Management of Mycophenolate and Prednisone in Cardiac Transplantation with Infectious Diarrhea

Introduction to Management Strategies

The American Thoracic Society recommends that in a cardiac transplant recipient with infectious diarrhea, mycophenolate should be interrupted or its dose reduced immediately, while prednisone should be continued without changes to avoid acute rejection 1, 2

The International Society for Heart and Lung Transplantation suggests interrupting or reducing the dose of mycophenolate when diarrhea occurs, as this is the most common gastrointestinal adverse effect and can compromise the absorption of other critical immunosuppressants 1, 2, 3
The European Society of Cardiology states that mycophenolate-induced diarrhea can significantly increase tacrolimus levels by up to 30%, requiring a reduction in the dose of the calcineurin inhibitor to avoid toxicity 1, 2, 3

The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommend that prednisone should be continued without changes in patients with transplants who are beyond the first week post-transplant 6, 7, 8, 9
The KDIGO guidelines specifically recommend that if prednisone is being used beyond the first week after transplant, it should be continued rather than withdrawn (Grade 2C) 6, 7, 8, 9
The American College of Cardiology advises against reducing prednisone during acute infectious episodes in the context of adjustments of other immunosuppressants, as this would dramatically increase the risk of acute rejection 6, 7

The Infectious Diseases Society of America recommends monitoring tacrolimus levels every 2-3 days during the episode of diarrhea, as they can increase significantly even with stable doses 7
The European Renal Association - European Dialysis and Transplant Association suggests considering mycophenolic acid levels if there is concern for rejection or gastrointestinal intolerance, although this is not routinely recommended 4, 5
The International Society for Heart and Lung Transplantation advises against simultaneously reducing multiple immunosuppressants, as this exponentially increases the risk of acute rejection 1, 2, 3
The American Gastroenterological Association warns against assuming that all diarrhea in patients with mycophenolate is infectious; medication toxicity is extremely common 1, 2, 3