Overview of immunosuppression in liver transplantation

Table 1 Drugs that increase CNI and sirolimus levels

Drugs that increase CNI levels

Macrolides: clarithromycin, erythromycin, azithromycin

Antifungals: fluconazole, itraconazole, ketoconazole, voriconazole, clotrimazole

Calcium channel blockers: verapamil, diltiazem, nifedipine

Others: cisapride, metaclopramide, amiodarone, cimetidine, protease inhibitors

Drugs that decrease CNI and sirolimus levels

Antibiotics: rifabutin, rifampin

Anticonvulsants: carbamazepine, phenobarbital, phenytoin, fosphenytoin

Others: St. John’s Wort

CNI: Calcineurin inhibitor.

Table 2 Common side effects of immunosuppressive agents

Drug	Adverse effects
Tacrolimus	Nephrotoxicity, neurotoxicity1, diabetes1, hyperkalemia, metabolic acidosis, hypertension, hyperlipidemia
Cyclosporine	Nephrotoxicity, neurotoxicity, diabetes, hyperlipidemia1, hypertension1, hyperkalemia, metabolic acidosis, gingival hyperplasia, hypertrichosis
MMF	Myelosuppression, gastrointestinal side effects, viral infections (CMV, HSV), spontaneous abortions in pregnant women
Sirolimus	Hyperlipidemia, myelosuppression, proteinuria, poor wound healing, pneumonitis, skin rash
Corticosteroids	Diabetes, hypertension, obesity, osteoporosis, avascular necrosis, growth retardation, Cushingoid features, psychosis, poor wound healing, adrenal suppression, cataracts

¹More common in respective agent. MMF: Mycophenolate mofetil; CMV: Cytomegalovirus; HSV: Herpes simplex virus.