Immunosuppressants are a class of medications that inhibit or decrease immune system activity. They can help treat certain autoimmune conditions or reduce the risk of the body rejecting an organ or stem cell transplant.
There are many types of immunosuppressants, each targeting specific cells of the immune system. All immunosuppressants may cause side effects, including an increased risk of infections.
Doctors may prescribe immunosuppressants for the following reasons:
Autoimmune conditions
Immunosuppressants can help treat a range of autoimmune conditions, including:
- multiple types of autoimmune arthritis
- autoimmune skin diseases such as psoriasis and chronic hives
- inflammatory bowel diseases such as Crohn’s disease and ulcerative colitis
- asthma
- lupus
- ankylosing spondylitis
Organ transplants
Most immunosuppressant medications are designed to reduce the risk that the body will reject a transplanted organ, such as a donor kidney, liver, or heart.
There are three main types of anti-rejection immunosuppressants:
- Induction medications: A person receives these intravenous (IV) anti-rejection medications before an organ transplant and again in the days after the transplant surgery. These medications prepare the body to accept the donor organ.
- Maintenance medications: A person takes these anti-rejection medications for as long as they have their donor organ. They will typically receive the first dose in the hospital shortly after their surgery.
- Rejection treatments: Doctors will administer these medications if a person’s body starts to reject the donor organ.
Stem cell transplants
Stem cells are unspecialized cells that can differentiate and grow into various types of cells and tissues.
People with certain conditions, such as leukemia or lymphoma, may need a stem cell transplant as part of their treatment. This procedure involves replacing the person’s own damaged or diseased blood-forming stem cells with healthy stem cells from a donor.
A stem cell transplant can cause a serious and potentially life threatening condition called graft-versus-host disease (GVHD). This occurs when the donor stem cells (the graft) attack healthy cells in the recipient (the host).
Doctors administer immunosuppressant medications before and after stem cell infusions to try to prevent GVHD. These medications work by suppressing the function of a type of immune cells called T cells in the donor cells.
The following sections outline the available types of immunosuppressants.
Steroids
Steroids help treat a range of autoimmune conditions. These drugs work by:
- stopping the body from making immune cells called cytokines, which trigger inflammation
- reducing levels of immune cells such as T cells, B cells, and eosinophils
- making it difficult for immune cells to travel to areas of infection or injury in the body
Colchicine
Colchicine can help treat autoinflammatory disorders. They inhibit the function of white blood cells called neutrophils, which are the body’s first line of defense against infection and injury.
Hydroxychloroquine
Hydroxychloroquine works by suppressing immune cell signaling, which reduces inflammation in the body.
Sulfasalazine
Sulfasalazine contains the active ingredient 5-aminosalicylate, which inhibits the production of hormone-like chemicals called prostaglandins. High levels of prostaglandins can cause inflammation.
Dapsone
Doctors may prescribe dapsone to help treat the autoimmune skin condition dermatitis herpetiformis. This medication works by:
- interfering with the ability of bacteria to produce the nutrients they need to survive
- inhibiting chemicals called leukotrienes and prostaglandins, which may cause inflammation
- helping to prevent cell damage from free radicals
Methotrexate
Methotrexate can treat certain cancers and a wide range of autoimmune diseases, including rheumatoid arthritis.
This medication works by interfering with the ability of T cells and B cells to make the DNA and RNA they need to survive and grow. This, in turn, helps control inflammation.
Mycophenolate mofetil
Doctors may prescribe mycophenolate mofetil to help treat a range of autoimmune conditions and to help prevent organ rejection after an organ transplant.
The medication targets the enzyme inosine-5′-monophosphate dehydrogenase (IMPDH), which T cells and B cells need for growth and division. This, in turn, helps suppress immune system reactions.
Azathioprine
Doctors may prescribe azathioprine to help treat various autoimmune conditions and to help prevent organ rejection after an organ transplant.
This drug works by breaking down into a molecule that interferes with the correct construction of DNA. This, in turn, helps slow the growth and division of T cells and B cells, thereby controlling the immune response to autoimmune diseases.
Other examples
Other examples of immunosuppressants include:
- Biologics: Biologics are medications derived from living cells or organisms. Examples include:
- Interleukin (IL) inhibitors: Interleukins regulate immune responses and inflammatory reactions. IL inhibitors are medications that inhibit the production of specific interleukins.
- Tumor necrosis factor (TNF) inhibitors: These medications reduce the production of the cytokine called TNF, which in turn helps reduce inflammation.
- IgE biologics: These medications target the antibody immunoglobulin E (IgE), which plays a key role in allergic reactions.
- Janus kinase (JAK) inhibitors: JAK enzymes are proteins inside cells that communicate messages from the outside of the cell to the inside of the cell. JAK inhibitors block JAKs, thereby decreasing signals that tell the cell to make and release cytokines and other inflammatory molecules.
- Adaptive immunity T cells: This medication contains cyclosporine, which binds to a protein called calcineurin in T cells. This stops the T cells from making cytokines and other T cells, thereby suppressing the immune system.
People should take their immunosuppressant medications according to their doctor’s instructions. It is important to take these medications at the correct time and not to miss doses.
For people who are taking immunosuppressants to prevent organ rejection after organ donation, missing doses can lead to serious complications such as:
- acute organ rejection
- chronic transplant damage
- transplant failure
Anyone who misses a dose of their medication should contact their doctor for advice on when to take the next dose.
Because all immunosuppressants suppress the immune system, they all increase the risk of viral and bacterial infections.
Doctors will closely monitor people who are taking immunosuppressants and recommend regular blood tests to monitor blood cell counts and liver and kidney function. The frequency of these blood tests will depend partly on the type of immunosuppressant the person takes and the dosage and treatment duration.
Anyone who experiences symptoms of infection or other side effects while taking an immunosuppressant should notify their doctor immediately.
General immune suppressants
Some general immune suppressants can cause low blood cell counts, and most cause gastrointestinal issues such as diarrhea, nausea, and vomiting.
Some may cause additional side effects, such as:
- rash
- headache
- kidney or liver damage
- male fertility issues
Steroids can also cause complications, such as high blood pressure, if a person takes them long term.
Biologics
All biologics increase the risk of viral and bacterial infections, and some increase the risk of parasitic infections. Some biologics can also reactivate infections a person has had in the past.
TNF inhibitors and IL inhibitors may increase the risk of certain cancers, though further research is necessary to confirm this effect.
JAK inhibitors
Like other types of immunosuppressants, JAK inhibitors increase the risk of infections. The herpes zoster virus is particularly common among people who take this type of immunosuppressant.
The most common side effects among people who take JAK inhibitors to treat a skin condition are:
Less commonly, people who take JAK inhibitors to treat a skin condition experience serious side effects such as:
Adaptive immunity T cells
The most common side effects of adaptive immunity T cells are high blood pressure and decreased kidney function. These medications also increase the risk of infections and may increase the risk of cancer.
Immunosuppressants can interact with other medications and supplements, as well as certain foods and beverages.
For example, a person should not take colchicine with grapefruit juice. This is
People who need to take some immunosuppressants must receive certain vaccinations before they can begin taking the medication. Scientists are not yet sure whether and to what extent the immune system can mount a response to the vaccine while a person is taking a particular immunosuppressant.
A person can talk with their doctor for further information on the exact type of immunosuppressant they are taking, its associated risks, and possible drug interactions.
The Sepsis Alliance offers the following recommendations for infection prevention in people with compromised immunity from various causes, including immunosuppressant use:
- washing the hands frequently with soap and water for at least 20 seconds at a time, taking care to clean under the nails and between the fingers
- using alcohol-based hand sanitizer to clean and disinfect the hands when soap and water are not available
- cleaning skin wounds, keeping the wounds clean and dry as they heal, and taking care to wash the hands before and after touching any wounds
- treating open wounds with topical antibiotics, if a doctor recommends this
- wearing a face mask when in crowded places
- receiving all vaccinations that a doctor recommends
The Immune Deficiency Foundation states that having a compromised immune system qualifies as a disability under the Americans with Disabilities Act.
Federal and state laws protect people with disabilities from job discrimination and afford them the right to negotiate with their employer for reasonable accommodations to perform their work.
People with compromised immunity may make the following requests to their employer to help reduce their risk of exposure to infectious diseases in the workplace:
- full-time or part-time work from home
- an air filter, purifier, or cleaning unit in their workspace
- an office or cubicle rather than a shared workspace
- virtual meetings rather than in-person meetings
- access to personal protective equipment in the workplace, such as a mask and disposable gloves
Employees with compromised immunity may also want to request the following from their employers:
- a modified work schedule or modified leave policy to help accommodate immunosuppressive treatments
- the option to work from home when needed
- limited or no requirement to travel
Immunosuppressants are medications that help suppress the immune system’s activity. Doctors may prescribe these medications to help treat autoimmune conditions or to reduce the risk of organ or tissue rejection after a solid organ transplant or stem cell transplant.
There are many types of immunosuppressants that target different cells within the immune system.
Because these medications suppress the immune system, they increase the risk of infections. Depending on the type of drug, a person may experience additional side effects, such as gastrointestinal upset, headache, and skin rash.
A person can talk with a doctor about the risks and benefits of taking an immunosuppressant as part of their treatment. They may also want to take this opportunity to ask questions about possible medication interactions, what to do in case of a missed dose, and how their doctor will monitor their condition and medication in the long term.
