When Drugs Run Out: Tolerability of Mycophenolate Mofetil and Azathioprine in Lung Transplant Recipients over the Age of Sixty
Pharmacy, Emory University Hospital, Atlanta, NC
Pharmacy, Duke University Hospital, Durham, NC
Meeting: 2013 American Transplant Congress
Abstract number: B906
Triple-drug therapy with tacrolimus, azathioprine (AZA), and prednisone is the standard immunosuppression protocol for lung transplant at Duke University Hospital (DUH). The recent shortage of intravenous AZA resulted in a switch to mycophenolate mofetil (MMF). Furthermore, limited data exists regarding the tolerance of these agents in the elderly. The primary objective of this study was to describe the incidence of intolerance to either MMF or AZA at 3 months post-transplant in patients over the age of sixty.
Methods:
This was a single center, retrospective study of patients receiving MMF or AZA in combination with a calcineurin inhibitor and prednisone, for the prevention of rejection after lung transplant between 1/1/2008 and 9/30/2011 at DUH.
Results:
Baseline characteristics were similar between groups (table 1) but the MMF group had more females (p=0.03) and lower baseline platelets (Plts) (p<0.05). The amount of dose reductions were similar in the MMF and AZA groups (27 vs 34, p=NS) and the primary reason for dose reductions in both groups was active infection. Fungal infections occurred in 44% and 56% and bacterial occurred in 52% and 56% of the MMF and AZA groups respectively. Hematologic findings were similar between groups during the study time period (table 2). Rejection was common with 67% of patients having ≥ 1 episode in each group.
| MMF (n=75) | AZA (n=75) | |
| Age (years), mean ± SD | 67 ± 5 | 68 ± 4 |
| Female (%)^ | 36 | 19 |
| Bilateral transplant (%) | 48 | 47 |
| Caucasian (%) | 92 | 99 |
| African American (%) | 3 | 1 |
| Other (%) | 5 | 0 |
| IPF (%) | 41 | 37 |
| COPD/Emphysema (%) | 32 | 21 |
| Pulmonary Fibrosis Other (%) | 15 | 24 |
| Other (%) | 12 | 17 |
| MMF (n=75) | AZA (n=75) | P Value | |
| Dose Reductions, n | 27 | 34 | NS |
| Agent Change, n | 2 | 8 | NS |
| Reason ⇓Hct | 0 | 1 | NA |
| Reason ⇓WBC | 4 | 8 | NA |
| Reason ⇓Plt | 1 | 1 | NA |
| Reason Thymo | 2 | 5 | NA |
| Reason Infection | 9 | 10 | NA |
| Reason Other | 13 | 9 | NA |
| HCT Baseline* | 39 ± 4 | 40 ± 4 | NS |
| HCT Trough* | 28 ± 4 | 27 ± 4 | NS |
| Plt Baseline* | 235 ± 65 | 258 ± 77 | 0.05 |
| Plt Trough* | 152 ± 55 | 162 ±73 | NS |
| WBC Baseline* | 8.4± 2.7 | 9.1 ± 2.5 | NS |
| WBC Trough* | 4.7 ± 2.2 | 4.2 ± 1.9 | NS |
Conclusions:
Maintenance immunosuppression including MMF or AZA was well tolerated in this cohort of elderly lung transplant patients. There were high rates of rejection and infection in both groups warranting larger prospective studies. Based on this study it does not appear that the shortage of AZA is affecting outcomes.
To cite this abstract in AMA style:
Hurtik M, Byrns J, Patel N, Harris M. When Drugs Run Out: Tolerability of Mycophenolate Mofetil and Azathioprine in Lung Transplant Recipients over the Age of Sixty [abstract]. Am J Transplant. 2013; 13 (suppl 5). https://atcmeetingabstracts.com/abstract/when-drugs-run-out-tolerability-of-mycophenolate-mofetil-and-azathioprine-in-lung-transplant-recipients-over-the-age-of-sixty/. Accessed May 17, 2025.« Back to 2013 American Transplant Congress