Immunosuppressive therapy evaluation

Lewis R, Canafax D, Pettit K, et al. Use of Markov model for evaluating the cost-effectiveness of immunosuppressive therapies in renal transplant recipients. Transpl Proc 1996 28 2214-17. 

Serious life-threatening infections, including sepsis and pneumonia, have been reported with the use of TNF inhibitors. Patients should be evaluated for tuberculosisrisk factors and tested for latent tuberculosis infection prior to starting therapy. Concurrent use with other immunosuppressive therapy should be avoided. In clinical trials of all TNF-blocking agents more cases of lymphoma were observed compared with control patients. Patients with a prior history of prolonged phototherapy treatment should be monitored for nonmelanoma skin cancers. 

Severe neurological involvement in SLE particularly during acute onset is a particularly devastating diagnosis. Management of CNS SLE is reviewed by Sanna et al., 2003a. Cyclophosphamide is the treatment of choice for severe acute non-thrombotic CNS disease. Treatment with steroids versus immunosuppressant therapy with cyclophosphamide is evaluated in a controlled clinical trial of 32 SLE patients with onset of severe neuropsychiatric involvement for < 15 days. Induction treatment involved IV methylprednisolone (3 g) followed by either IV monthly cyclophosphamide or IV MP every 3 m for 1 year. Overall response rate was 75% for either treatment but those on cyclophosphamide had a significandy better response to treatment (p < 0.03) (Barile-Fabris et al., 2005). 

Randomized controlled trials of azathioprine, methotrexate, cladribine, intravenous immunoglobulin and cyclophosphamide have not shovm definite modification to the aggressive course of PP MS (Leary and Thompson, 2005). However, these immunosuppressant therapies continue to be evaluated in patients with active aggressive MS. 

Note TNF blocking agents may lead to serious infections, lymphoma, or fatalities, particularly in patients receiving concomitant immunosuppressive therapy. Patients should be evaluated for latent tuberculosis prior to treatment with adalimumab. 

REFRACTORY CELIAC DISEASE Recently, immunohistochemistry has been shown to have utility in the evaluation of patients with refractory celiac disease. These patients continue to suffer from symptoms despite adherence to a gluten-free diet and are more likely to develop further complications such as ulcerative jejunoileitis and enteropathy-associated T-cell lymphoma. The group of patients with refractory sprue and loss of CDS expression in more than 50% of the CD3-positive intraepithelial lymphocytes are more likely to develop enteropathy-associated T-cell lymphoma. These patients with an abnormal T-cell phenotype are more likely to receive more aggressive immunosuppressive therapy. 

Clinically, the most common symptoms include dyspnea and pleuritic chest pain (38). Chest radiography reveals elevated hemidiaphragms. Some improvement has been noted using inhaled p agonists and theophylUine. A more global evaluation of SLE disease activity usually leads to an increase in immunosuppressive therapy using corticosteroids, methotrexate, cyclosporine, mycophenalate, cyclophosphamide, or azathioprine, with subsequoit improvement in symptoms (38). 

Concerns regarding potential HPV vaccine safety in systemic lupus erythematosus (SLE) patients were addressed by a prospective case-control study which evaluated the quadrivalent HPV vaccine. Fifty SLE patients were compared to 50 healthy controls. Importantly, no increase in SLE disease activity was observed in the 12-month follow-up period. However, seroconversion rates of antibodies to HPV serotypes (6,11,16 and 18) for the SLE group were lower than the control group, and the role of immunosuppressive therapy in SLE needs furtiier investigation [11 ]. 

The principal cause of graft loss after the first year is chronic allograft nephropathy (CAN), followed by patient death, late acute rejections, nephropathy recurrence and polyomavirus infection (Hariharan 2001). However, prolongation of graft survival also means extended exposure of the patient to side-effects associated with immunosuppressive therapies, mainly infections and cancers, and other late-onset cardiovascular, bone and/or metabolic complications. The first year after transplantation is special, as it is characterized by the highest rates of acute rejection and opportunistic infections, such as cytomegalovirus. In this review, we successively address the presurgical evaluation of the patient, the operation itself and its possible complications, then the early (first year) and late (after the first year) medical complications. 

Patients with CD are at high risk for disease relapse after induction of remission. Within 2 years, up to 80% of patients suffer a relapse therefore, most patients should be evaluated for indefinite maintenance therapy. Maintenance of remission of CD may be achieved with oral or topical aminosalicylate derivatives, immunosuppressants (such as azathioprine, 6-mercaptopurine, and methotrexate), or infliximab. 

Assess the patient s symptoms to determine if selftreatment with OTC antifungal therapy is appropriate or whether the patient should be evaluated by a practitioner. Exclusions for self-treatment include infection of nails or hair, unsuccessful initial treatment, worsening condition, signs of secondary bacterial or systemic infection, or chronic medical conditions such as diabetes, immunosuppression, or impaired circulation. 

Each of the collagen-vascular diseases has its own recommended form of therapy. For most of these diseases, there are few well-controlled clinical trials evaluating pharmacotherapy. Treatment of most of these diseases requires anti-inflammatory or immunosuppressive drugs. Monitoring therapeutic outcomes is essential because drugs and drug doses may need to be modified frequently. 

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