What to Know About Immunosuppressive Therapies

Drugs and Biologic Treatments That Tone Down the Immune System

In This Article

Therapies that block parts of the immune system are sometimes given for several kinds of medical situations, including autoimmune diseases and organ transplantation. Other treatments may impair the immune system as a side effect. As a group, these therapies suppress part or all of the immune system, which is why they are called “immunosuppressants.”

Some immunosuppressants are traditional pharmaceutical drugs. Other types of immunosuppressants are biologics, which are medical therapies made from part of a living thing. Depending on the specific therapy, they might be taken orally, by injection, or through an intravenous line.

Immunosuppressant therapies improve the quality of life for people with various medical conditions, and sometimes they are life-saving treatments. However, because the immune system doesn’t work completely normally in people using these therapies, people using immunosuppressants are at risk of certain medical complications, including infections.

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Uses of Immunosuppressants Treatments

Immunosuppressants are used in a variety of medical contexts. Some inhibit a specific part of the immune response, like blocking an immune signaling molecule. Others affect many different parts of the immune system. There are many different categories of immunosuppressants that work in slightly different ways.

Some of the same immunosuppressants are used in different types of diseases. Below are several of the most important categories.

Autoimmune Disease

Immunosuppressive therapies are used to treat many autoimmune diseases. In autoimmune disease, specific parts of the immune system become overactive. Ultimately, this leads to inflammation and damage to the body by its own immune system. Researchers have developed immunosuppressives that target different parts of the immune system and can help treat autoimmune diseases.

Autoimmune diseases sometimes treated with immunosuppressive therapies include:

Some of the immunosuppressive therapies to treat autoimmune disease are traditional pharmaceutical drugs. Examples include:

More recently, biologic therapies have become available. These are usually given through an injection or an intravenous line. These newer therapies target specific parts of the immune system, like blocking a specific type of receptor on immune cells.

Some of the broad categories of immunosuppressive biologics to treat autoimmune disease include the following:

  • TNF-inhibitors, like Humira (adalimumab)
  • IL-6 blockers, like Actemra (tocilizumab)
  • IL-1 blockers, like Kineret (anakinra)
  • Biologics blocking T cell activity, like Orencia (abatacept)
  • JAK inhibitors, like Xeljanx (tofacitinib)
  • Biologics affecting B cells, like Truxima (rituximab)

Certain immunosuppressives are sometimes given temporarily. For example, you might need to take prednisone for a brief period if your symptoms are flaring out of control. You also might need to take a higher dose of an immunosuppressive, like prednisone, if you are having a disease flare. However, you may need to take maintenance doses of certain therapies long-term.

Not all treatments helpful in these conditions are immunosuppressive therapies. For example, an individual might take a medication to reduce pain that doesn’t affect the immune system. Talk to your doctor if you aren’t sure if your therapy is an immunosuppressive or not.

Organ Transplant

Immunosuppressives are also a critical therapy for people who have had an organ transplant, like a donated kidney or liver.

The immune system works hard to tell apart its own normal cells from possible invaders (like bacteria) that might need to be attacked. When you receive a donated organ, specific cells of the immune system may bind to the donated organ and send up an alarm. This can lead to the body attacking the newly donated organ (called “organ rejection”). If this happens, the new organ won’t be able to work properly, and people can get very sick. This is a concern for everybody, except sometimes for people who were able to receive an organ from an identical twin.

To prevent organ rejection, it is necessary to tone down parts of the immune system. This makes it much less likely that the immune system will damage the new organ.

Stronger immunosuppressives might be needed just after an organ transplant. However, people who have had an organ transplant need to continue some combination of immunosuppressive therapies for as long as they live.

Some of the main types of immunosuppressant drugs used for organ transplant are:

  • Calcineurin inhibitors like Prograf (tacrolimus)
  • Antiproliferative agents like CellCept (mycophenolate mofetil)
  • mTOR inhibitors like Rapamune (Sirolimus)
  • Corticosteroids (like prednisone)

Cancer

Cancer is another big category of diseases treated with therapies that affect your immune system. Unlike autoimmune diseases and organ transplantation, suppressing the immune system isn’t the goal in cancer treatment. But immunosuppression is a side effect of many types of cancer treatment, including chemotherapy and radiation treatments. The chemotherapy treatment intended to kill cancerous cells also kills many immune cells, and the remaining immune cells may not work normally. This can leave you vulnerable to infections.

Stem Cell Transplant

Immunosuppressive therapies are also a key part of stem cell transplants. Such transplants may be given for many different types of medical problems. For example, it can be used to treat certain cancers of the blood or bone marrow. However, stem cell transplants are also now used to treat certain rare genetic diseases, like sickle cell anemia.

Before receiving the stem cell transplant, a person is hit heavily with radiation and immunosuppressive therapies to kill off existing stem cells in their bone marrow. During this time, individuals are at a high risk of serious infection. People receiving stem cell transplants also usually need to take life-long immunosuppressive medications, just like people who have received organ transplants.

Picking the Right Immunosuppressant for You

You may have options about the type of immunosuppressant that can be used to treat your health condition. These therapies vary in their risk of side effects, their effectiveness, their cost, mode of administration, and other factors. Talk to your healthcare provider about your options.

Before Taking Immunosuppressant Drugs

You will have a variety of assessments and tests before taking an immunosuppressant drug.

Medical Assessment

Your clinician will need to do a full medical assessment. This may include medical history, exam, laboratory tests, and sometimes medical imaging. This will be tailored to your specific medical situation and the immunosuppressive you are considering. This will help make sure that the risks and benefits of the therapy make sense for you.

Hepatitis Testing

For some immunosuppressive therapies, your clinician will need to screen you for hepatitis B and hepatitis C before you begin. Depending on your risk factors, you might need blood tests to see if you are infected. Some people are infected with either virus without knowing it.

The hepatitis virus may be inactive and not causing you any problems. However, if you start immunosuppressive medication, the virus might start to become more active. In some cases, this might lead to liver damage or even liver failure. So it’s important to make sure that you don’t have these viruses before starting therapy.

Tuberculosis (TB) Testing

Tuberculosis screening is also sometimes done before starting an immunosuppressive treatment. TB is another important infection that many people might not know that they have. When it is inactive, it may not cause any symptoms at all. But if you have inactive tuberculosis and start taking an immunosuppressive, your infection might start to cause you problems.

You may need a blood test or skin prick test to see if you have a dormant tuberculosis infection. If either of these tests is worrisome for tuberculosis, you may need follow up tests, like a chest X-ray. If it turns out that you do have tuberculosis, you will most likely need to receive treatment before you can start your immunosuppressive.

If you have any risk factors for tuberculosis, you may need to have regular screenings as long as you continue your immunosuppressive. For example, this might be the case if you regularly visit a part of the world where a lot of people are still infected with TB.

Vaccine Assessment

Certain vaccines cannot be given safely while a person is taking immunosuppressive therapies. This particularly applies to certain “live” vaccines, vaccines that contain a small amount of weakened, live virus.

For example, it’s recommended that the shingles vaccine not be given to someone who is currently taking certain immunosuppressive drugs. Other important vaccines to assess might be the measles, mumps, and rubella vaccine, which also cannot be taken while on certain immunosuppressives. On the other hand, vaccines, like the pneumococcal vaccine for pneumonia might be able to be safely taken while you are on an immunosuppressive.

Because of this, it’s a good idea to work with your healthcare provider to make sure your vaccines are up to date. If not, you might opt to get fully vaccinated before you begin your therapy.

Side Effects/Risks of Immunosuppressants

Immunosuppressants include a wide variety of therapies, and each specific treatment carries its own particular risk of side effects. Often such side effects are not a big deal, such as mild stomach discomfort. But more serious side effects might also be possible, depending on the therapy involved. For example, some immunosuppressive drugs taken after organ transplantation might increase your risk of getting certain kinds of cancer.

Risk of Infection

Immunosuppressants have one risk in common—people taking these therapies have a greater risk of infections. Often, this risk will increase if a person is taking a higher dose of their treatment.

In some cases, this might result in a minor infection. However, sometimes serious and even life-threatening infections may happen. Taking an immunosuppressant might make you more likely to get sick from a common illness, like a cold.

In some cases, it might make you more likely to get sick from something that usually doesn’t cause people to get sick. For example, you might be more likely to get an unusual pneumonia resulting from a fungal infection. You also may have a harder time recovering from an illness if you do get infected.

Not all immunosuppressive therapies affect the immune system in the same way. Some affect the immune system more strongly than others, which may put you at greater risk of infection. Your immunosuppressant might put you at greater risk of certain types of infections, but not others. For example, you might be at greater risk of bacterial infections but not have much of an increased risk of infections from viruses or parasites.

Your specific risks may vary based on the specific immunosuppressant you are taking, the dosage, and your whole medical situation.

Reducing Infection Risk

Fortunately, there are some steps that can help you lower your risk of infection while taking an immunosuppressant. These tips may also be helpful for people who have reduced ability to fight off infections from another cause, like certain genetic illnesses or HIV.

  • Wash your hands frequently and often. Use soap and water for at least 20 seconds. Wash before eating and preparing food, after using the bathroom, gardening, or touching animals.
  • Wash and cook your food well.
  • Avoid touching pet feces. (Use gloves if necessary).
  • Avoid people who have active infections.
  • Get all vaccinations recommended by your clinician.
  • Adopt healthy habits. Getting enough sleep, exercising regularly, and eating a healthy diet may help you lower your risk of a serious illness.

Preventing Infection During the COVID-19 Pandemic

People who are taking immunosuppressive therapies may be more likely to have severe and even life-threatening disease from COVID-19. Such people may need extra precautions, such as the following:

  • Avoiding leaving the home, except when necessary.
  • Washing hands well after being in a public place.
  • Covering face and nose with a cloth face covering when in public.
  • Practicing social distancing by staying at least 6 feet away from people not in their household.
  • Regularly cleaning surfaces that are frequently touched (such as doorknobs)

The Centers for Disease Control and your local health department can continue to provide you with up-to-date guidance.

If you are taking an immunosuppressive therapy, it may be worth talking about your current treatment with your doctor. For some immunosuppressive therapies, an increased dose might increase your risk of having severe complications from COVID-19. However, it is not completely straightforward. Some immunosuppressive therapies are actually being studied as possible treatments for some severe symptoms of COVID-19 (such as cytokine storm).

However, do not stop taking your immunosuppressive therapies without talking to your doctor. For many people, this would be a much greater medical risk. Instead, you can have a conversation about whether lowering your current dosage of your immunosuppressant (or switching to another treatment) might make sense for you.

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