID-19, therapeutic drug monitoring of CNIs/mTOR inhibitors and appropriate dose reduction is recommended in co-administration with protease inhibitors, hydroxychloroquine/chloroquine, or interleukin (IL)-1/IL-6 receptor antagonists. Complete blood count monitoring is recommended in patients who continue taking antimetabolites or mTOR inhibitors. Dose modification/avoidance should be considered for chloroquine, atazanavir, oseltamivir, ribavirin, anakinra, and Janus associated kinase inhibitors in patients with organ function impairment.

KEYWORDS:

• Coronavirus disease 2019
• COVID-19
• drug interaction
• solid organ transplantation

Article highlights

 

• There is no consensus on antiviral therapy and modulation of immunosuppressive therapy among SOT patients with COVID-19.

• SOT patients with COVID-19 should receive supportive care as with the general population. Antiviral therapy can be done based on local and institutional protocols.

• Prophylactic administration of antiviral agents or reduction of immunosuppressive therapy to prevent COVID-19 in SOT patients is not suggested.

• Continuing immunosuppressive drugs with the lowest effective dose/therapeutic blood levels is suggested in SOT patients with mild to moderate COVID-19.

• Discontinuation of antimetabolites (mycophenolate or azathioprine) and perhaps mTOR inhibitors is suggested in SOT patients with moderate to severe COVID-19. In these patients, CNIs with the lowest therapeutic concentration can be continued.

• Therapeutic drug monitoring of mTOR inhibitors and CNIs is recommended if these drugs are co-administered with protease inhibitors, hydroxychloroquine/chloroquine, or antagonists of IL-6 or IL-1 receptors.

• Cardiac monitoring is recommended for SOT patients with COVID-19 who receive tacrolimus concomitant with protease inhibitors, hydroxychloroquine/chloroquine, or azithromycin.

This box summarizes the key points contained in the article.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership, or options, expert testimony, grants, or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This manuscript was not funded.