The decision to withdraw immunosuppression medications in solid organ transplant (SOT) patients dying from a comorbid illness arises frequently.
Commonly used medications are: cyclosporine, tacrolimus, sirolimus, mycophenolic acid, azathioprine, and corticosteroids. The objective of these medications is to prevent antibody-mediated hyper acute rejection immediately after transplantation, lymphocyte-mediated acute rejection during the first-year post-transplantation, and chronic rejection subsequently. The increased use of immunosuppression medications caused better life expectancy of transplant recipients.
Patients and their families may resist discontinuation of immunosuppression medications, which can be interpreted as medical abandonment as the importance of immunosuppressant adherence is often routinely stressed by treating clinicians.
Several factors may make these medications prohibitive for many patients receiving hospice care: high costs and side effects, increased risk for cancer and infections, requirement of close lab monitoring, and availability usually in oral formulations.
The decision to stop immunosuppression in SOT recipients does not automatically lead to imminent death and suffering.
Stopping these medications may lead to acute rejection within days to weeks of roughly one-quarter to one-half of patients. For many of these patients, the signs and symptoms of acute rejection closely resemble the dying process and include delirium, pain, fever, and malaise. Consequently, clinicians may decide to discontinue immunosuppression and palliate symptoms as they arise. If so, instead of completely stopping all immunosuppression, a rotation to a high-dose corticosteroid could be considered when significant symptomatology is anticipated. One care option is to discontinue all immunosuppression and start prednisone
at 50-80 mg per day (dose equivalent methylprednisolone
40-60 mg per day) to prevent acute rejection. Subsequent corticosteroid tapering could be considered on a case-by-case basis.
For patients with a prognosis as short as hours to days, stopping all immunosuppression is reasonable as it is unlikely that acute rejection will hinder their dying process. For patients with an anticipated survival of several weeks to months, continuation of previous immunosuppression or rotation to corticosteroids should be considered to prevent acute rejection.
See reference for more information
Adapted from Gillespie H, Smith MA, O’Neil TA. Transplant medication management for patients nearing end-of-life. Palliative Care Network of Wisconsin. Fast facts and concepts #333. Internet. Accessed on July 24, 2019.