Benefits and Risks of Immunosuppressive Drugs

Immunosuppressive drugs and therapies block parts of the immune system to treat autoimmune diseases and prevent rejection of a transplanted organ.

Known as “immunosuppressants," these treatments include traditional pharmaceutical drugs and biologics, 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, but they also pose the risk of medical complications, including infections.

This article explains the benefits and risks of immunosuppressants and types of treatments.

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.

Benefits of Immunosuppressants for Autoimmune Disease

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. For example, studies have focused on specific drugs used to treat conditions linked to T cell-related inflammation, such as:

• Psoriasis
• Crohn's disease
• Multiple sclerosis
• Rheumatoid arthritis
• Ulcerative colitis

Other autoimmune conditions treated with immunosuppressive therapies include lupus, Sjögren’s disease, and vasculitis. Some of the immunosuppressive therapies to treat autoimmune disease are traditional pharmaceutical drugs, like Plaquenil (hydroxychloroquine). Examples include:

• Corticosteroids (like prednisone)
• Methotrexate
• Imuran (azathioprine)
• Cyclosporine

More recently, biologic therapies for psoriasis and other conditions 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)

Other biologics block T cell activity, like Orencia (abatacept). They include JAK inhibitors, like Xeljanx (tofacitinib), and B-cell biologics 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.

Benefits of Immunosuppressants for Organ Transplants

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

The immune system often attacks perceived threats, like bacteria, and organ rejection is possible when it recognizes the donated organ as foreign to its own cells and tissues. This is a common concern, with strong immunosuppressive drugs limiting the response as part of treatment after an organ transplant.

After the transplant, people typically receive lifelong treatment with immunosuppressives. Some of the main types of immunosuppressant drugs used for organ transplant include:

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

Benefits of Immunosuppressants for Cancer Treatment

Cancer is another large 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.

However, 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.

Benefits of Immunosuppressants for Stem Cell Transplants

Immunosuppressive therapies are also a key part of stem cell transplants used to treat blood and bone marrow cancers, as well as other conditions like sickle cell disease.

People receiving stem cell transplants are at high risk of infection due to their treatment. They also may experience graft-versus-host-disease, a complication that can have various effects on the body when the immune system rejects the cells.

People receiving stem cell transplants also usually need to take life-long immunosuppressive medications, just like people who have received organ transplants.

Before Taking Immunosuppressive 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, which may include a medical history, exam, laboratory tests, and sometimes medical imaging. This will be tailored to your specific medical situation and the immunosuppressive you are considering to help ensure that the therapy's risks and benefits 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. Thus, 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. Inactive tuberculosis may not cause symptoms, but problems can arise if you start taking an immunosuppressive and have an infection.

An initial blood test or skin prick test for tuberculosis may require 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.

Research studies report complications with varicella and other vaccines when someone is currently taking certain immunosuppressive drugs. They include the measles, mumps, and rubella (MMR) 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. Talk with your healthcare provider to make sure your vaccines are up to date and what may not be safe for you. You might opt to get fully vaccinated before you begin a therapy.

Risk of Infection With Immunosuppressive Drugs and Therapies

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.

Or, 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.

How to Reduce the Risk of Infection

Fortunately, there are some steps that can help you lower your risk of infection while taking an immunosuppressant. These tips can help people during cancer treatment.

They may also be helpful for people who have reduced ability to fight off infections from another cause, like human immunodeficiency virus (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.

You also should know the signs of infection, such as a fever, and let your healthcare provider know if you have symptoms.

Summary

Immunosuppressant drugs offer benefits in treating health conditions driven by immune system activity, including lupus or psoriasis. They include the common use of drugs like prednisone or Methotrexate, as well as newer biologics like Humira (adalimumab) and Truxima (rituximab).

Although they can help to prevent organ transplant rejection or improve cancer care, they also have side effects and risks. You may need to be tested for certain health conditions before starting an immunosuppressant drug, and they can increase your risk of infection when taking them.

Talk to your healthcare provider about whether they recommend immunosuppressant drug treatment and how to evaluate the benefits and risks.