Balancing the risk of immunosupression and infection

Question 1

Balancing the immunosupreesion and infection

Answer 1

I acknowledge that it is a complex mx issue as pat is at increased risk of mortality due to unremitting infection and risk of progression of X/cancer /threatened an allograft.

1. I would like to assess the severity and extend of the infection ( markers of end organ dysfunction) by looking at the vital signs, inflammatory markers, microbiology, imaging and involvement of other end organs.
   (Tips- is this an immunosensitive infection e.g PML or BK virus, is this a deep seated infection e.g OM that cannot be controlled with immunosupression on board)

2.I would like to assess the risk of decreasing his immunosupression. ( i.e how active is underlying condition e.g Lymphoma, cancer, RA, renal allograft, lung allogarft) i.e the exact type, stage of disease and poor prognostic features- In cancer cases
( Allograft- I would like to know the current function and the trend of graft and any evidence of acute, current or previous rejection)

3. I would like to address the modifiable risk factors once patient is stable that is by looking ( in the medium term) by ensuring that patient
   —has approriate UTD immunisation.
   —I would advise pt to avoid high risk exposure. ( wearing mask in public places, using sterile technique, regular hand
   hygiene, appropriate wound dressing)
   —I would to optimise pt nutrition.
   — I would like to provide counselling for smoking cessation
   —I would like to address any other causes of impaired immunity ( hypogammaglobulinaemia, HIV antiretroviral therapy)
   —I would consult ID team re: appropriate prophylaxis AB, anti viral therapy.
   — I would like to ensure the level of immunosupression is appropriate by monitoring therapeutic level ( Aza, TPMT level, CNI,
   FBC- neutropenia, lymphopenia) and any possible drug- drug interaction such as CNI and CYP inh- azole, statin and diltiazem, AZA and allopurinol, MTX and trimethoprim)
4. I would discuss the risk and benefits with the patients.

Question 2

Immunosuppresive Medications safe to use in Pregnancy

Answer 2

Steroid
HCQ
Sulphasalazine
Cyclosporine/Tacrolimus

Question 3

immunosuppressive to be AVOIDED in pregnancy

Answer 3

-Methotrexate
-Leflunomide
-Mycophenolate
-Cyclophosphamide- especially in early pregnancy- can cause fetal abnormality and fetal loss
-Azathioprine
- Sirolimus avoided due to lack of information

Question 4

Calcineurin inhibitor

Answer 4

Question 5

Side effects

Answer 5

Azathioprine-

MMF-TMA, diarrhoea, neutropenia, skin rashes

Question 6

Side effects

Answer 6