Atgam

Other Immunosuppressants

 
Skin Test (Atgam)
Skin testing is recommended to identify patients at greatest risk for anaphylaxis.
A conservative, conventional approach is to use an epicutaneous (prick) test with undiluted Atgam. If the subject does not show a wheal 10 minutes after pricking, proceed to intradermal testing.
Use an intradermal injection of 0.02 mL of a 1:1,000 dilution of Atgam in 0.9% Sodium Chloride Injection. A control of 0.9% Sodium Chloride Injection should be placed as well.
Read the result at 10 minutes. A wheal at the Atgam site of 3 mm or more in diameter than that at the saline control site (or a positive prick test) suggests clinical sensitivity and an increased possibility of a systemic allergic reaction with intravenous administration. If the test is positive, consider alternative treatments. A risk to benefit ratio should be considered. If ATG is deemed appropriate to administer to a patient with a locally positive skin test, the presence of a physician who is familiar with the treatment of potentially life threatening allergic reactions is advised. Also, administer in a setting where intensive life support facilities are immediately available.
Desensitization protocol: A 4 year-old, with an immediate 14 mm wheal and flare acute hypersensitivity reaction without wheezing or difficulty breathing after the skin test, successfully received 40 mg/kg/day IV of equine ATG for 4 days by gradual dose escalation. After treatment with diphenhydramine 1 mg/kg IV and methylprednisolone sodium succinate 2 mg/kg IV, he received equine ATG 0.1 mcg, 1 mcg, 10 mcg, and 100 mcg IV at 15 minute intervals; vital signs were checked before the first dose and every 5 minutes. An infusion of equine ATG 0.16 mg/minute IV over 10 minutes was administered; vital signs were continuously monitored. Over the next 4 days, he received 40 mg/kg IV equine ATG at a concentration of 1 mg/mL plus methylprednisolone sodium succinate 55 mg. Thirty minutes before each full dose, he was given acetaminophen 15 mg/kg and diphenhydramine 1 mg/kg. Infusion rate reduction from 69 mL/hour and diphenhydramine and acetaminophen administration resolved hypersensitivity reactions of shivering, wheals, and hives that occurred on days 1 and 2. The methylprednisolone dose was tapered over 2 weeks.

Only administer under the supervision of a physician experienced with immunosuppressive therapy. Patients receiving antithymocyte globulin (ATG) should be treated in facilities equipped and staffed with adequate medical and life-support equipment.
Do not shake diluted or undiluted ATG because excessive foaming and/or denaturing of the protein may occur.
Visually inspect the dilution for particulate matter and discoloration before administration. Atgam can be transparent to slightly opalescent, colorless to faintly pink or brown, and may develop a slight granular or flaky deposit during storage.

Dilution (Atgam)
Dilute Atgam in an inverted glass bottle of 0.9% Sodium Chloride Injection, 5% Dextrose and 0.225% Sodium Chloride Injection, or 5% Dextrose and 0.45% Sodium Chloride Injection, so the undiluted solution does not contact the air inside. Add the total daily dose to the sterile vehicle. Gently rotate or swirl to mix; do not shake. The final concentration should not exceed 4 mg/mL.
It is not recommended to use dextrose solutions to dilute Atgam, as the low salt concentration can cause precipitation.
Store diluted solutions at room temperature. The diluted solution must be infused within 24 hours including infusion time.
 
Intravenous infusion (Atgam)
Allow the infusion to come to room temperature prior to infusing.
Infuse the first dose after negative skin test results obtained.
Administer through a vascular shunt, arterial-venous fistula, or a high-flow central vein using an in-line 0.22- to 1-micron filter. Infuse over at least 4 hours.
Closely observe the patient for any signs of an allergic reaction. Keep appropriate resuscitation equipment at the patient's bedside during the infusion.
 
Reconstitution and Dilution (Thymoglobulin)
Allow Thymoglobulin and diluent to come to room temperature prior to reconstituting the powder.
Reconstitute each vial with 5 mL of Sterile Water for Injection. Gently rotate the vial until powder is dissolved; final concentration is 5 mg/mL. If particulate matter persists, discard the vial.
Thymoglobulin may be diluted in 5% Dextrose Injection or 0.9% Sodium Chloride Injection.
Transfer the contents of the calculated number of Thymoglobulin vials into a bag of infusion solution. The recommended volume of infusion solution is 50 mL of infusion solution per each vial of drug. Final total volume of the diluted solution is typically 50 to 500 mL with a final concentration of 0.5 mg/mL. Mix the solution by inverting the bag gently once or twice. Do not shake.
Infusion solutions should be used immediately; no preservatives are in the vials. Discard any unused drug.
 
Intravenous infusion (Thymoglobulin)
Skin testing is not recommended for Thymoglobulin.
Premedication with corticosteroids, acetaminophen, and antihistamines 1 hour prior to each infusion is recommended and may reduce the incidence of infusion-related adverse reactions.
Infuse the first dose over at least 6 hours into a high-flow vein using an in-line 0.22-micron filter. Subsequent doses should be infused over at least 4 hours.
Closely observe the patient for any signs of an allergic reaction. Keep appropriate resuscitation equipment at the patient's bedside during the infusion.

hyperkalemia / Delayed / 27.0-57.0
serum sickness / Delayed / 0.6-2.0
bradycardia / Rapid / 1.5-1.5
anaphylactic shock / Rapid / 0-1.0
seizures / Delayed / 0.8-0.8
pleural effusion / Delayed / 0.8-0.8
toxic epidermal necrolysis / Delayed / 0.2-0.2
anaphylactoid reactions / Rapid / 0.2-0.2
laryngospasm / Rapid / 0.2-0.2
pulmonary edema / Early / 0.2-0.2
serious hypersensitivity reactions or anaphylaxis / Rapid / Incidence not known
hemolytic anemia / Delayed / Incidence not known
pancytopenia / Delayed / Incidence not known
cytokine release syndrome / Rapid / Incidence not known
acute respiratory distress syndrome (ARDS) / Early / Incidence not known
new primary malignancy / Delayed / Incidence not known
post-transplant lymphoproliferative disorder (PTLD) / Delayed / Incidence not known
GI bleeding / Delayed / Incidence not known
GI perforation / Delayed / Incidence not known
heart failure / Delayed / Incidence not known
apnea / Delayed / Incidence not known
vasculitis / Delayed / Incidence not known
thrombosis / Delayed / Incidence not known
coagulopathy / Delayed / Incidence not known
disseminated intravascular coagulation (DIC) / Delayed / Incidence not known
renal failure (unspecified) / Delayed / Incidence not known
myocardial infarction / Delayed / Incidence not known

antibody formation / Delayed / 68.0-78.0
leukopenia / Delayed / 17.9-63.0
thrombocytopenia / Delayed / 16.0-37.0
hypertension / Early / 2.9-37.0
constipation / Delayed / 15.0-33.0
dyspnea / Early / 1.1-28.0
anemia / Delayed / 12.0-25.0
sinus tachycardia / Rapid / 1.1-23.0
peripheral edema / Delayed / 20.0-20.0
hypotension / Rapid / 2.9-16.0
hyperlipidemia / Delayed / 15.0-15.0
hypokalemia / Delayed / 6.0-12.0
chest pain (unspecified) / Early / 2.7-9.0
hyperphosphatemia / Delayed / 7.0-7.0
candidiasis / Delayed / 6.0-6.0
hypophosphatemia / Delayed / 6.0-6.0
phlebitis / Rapid / 3.2-3.2
lymphadenopathy / Delayed / 1.3-1.3
elevated hepatic enzymes / Delayed / 1.0-1.0
stomatitis / Delayed / 0.6-0.6
hyperglycemia / Delayed / 0.6-0.6
proteinuria / Delayed / 0.4-0.4
dyskinesia / Delayed / Incidence not known
flank pain / Delayed / Incidence not known
hemolysis / Early / Incidence not known
eosinophilia / Delayed / Incidence not known
neutropenia / Delayed / Incidence not known
hepatitis / Delayed / Incidence not known
edema / Delayed / Incidence not known
infusion-related reactions / Rapid / Incidence not known

infection / Delayed / 0-76.0
chills / Rapid / 9.0-57.0
fever / Early / 13.0-46.0
headache / Early / 5.3-40.0
abdominal pain / Early / 2.7-38.0
nausea / Early / 4.2-37.0
rash / Early / 13.0-25.6
insomnia / Early / 12.0-20.0
diarrhea / Early / 2.9-20.0
vomiting / Early / 3.4-20.0
arthralgia / Delayed / 14.0-17.2
anxiety / Delayed / 7.0-14.0
diaphoresis / Early / 6.0-13.0
leukocytosis / Delayed / 13.0-13.0
asthenia / Delayed / 0.4-13.0
malaise / Early / 4.0-13.0
acne vulgaris / Delayed / 12.0-12.0
myalgia / Early / 11.0-11.0
dyspepsia / Early / 10.0-10.0
urticaria / Rapid / 9.2-9.2
cough / Delayed / 7.0-7.0
pruritus / Rapid / 4.6-6.0
anorexia / Delayed / 6.0-6.0
back pain / Delayed / 1.5-1.5
dizziness / Early / 1.1-1.1
night sweats / Early / 0.8-0.8
agitation / Early / 0.4-0.4
hiccups / Early / 0.4-0.4
paresthesias / Delayed / 0.2-0.2
tremor / Early / Incidence not known
syncope / Early / Incidence not known
injection site reaction / Rapid / Incidence not known
lethargy / Early / Incidence not known
hyperhidrosis / Delayed / Incidence not known
restlessness / Early / Incidence not known
epistaxis / Delayed / Incidence not known

Antithymocyte globulin (ATG) therapy requires an experienced clinician. Only clinicians experienced in immunosuppressant therapy and organ transplantation should use ATG. Increased susceptibility to infection and possible development of neoplastic disease, especially lymphoma, may result from combination immunosuppression. ATG (equine) therapy requires a specialized care setting. Patients receiving ATG should be managed in facilities equipped and staffed with adequate laboratory and supportive medical services. Bacterial, viral, protozoal, or fungal infection occurs commonly during immunosuppressive therapy and can be fatal. Thymoglobulin is contraindicated in patients who have active acute or chronic infections that contraindicate any additional immunosuppression. Prophylactic antiviral therapy is recommended. One study has suggested an increased incidence of cytomegalovirus in patients receiving equine ATG. It may be possible to decrease this risk by decreasing the dose of other immunosuppressive agents administered concomitantly. Reactivation of a latent viral infection, especially herpes infection or varicella, can occur with immunosuppressive therapy. As with other products derived from or purified with human blood components, the possibility of transmission of infection exists in patients receiving ATG. Patients should be instructed to promptly report signs of infection.

Atgam, Thymoglobulin

Rx

Immunosuppressant, polyclonal IgG against human T-lymphocytes derived from horses (Atgam) or rabbits (Thymoglobulin)
Used for kidney organ transplant rejection, organ transplant rejection prophylaxis, and moderate to severe aplastic anemia
Risk of serious hypersensitivity reactions, including anaphylaxis or cytokine release syndrome (CRS)

Specific guidelines for dosage adjustments in hepatic impairment are not available; it appears that no dosage adjustments are needed.

Specific guidelines for dosage adjustments in renal impairment are not available; it appears that no dosage adjustments are needed.

Abatacept: (Moderate) Concomitant use of immunosuppressives may potentially increase the risk of serious infection in abatacept treated patients. Advise patients taking abatacept to seek immediate medical advice if they develop signs and symptoms suggestive of infection.
Adalimumab: (Moderate) The safety and efficacy of adalimumab in patients with immunosuppression have not been evaluated. Patients receiving immunosuppressives along with adalimumab may be at a greater risk of developing an infection. Many of the serious infections occurred in patients on immunosuppressive therapy that received adalimumab.
Albuterol; Budesonide: (Moderate) Because systemically administered corticosteroids exhibit immunosuppressive effects when given in high doses and/or for extended periods, additive effects may be seen with other immunosuppressives or antineoplastic agents.
Aldesleukin, IL-2: (Moderate) Because antithymocyte globulin is an immunosuppressant, additive affects may be seen with other immunosuppressives or antineoplastic agents. While therapy is designed to take advantage of this effect, patients may be predisposed to over-immunosuppression resulting in an increased risk of infection or other side effects.
Azelastine; Fluticasone: (Moderate) Because systemically administered corticosteroids exhibit immunosuppressive effects when given in high doses and/or for extended periods, additive effects may be seen with other immunosuppressives or antineoplastic agents.
Bacillus Calmette-Guerin Vaccine, BCG: (Contraindicated) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
Beclomethasone: (Moderate) Because systemically administered corticosteroids exhibit immunosuppressive effects when given in high doses and/or for extended periods, additive effects may be seen with other immunosuppressives or antineoplastic agents.
Belatacept: (Moderate) Coadministration at the same time or nearly the same time of belatacept and anti-thymocyte immune globulin in patients with other predisposing risk factors for venous thrombosis of the renal allograft may pose a risk for venous thrombosis of the renal allograft.
Betamethasone: (Moderate) Because systemically administered corticosteroids exhibit immunosuppressive effects when given in high doses and/or for extended periods, additive effects may be seen with other immunosuppressives or antineoplastic agents.
Bortezomib: (Moderate) Because antithymocyte globulin is an immunosuppressant, additive effects may be seen with other immunosuppressives or antineoplastic agents. While therapy is designed to take advantage of this effect, patients may be predisposed to over-immunosuppression resulting in an increased risk of infection or other side effects. Some protocols recommend decreasing the dosage of the standard immunosuppressive agents during treatment with antithymocyte globulin. Carefully observe patients for new adverse effects if the dose of immunosuppressants is reduced, as adverse effects of antithymocyte globulin may have been masked.
Budesonide: (Moderate) Because systemically administered corticosteroids exhibit immunosuppressive effects when given in high doses and/or for extended periods, additive effects may be seen with other immunosuppressives or antineoplastic agents.
Budesonide; Formoterol: (Moderate) Because systemically administered corticosteroids exhibit immunosuppressive effects when given in high doses and/or for extended periods, additive effects may be seen with other immunosuppressives or antineoplastic agents.
Budesonide; Glycopyrrolate; Formoterol: (Moderate) Because systemically administered corticosteroids exhibit immunosuppressive effects when given in high doses and/or for extended periods, additive effects may be seen with other immunosuppressives or antineoplastic agents.
Certolizumab pegol: (Moderate) The safety and efficacy of certolizumab in patients with immunosuppression have not been evaluated. Patients receiving immunosuppressives along with certolizumab may be at a greater risk of developing an infection. Many of the serious infections occurred in patients on immunosuppressive therapy who received certolizumab.
Cholera Vaccine: (Moderate) Patients receiving immunosuppressant medications may have a diminished response to the live cholera vaccine. When feasible, administer indicated vaccines prior to initiating immunosuppressant medications. Counsel patients receiving immunosuppressant medications about the possibility of a diminished vaccine response and to continue to follow precautions to avoid exposure to cholera bacteria after receiving the vaccine.
Ciclesonide: (Moderate) Because systemically administered corticosteroids exhibit immunosuppressive effects when given in high doses and/or for extended periods, additive effects may be seen with other immunosuppressives or antineoplastic agents.
Corticosteroids: (Moderate) Because systemically administered corticosteroids exhibit immunosuppressive effects when given in high doses and/or for extended periods, additive effects may be seen with other immunosuppressives or antineoplastic agents.
Cortisone: (Moderate) Because systemically administered corticosteroids exhibit immunosuppressive effects when given in high doses and/or for extended periods, additive effects may be seen with other immunosuppressives or antineoplastic agents.
Deflazacort: (Moderate) Because systemically administered corticosteroids exhibit immunosuppressive effects when given in high doses and/or for extended periods, additive effects may be seen with other immunosuppressives or antineoplastic agents.
Dexamethasone: (Moderate) Because systemically administered corticosteroids exhibit immunosuppressive effects when given in high doses and/or for extended periods, additive effects may be seen with other immunosuppressives or antineoplastic agents.
Fludrocortisone: (Moderate) Because systemically administered corticosteroids exhibit immunosuppressive effects when given in high doses and/or for extended periods, additive effects may be seen with other immunosuppressives or antineoplastic agents.
Flunisolide: (Moderate) Because systemically administered corticosteroids exhibit immunosuppressive effects when given in high doses and/or for extended periods, additive effects may be seen with other immunosuppressives or antineoplastic agents.
Fluticasone: (Moderate) Because systemically administered corticosteroids exhibit immunosuppressive effects when given in high doses and/or for extended periods, additive effects may be seen with other immunosuppressives or antineoplastic agents.
Fluticasone; Salmeterol: (Moderate) Because systemically administered corticosteroids exhibit immunosuppressive effects when given in high doses and/or for extended periods, additive effects may be seen with other immunosuppressives or antineoplastic agents.
Fluticasone; Umeclidinium; Vilanterol: (Moderate) Because systemically administered corticosteroids exhibit immunosuppressive effects when given in high doses and/or for extended periods, additive effects may be seen with other immunosuppressives or antineoplastic agents.
Fluticasone; Vilanterol: (Moderate) Because systemically administered corticosteroids exhibit immunosuppressive effects when given in high doses and/or for extended periods, additive effects may be seen with other immunosuppressives or antineoplastic agents.
Formoterol; Mometasone: (Moderate) Because systemically administered corticosteroids exhibit immunosuppressive effects when given in high doses and/or for extended periods, additive effects may be seen with other immunosuppressives or antineoplastic agents.
Golimumab: (Moderate) The safety and efficacy of golimumab in patients with immunosuppression have not been evaluated. Patients receiving immunosuppressives along with golimumab may be at a greater risk of developing an infection.
Hydrocortisone: (Moderate) Because systemically administered corticosteroids exhibit immunosuppressive effects when given in high doses and/or for extended periods, additive effects may be seen with other immunosuppressives or antineoplastic agents.
Infliximab: (Moderate) Many serious infections during infliximab therapy have occurred in patients receiving concurrent immunosuppressives that, in addition to their underlying Crohn's disease or rheumatoid arthritis, predisposes patients to infections.
Interferon Gamma-1b: (Moderate) Caution is advised with the concomitant use of antithymocyte globulin and interferon gamma-1b as an additive risk of bleeding may occur. Interferon gamma-1b can cause severe, reversible neutropenia and thrombocytopenia that may be dose-related.
Intranasal Influenza Vaccine: (Contraindicated) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
Live Vaccines: (Contraindicated) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
Measles Virus; Mumps Virus; Rubella Virus; Varicella Virus Vaccine, Live: (Contraindicated) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
Measles/Mumps/Rubella Vaccines, MMR: (Contraindicated) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
Methylprednisolone: (Moderate) Because systemically administered corticosteroids exhibit immunosuppressive effects when given in high doses and/or for extended periods, additive effects may be seen with other immunosuppressives or antineoplastic agents.
Mometasone: (Moderate) Because systemically administered corticosteroids exhibit immunosuppressive effects when given in high doses and/or for extended periods, additive effects may be seen with other immunosuppressives or antineoplastic agents.
Olopatadine; Mometasone: (Moderate) Because systemically administered corticosteroids exhibit immunosuppressive effects when given in high doses and/or for extended periods, additive effects may be seen with other immunosuppressives or antineoplastic agents.
Penicillamine: (Major) Agents such as immunosuppressives have adverse reactions similar to those of penicillamine. Concomitant use of penicillamine with these agents is contraindicated because of the increased risk of developing severe hematologic and renal toxicity.
Platelet Inhibitors: (Moderate) An increased risk of bleeding may occur when platelet inhibitors are used with agents that cause clinically significant thrombocytopenia, such as antithymocyte globulin. Platelet inhibitors should be used cautiously in patients with thrombocytopenia following the administration of antithymocyte globulin or other drugs that cause significant thrombocytopenia due to the increased risk of bleeding.
Prednisolone: (Moderate) Because systemically administered corticosteroids exhibit immunosuppressive effects when given in high doses and/or for extended periods, additive effects may be seen with other immunosuppressives or antineoplastic agents.
Prednisone: (Moderate) Because systemically administered corticosteroids exhibit immunosuppressive effects when given in high doses and/or for extended periods, additive effects may be seen with other immunosuppressives or antineoplastic agents.
Rilonacept: (Moderate) Patients receiving immunosuppressives along with rilonacept may be at a greater risk of developing an infection.
Rotavirus Vaccine: (Contraindicated) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
SARS-CoV-2 (COVID-19) vaccines: (Moderate) Patients receiving immunosuppressant medications may have a diminished response to the SARS-CoV-2 virus vaccine. When feasible, administer indicated vaccines prior to initiating immunosuppressant medications. Counsel patients receiving immunosuppressant medications about the possibility of a diminished vaccine response and to continue to follow precautions to avoid exposure to SARS-CoV-2 virus after receiving the vaccine.
Sipuleucel-T: (Major) Concomitant use of sipuleucel-T and immunosuppressives should be avoided. Concurrent administration of immunosuppressives with the leukapheresis procedure that occurs prior to sipuleucel-T infusion has not been studied. Sipuleucel-T stimulates the immune system and patients receiving immunosuppressives may have a diminished response to sipuleucel-T. When appropriate, consider discontinuing or reducing the dose of immunosuppressives prior to initiating therapy with sipuleucel-T.
Smallpox and Monkeypox Vaccine, Live, Nonreplicating: (Contraindicated) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
Smallpox Vaccine, Vaccinia Vaccine: (Contraindicated) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
Triamcinolone: (Moderate) Because systemically administered corticosteroids exhibit immunosuppressive effects when given in high doses and/or for extended periods, additive effects may be seen with other immunosuppressives or antineoplastic agents.
Typhoid Vaccine: (Contraindicated) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
Upadacitinib: (Major) Do not use upadacitinib in combination with potent immunosuppressants such as anti-thymocyte immune globulin. A risk of added immunosuppression exists when upadacitinib is coadministered with potent immunosuppressives. Combined use of multiple-dose upadacitinib with potent immunosuppressives has not been studied.
Varicella-Zoster Virus Vaccine, Live: (Contraindicated) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
Yellow Fever Vaccine, Live: (Contraindicated) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.

Atgam Intravenous Inj Sol: 1mL, 50mg
Thymoglobulin Intravenous Inj Pwd F/Sol: 25mg

1.5 mg/kg/day IV for Thymoglobulin; 30 mg/kg/day IV for Atgam.

1.5 mg/kg/day IV for Thymoglobulin; 30 mg/kg/day IV for Atgam.

Safe and effective use has not been established for Thymoglobulin; 25 mg/kg/day IV for Atgam.

Safe and effective use has not been established for Thymoglobulin; 25 mg/kg/day IV for Atgam.

Antithymocyte globulin (ATG) is a potent immunosuppressant. Although T-lymphocyte depletion is the primary means, the full mechanism by which ATG suppresses immune responses is not completely understood. ATG induces lymphocyte depletion in the periphery by complement-dependent cell lysis. Lymphocyte depletion may also result from antibody-mediated cytotoxicity and activation-induced apoptosis. T-cells are also depleted in secondary lymphoid tissues. Dose dependent depletion of CD2, CD3, CD4, CD8, CD20, and CD56 lymphocyte subsets has occurred. T-cell depletion is usually observed within a day following initiation. At certain concentrations, ATG may activate T-cells resulting in the synthesis of pro-inflammatory cytokines such as interleukin-2, interferon-gamma, and tumor necrosis factor-alpha. There appears to be a balance between the activating, co-activating, and inhibitory antibody specificities in ATG. Apoptosis in B-cell lineages, interference with dendritic cell function, and induction of regulatory T and natural killer cells has been observed. Additionally, equine ATG directly stimulates the growth of hematopoietic stem cells and the release of hematopoietic growth factors such as interleukin-3 and granulocyte/macrophage colony stimulating factor.

Antithymocyte globulin (ATG) is administered intravenously. Following administration, there is a short distribution phase that lasts approximately 8 hours. Reported mean elimination half-lives for rabbit immunoglobulin (IgG) are 2 to 3 days after first dose and 35.5 days after a 10-day course. The elimination half-life for equine IgG is 5.7 +/- 3 days (range 1.5 to 13 days) in renal transplant patients. Pharmacokinetic activity of the subset of IgG with relevant antilymphocyte activity within the antithymocyte globulin dose may exhibit different pharmacokinetic properties, perhaps partially arising from rapid elimination associated with antigen binding. Reductions in lymphocyte count begin within 24 hours after administration of rabbit antithymocyte globulin and absolute lymphocyte reductions have been demonstrated to persist for up to 1-year in renal transplant patients.

During treatment of acute renal allograft rejection, peak plasma concentrations of rabbit IgG of 87 mcg/mL (23 to 170 mcg/mL) after the last dose have been reported. Following doses of 10 to 15 mg/day, mean peak plasma equine IgG concentrations were 727 +/- 310 mcg/mL and weakly correlated to the total ATG dose.

Administer antithymocyte globulin (ATG) during pregnancy only if the potential benefit justifies the potential risk to the fetus. There are no adequate and well controlled studies of ATG in pregnant women. It is not known if ATG can cause fetal harm if administered to a pregnant woman or if ATG affects reproductive capacity. At a dose up to 20 mg/kg, Atgam was not teratogenic in rats or monkeys; however, Atgam 20 mg/kg/day for 16 days during organogenesis was fetotoxic in monkeys. No maternal or fetal toxicity was observed with Atgam 10 mg/kg/day for 16 days during organogenesis.

It is not known if antithymocyte globulin (ATG) is excreted in breast milk. Because other immunoglobulins and many drugs are excreted into human breast milk and because of the potential for serious adverse reactions in the breast-feeding infant from ATG, discontinue breast-feeding or discontinue ATG taking into consideration the importance of the drug to the mother.