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Antithymocyte globulin (rabbit derived, Thymoglobulin): Drug information

Antithymocyte globulin (rabbit derived, Thymoglobulin): Drug information
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For additional information see "Antithymocyte globulin (rabbit derived, Thymoglobulin): Patient drug information" and "Antithymocyte globulin (rabbit derived, Thymoglobulin): Pediatric drug information"

For abbreviations, symbols, and age group definitions show table
ALERT: US Boxed Warning
Experienced physician:

Anti-thymocyte globulin should only be used by physicians experienced in immunosuppressive therapy in transplantation.

Brand Names: US
  • Thymoglobulin
Brand Names: Canada
  • Thymoglobulin
Pharmacologic Category
  • Immune Globulin;
  • Immunosuppressant Agent;
  • Polyclonal Antibody
Dosing: Adult

Note: Premedicate with corticosteroids, acetaminophen, and/or an antihistamine 1 hour prior to infusion to reduce the incidence and severity of infusion-related reactions. Administer antifungal and antibacterial prophylaxis therapy if clinically indicated. Antiviral prophylaxis is recommended in all patients against herpes simplex virus (Ref) and prophylaxis against cytomegalovirus (CMV) in patients who are CMV-seropositive at the time of transplant and for CMV-seronegative patients scheduled to receive an organ from a CMV-seropositive donor.

Graft-versus-host disease, chronic, prevention

Graft-versus-host disease, chronic, prevention (in hematopoietic cell transplantation) (off-label use): IV: 0.5 mg/kg administered 2 days prior to transplant and 2 mg/kg administered 1 day before and 1 day after transplant (Ref) or 2.5 mg/kg once daily for 3 days beginning 3 days prior to transplant (Ref).

Heart transplant, acute cellular rejection, treatment

Heart transplant, acute cellular rejection, treatment (off-label use): IV: 0.75 to 1.5 mg/kg/day for 5 to 14 days (Ref).

Heart transplant, induction therapy

Heart transplant, induction therapy (in high-risk patients) (off-label use): IV: 1 to 1.5 mg/kg once daily for up to 7 days; frequency of dosing may be modified based on CD3 count (eg, repeat dose only administered when CD3 count >25 cells/mm3) (Ref).

Intestinal and multivisceral transplantation, induction therapy

Intestinal and multivisceral transplantation, induction therapy (off-label use): IV: 2 mg/kg/day on postoperative days 0, 2, 4, 6, and 8 (in combination with rituximab ± basiliximab) (Ref).

Intestinal transplant, acute cellular rejection, treatment

Intestinal transplant, acute cellular rejection, treatment (off-label use): Note: Optimal dose, frequency, and duration of therapy have not been established and vary based on institutional protocols. Administer as part of an appropriate combination regimen.

IV: 1.5 mg/kg once daily for 10 to 14 doses (Ref).

Liver transplant, induction therapy

Liver transplant, induction therapy (off-label use): Note: Optimal dose, frequency, and duration of therapy have not been established and vary based on institutional protocols. Administer as part of an appropriate combination regimen.

IV: 1.5 mg/kg every other day for 2 to 3 doses (Ref) or 1.5 mg/kg once daily for 3 doses (Ref).

Liver transplant, severe acute cellular rejection, treatment

Liver transplant, severe acute cellular rejection, treatment (off-label use): Note: Optimal dose, frequency, and duration of therapy have not been established and vary based on institutional protocols. Administer as part of an appropriate combination regimen for steroid resistant rejection.

IV: 1 mg/kg to 1.5 mg/kg once daily for 4 to 7 doses (Ref).

Kidney transplant, induction therapy

Kidney transplant, induction therapy: Note: The manufacturer recommends actual body weight for dosing; however, other strategies have been used. These include ideal body weight (Ref) or cumulative dosing (ie, 5 mg/kg) (Ref); refer to center-specific protocols.

IV: 1.5 mg/kg/day for 4 to 7 days; the first dose should be administered prior to reperfusion of the donor kidney; the dose and duration may vary depending on concurrent maintenance immunosuppression and patient- and/or allograft-specific variables (Ref).

Kidney transplant, rejection

Kidney transplant, rejection: IV: 1.5 mg/kg/day for 7 to 14 days.

Lung transplant, induction therapy

Lung transplant, induction therapy (off-label use): IV: 1.5 mg/kg/day for 3 days; the first dose was administered within 24 hours of transplantation (Ref). Additional trials may be necessary to further define the role of antithymocyte globulin (rabbit) for prevention of rejection after lung transplant.

Lung transplant, persistent acute cellular rejection, treatment

Lung transplant, persistent acute cellular rejection, treatment (off-label use): IV: Pulse treatments have been used to manage persistent acute cellular rejection (Ref). Additional data may be necessary to further define the role of antithymocyte globulin (rabbit) in treatment of acute cellular rejection after lung transplantation.

Pancreas transplant, induction therapy

Pancreas transplant, induction (off-label use): Note: Optimal dose, frequency, and duration of therapy have not been established and vary based on institutional protocols. Administer as part of an appropriate combination regimen.

IV: 1 to 1.5 mg/kg once daily or every other day for 3 to 7 doses (Ref).

Pancreas transplant, severe acute cellular rejection, treatment

Pancreas transplant, severe acute cellular rejection, treatment (off-label use): Note: Optimal dose, frequency, and duration of therapy have not been established and vary based on institutional protocols. Administer as part of an appropriate combination regimen.

IV: 1.5 mg/kg once daily for 5 to 10 doses (Ref).

Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Dosing: Kidney Impairment: Adult

There are no dosage adjustments provided in the manufacturer's labeling.

Dosing: Liver Impairment: Adult

There are no dosage adjustments provided in the manufacturer's labeling.

Dosing: Obesity: Adult

American Society for Blood and Marrow Transplantation (ASBMT) practice guideline committee position statement on chemotherapy dosing in obesity: Utilize actual body weight (full weight) to calculate mg/kg dosing for hematopoietic stem cell transplant conditioning regimens (Ref).

Dosing: Adjustment for Toxicity: Adult

Solid organ transplantation:

WBC count 2,000 to 3,000 cells/mm3 or platelet count 50,000 to 75,000 cells/mm3: Reduce dose by 50%.

WBC count <2,000 cells/mm3 or platelet count <50,000 cells/mm3: Consider discontinuing or holding dose until counts rebound.

CD3+ lymphocyte count: Thresholds for discontinuing, holding, or decreasing dose vary based on center-specific protocols; length of CD3 suppression depends on type of organ transplant, concurrent immunosuppression, and other organ function (eg, kidney function); one example of dose adjustment based on CD3 count is to discontinue or hold the dose at a CD3 count <25 cells/mm3 and redose when CD3 count is >25 cells/mm3; these strategies require daily to every-other-day CD3 count monitoring (Ref).

Dosing: Older Adult

Refer to adult dosing.

Dosing: Pediatric

(For additional information see "Antithymocyte globulin (rabbit derived, Thymoglobulin): Pediatric drug information")

Note: Premedicate with corticosteroids, acetaminophen, and/or an antihistamine 1 hour prior to infusion to reduce the incidence and severity of infusion-related reactions. Administer antifungal and antibacterial prophylaxis therapy if clinically indicated. For use in solid organ transplantation (ie, kidney), antiviral prophylaxis is recommended in patients who are CMV-seropositive at the time of transplant and for CMV-seronegative patients scheduled to receive a kidney from a CMV-seropositive donor.

Aplastic anemia, refractory

Aplastic anemia, refractory: Limited data available: Children and Adolescents: IV: 3.5 mg/kg/day once daily for 5 days in combination with cyclosporine (Ref); Note: Consistent with observations in adult patients, rabbit-antithymocyte globulin is less effective than horse-antithymocyte globulin when either combined with cyclosporine in children and adolescents for initial treatment of severe aplastic anemia (Ref)

Hematopoietic stem cell transplant; graft-versus-host disease prevention

Hematopoietic stem cell transplant; graft-versus-host disease (GVHD) prevention: Limited data available; regimens and protocols variable; refer to institutional protocols: Infants, Children, and Adolescents: IV: Usual reported TOTAL dose range: 4.5 to 15 mg/kg total divided into 3 to 5 once daily doses administered pretransplant; usual regimen is 3 to 4 doses on consecutive days in combination with chemotherapy or radiation (Ref). In adolescents ≥16 years, a lower total dose and timing approach has been successfully used: IV: 0.5 mg/kg/day 2 days before transplantation, 2 mg/kg/day 1 day before transplantation, and 2 mg/kg/day 1 day after transplantation (total dose: 4.5 mg/kg; in addition to standard GVHD prophylaxis) (Ref)

Solid organ transplantation

Solid organ transplantation: Note: Doses and timing may vary; refer to institutional specific protocols:

Kidney transplantation: Infant, Children, and Adolescents:

Induction, prophylaxis: IV: 1.5 mg/kg/dose once daily for 4 to 10 doses initiated at time of transplant prior to reperfusion of donor kidney; during variable and dependent on other immunosuppressive regimens (Ref)

Acute rejection, treatment: IV: 1.5 mg/kg/dose once daily for 7 to 14 days

Heart/lung transplantation: Limited data available: Infant, Children, and Adolescents:

Induction, prophylaxis: Reported range: IV: 1 to 2 mg/kg/dose once daily infused over 12 hours for 5 days; dose dependent on baseline platelet count; in trials the following doses were used based on platelet count (Ref):

>150,000/mm3: IV: 2 mg/kg/dose

100,000 to 150,000/mm3: IV: 1.5 mg/kg/dose

50,000 to <100,000/mm3: IV: 1 mg/kg/dose

Acute rejection, treatment: IV: 2 mg/kg/dose once daily for 5 days (Ref)

Liver, intestinal, or multivisceral transplant: Limited data available: Infants, Children, and Adolescents:

Induction, prophylaxis: IV: Total dose of 5 mg/kg divided into separate pre- and post-op doses: 2 to 3 mg/kg over 6 to 8 hours before allograft reperfusion, followed by the remainder 2 to 3 mg/kg over 6 to 8 hours post-operative; used in combination with other immunosuppressives (Ref)

Rejection: 1.5 mg/kg/dose once daily; duration variable (usually at least 4 to 5 days) based upon biopsy results (Ref)

Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Dosing: Kidney Impairment: Pediatric

There are no dosage adjustments provided in the manufacturer's labeling.

Dosing: Liver Impairment: Pediatric

There are no dosage adjustments provided in the manufacturer's labeling.

Adverse Reactions

The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified.

>10%:

Cardiovascular: Hypertension (18% to 37%), hypotension (10% to 16%), peripheral edema (20%), tachycardia (7% to 23%)

Dermatologic: Acne vulgaris (12%), diaphoresis (6% to 13%), skin rash (7% to 13%)

Endocrine & metabolic: Hyperkalemia (17% to 57%), hyperlipidemia (15%), hypokalemia (6% to 12%)

Gastrointestinal: Abdominal pain (8% to 38%), constipation (15% to 33%), diarrhea (6% to 20%), nausea (29% to 37%), vomiting (12% to 20%)

Genitourinary: Urinary tract infection (39% to 42%)

Hematologic & oncologic: Anemia (12% to 25%), leukocytosis (13%), leukopenia (21% to 63%), thrombocytopenia (9% to 37%)

Infection: Cytomegalovirus disease (6% to 13%), infection (17% to 76%; severe infection: 23%), sepsis (6% to 12%)

Nervous system: Anxiety (7% to 14%), chills (9% to 57%), headache (18% to 40%), insomnia (12% to 20%), malaise (9% to 13%), pain (26%)

Neuromuscular & skeletal: Arthralgia (15%), asthenia (13%), back pain (12%), myalgia (11% to 20%)

Respiratory: Dyspnea (15% to 28%), lower respiratory tract infection (≤13%), pulmonary disease (12%), upper respiratory tract infection (11%)

Miscellaneous: Fever (13% to 46%)

1% to 10%:

Cardiovascular: Chest pain (9%), edema (6%)

Dermatologic: Pruritus (6%)

Endocrine & metabolic: Acidosis (6% to 9%), hyperphosphatemia (6% to 7%), hypophosphatemia (6%)

Gastrointestinal: Anorexia (6%), dyspepsia (10%), gastritis (1%), intestinal candidiasis (5%), oral candidiasis (6%)

Hematologic & oncologic: Lymphoproliferative disorder (posttransplant: 2%), malignant neoplasm (4%)

Hypersensitivity: Serum sickness (1% to 2%)

Infection: Herpes simplex infection (5%), herpes zoster infection (5%)

Respiratory: Increased cough (7%), nasopharyngitis (5%)

<1%: Hypersensitivity: Anaphylactic shock

Frequency not defined: Miscellaneous: Infusion related reactions

Postmarketing:

Hematologic & oncologic: Disorder of hemostatic components of blood, disseminated intravascular coagulation, febrile neutropenia, malignant lymphoma, malignant solid tumor

Hepatic: Increased serum transaminases

Hypersensitivity: Anaphylaxis, cytokine release syndrome

Miscellaneous: Reactivation of disease

Contraindications

Hypersensitivity (allergy or anaphylaxis) to rabbit proteins or any component of the formulation; active acute or chronic infection which contraindicate additional immunosuppression

Warnings/Precautions

Concerns related to adverse effects:

• Hematologic effects: Reversible leukopenia, neutropenia, thrombocytopenia, and lymphopenia may occur. Monitor blood counts. Leukopenia and/or thrombocytopenia may require dosage adjustment.

• Hypersensitivity: Hypersensitivity and fatal anaphylactic reactions have been reported. Stop infusion immediately if anaphylactic reaction occurs. Immediate treatment (including subcutaneous epinephrine and corticosteroids) should be available during infusion for management of hypersensitivity.

• Infection: Severe infections (bacterial, fungal, viral and/or protozoal) may develop following concomitant use of immunosuppressants with antithymocyte globulin. Reactivation of infections (particularly CMV) and sepsis have been reported. Appropriate antiviral, antibacterial, antiprotozoal, and/or antifungal prophylaxis is recommended. Monitor closely for infection.

• Infusion reactions: Release of cytokines by activated monocytes and lymphocytes may lead to cytokine release syndrome (CRS) during infusion; may cause serious cardiopulmonary events (sometimes fatal). Rapid infusion rates have been associated with CRS (case reports). Other infusion reaction symptoms, including flu-like symptoms (fever, chills, nausea, muscle/joint pain) may also occur. Local infusion site reactions (pain, swelling, skin redness) have been reported.

• Malignancy: Immunosuppressants, including antithymocyte globulins may increase the incidence of malignancies, including lymphoma, post-transplant lymphoproliferative disease (PTLD) or other malignancies; may be fatal.

Concurrent drug therapy issues:

• Immunizations: Patients should not be immunized with attenuated live viral vaccines during or shortly after treatment; safety of immunization following therapy has not been studied.

Disease-related concerns:

• Liver transplantation induction: Antithymocyte globulin (rabbit) has been associated with increased adverse effects when used for induction in liver transplantation and should be used cautiously in this population (Boillot 2009)

Other warnings/precautions:

• Administration: Initial dose must be administered over at least 6 hours into a high flow vein. Reducing the infusion rate (and prolonging the administration time) may minimize infusion reactions. May pretreat with an antipyretic, antihistamine, and/or corticosteroid.

• Experienced physician: [US Boxed Warning]: Should only be used by physicians experienced in immunosuppressive therapy in transplantation. Maintenance immunosuppression may require dosage reduction. Medical surveillance is required during the infusion. Should be administered in combination with other immunosuppressants.

• Product selection: Antithymocyte globulin (ATG) (rabbit) is available (based on region) in different product formulations, ATG-Thymoglobulin and ATG-Fresenius; the dosing differs among the formulations. Dosing of antithymocyte globulin (rabbit) also differs from dosing of other antithymocyte globulin products (eg, ATG [equine]); protein compositions and concentrations are different. Use caution to ensure dose prescribed is intended for product being administered.

Dosage Forms: US

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Solution Reconstituted, Intravenous:

Thymoglobulin: 25 mg (1 ea) [contains glycine, mannitol, sodium chloride]

Generic Equivalent Available: US

No

Pricing: US

Solution (reconstituted) (Thymoglobulin Intravenous)

25 mg (per each): $1,343.36

Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.

Dosage Forms: Canada

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Solution Reconstituted, Intravenous:

Thymoglobulin: 25 mg (1 ea)

Administration: Adult

IV: Infuse the first dose over at least 6 hours; subsequent doses may be infused over at least 4 hours. Infuse through a high-flow vein (central line). Administer through an in-line 0.22 micron filter. Premedication with corticosteroids, acetaminophen, and/or an antihistamine 1 hour prior to infusion may reduce the incidence and severity of infusion-related reactions. Reducing the infusion rate may minimize infusion reactions. Infusion rate may vary for off-label uses; refer to specific protocol.

In kidney transplantation, administration through a peripheral vein has been reported with the addition of 1,000 units heparin and 20 mg hydrocortisone (in 500 mL NS only) to decrease the risk of thrombosis and phlebitis (Ref). The first 2 doses were infused over 6 hours and subsequent doses were infused over 4 hours (Ref). Some centers choose not to use additives and administer the dose at a concentration of 1 mg/mL diluted in NS, with the first dose administered over 4 to 6 hours and subsequent doses over 2 to 4 hours (Ref).

Administration: Pediatric

Parenteral: Administer by slow IV infusion over 6 to 12 hours for the preconditioning/induction dose or over 6 hours for the initial acute rejection treatment dose; infuse over 4 hours for subsequent doses if first dose tolerated. Administer through an in-line filter with pore size of 0.22 microns via central line or high flow vein. Premedication with corticosteroids, acetaminophen, and/or an antihistamine may reduce infusion-related reactions.

Use: Labeled Indications

Kidney transplant rejection: Prophylaxis and treatment of acute rejection in kidney transplantation (in conjunction with concomitant immunosuppression).

Note: In a multicenter, double-blind, randomized trial, antithymocyte globulin (rabbit) was shown to be superior to antithymocyte globulin (equine) in reversing acute rejection and preventing subsequent episodes (Gaber 1998). Based on data from studies (including 10 years follow up) comparing ATG (rabbit) to ATG (equine) for induction, ATG (rabbit) has emerged as the T-cell lymphocyte depleting induction therapy of choice over ATG (equine) in adult kidney transplantation due to its improved efficacy and lower incidence of acute rejection (Brennan 1999; Hardinger 2008).

Use: Off-Label: Adult

Chronic graft-versus-host disease, prevention (in hematopoietic cell transplantation); Heart transplant, acute cellular rejection, treatment; Heart transplant, induction therapy; Intestinal and multivisceral transplantation, induction therapy; Intestinal transplant, acute cellular rejection, treatment; Liver transplant, induction therapy; Liver transplant, severe acute cellular rejection, treatment; Lung transplant, induction therapy; Lung transplant, persistent acute cellular rejection, treatment; Pancreas transplant, induction therapy; Pancreas transplant, severe acute cellular rejection, treatment

Medication Safety Issues
Sound-alike/look-alike issues:

Antithymocyte globulin rabbit (Thymoglobulin) may be confused with antithymocyte globulin equine (Atgam)

High alert medication:

The Institute for Safe Medication Practices (ISMP) includes this medication among its list of drug classes (immunosuppressant agent, parenteral and oral) which have a heightened risk of causing significant patient harm when used in error (High-Alert Medications in Community/Ambulatory Care and Long-Term Care Settings).

Metabolism/Transport Effects

None known.

Drug Interactions

Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the drug interactions program by clicking on the “Launch drug interactions program” link above.

5-Aminosalicylic Acid Derivatives: May increase myelosuppressive effects of Myelosuppressive Agents. Risk C: Monitor

Abrocitinib: May increase immunosuppressive effects of Immunosuppressants (Therapeutic Immunosuppressant Agents). Risk X: Avoid

Antithymocyte Globulin (Equine): Immunosuppressants (Therapeutic Immunosuppressant Agents) may increase adverse/toxic effects of Antithymocyte Globulin (Equine). Specifically, these effects may be unmasked if the dose of immunosuppressive therapy is reduced. Immunosuppressants (Therapeutic Immunosuppressant Agents) may increase immunosuppressive effects of Antithymocyte Globulin (Equine). Specifically, infections may occur with greater severity and/or atypical presentations. Risk C: Monitor

Antithyroid Agents: Myelosuppressive Agents may increase neutropenic effects of Antithyroid Agents. Risk C: Monitor

Baricitinib: Immunosuppressants (Therapeutic Immunosuppressant Agents) may increase immunosuppressive effects of Baricitinib. Risk X: Avoid

BCG Products: Immunosuppressants (Therapeutic Immunosuppressant Agents) may decrease therapeutic effects of BCG Products. Immunosuppressants (Therapeutic Immunosuppressant Agents) may increase adverse/toxic effects of BCG Products. Specifically, the risk of vaccine-associated infection may be increased. Risk X: Avoid

Belatacept: Antithymocyte Globulin (Rabbit) may increase adverse/toxic effects of Belatacept. Specifically, the risk for venous thrombosis of the renal allograft may be increased. Management: A 12-hour interval between administration of these 2 agents is suggested if these agents are to be used concomitantly. Monitor for venous thrombosis of the renal allograft. Risk D: Consider Therapy Modification

Brincidofovir: Immunosuppressants (Therapeutic Immunosuppressant Agents) may decrease therapeutic effects of Brincidofovir. Risk C: Monitor

Brivudine: May increase adverse/toxic effects of Immunosuppressants (Therapeutic Immunosuppressant Agents). Risk X: Avoid

Chikungunya Vaccine (Live): Immunosuppressants (Therapeutic Immunosuppressant Agents) may increase adverse/toxic effects of Chikungunya Vaccine (Live). Specifically, the risk of vaccine-associated infection may be increased. Immunosuppressants (Therapeutic Immunosuppressant Agents) may decrease therapeutic effects of Chikungunya Vaccine (Live). Risk X: Avoid

Chloramphenicol (Ophthalmic): May increase adverse/toxic effects of Myelosuppressive Agents. Risk C: Monitor

Chloramphenicol (Systemic): Myelosuppressive Agents may increase myelosuppressive effects of Chloramphenicol (Systemic). Risk X: Avoid

Cladribine: Immunosuppressants (Therapeutic Immunosuppressant Agents) may increase immunosuppressive effects of Cladribine. Risk X: Avoid

CloZAPine: Myelosuppressive Agents may increase adverse/toxic effects of CloZAPine. Specifically, the risk for neutropenia may be increased. Risk C: Monitor

Coccidioides immitis Skin Test: Coadministration of Immunosuppressants (Therapeutic Immunosuppressant Agents) and Coccidioides immitis Skin Test may alter diagnostic results. Management: Consider discontinuing therapeutic immunosuppressants several weeks prior to coccidioides immitis skin antigen testing to increase the likelihood of accurate diagnostic results. Risk D: Consider Therapy Modification

COVID-19 Vaccine (Inactivated Virus): Immunosuppressants (Therapeutic Immunosuppressant Agents) may decrease therapeutic effects of COVID-19 Vaccine (Inactivated Virus). Risk C: Monitor

COVID-19 Vaccine (mRNA): Immunosuppressants (Therapeutic Immunosuppressant Agents) may decrease therapeutic effects of COVID-19 Vaccine (mRNA). Management: Give a 3-dose primary series for all patients aged 6 months and older taking immunosuppressive medications or therapies. Booster doses are recommended for certain age groups. See CDC guidance for details. Risk D: Consider Therapy Modification

COVID-19 Vaccine (Subunit): Immunosuppressants (Therapeutic Immunosuppressant Agents) may decrease therapeutic effects of COVID-19 Vaccine (Subunit). Risk C: Monitor

Deferiprone: Myelosuppressive Agents may increase neutropenic effects of Deferiprone. Management: Avoid the concomitant use of deferiprone and myelosuppressive agents whenever possible. If this combination cannot be avoided, monitor the absolute neutrophil count more closely. Risk D: Consider Therapy Modification

Dengue Tetravalent Vaccine (Live): Immunosuppressants (Therapeutic Immunosuppressant Agents) may decrease therapeutic effects of Dengue Tetravalent Vaccine (Live). Immunosuppressants (Therapeutic Immunosuppressant Agents) may increase adverse/toxic effects of Dengue Tetravalent Vaccine (Live). Specifically, the risk of vaccine-associated infection may be increased. Risk X: Avoid

Denosumab: Immunosuppressants (Therapeutic Immunosuppressant Agents) may increase immunosuppressive effects of Denosumab. Management: Consider the risk of serious infections versus the potential benefits of coadministration of denosumab and immunosuppressants. If combined, monitor for signs/symptoms of serious infections. Risk D: Consider Therapy Modification

Deucravacitinib: May increase immunosuppressive effects of Immunosuppressants (Therapeutic Immunosuppressant Agents). Risk X: Avoid

Dinutuximab Beta: Immune Globulins may decrease therapeutic effects of Dinutuximab Beta. Risk X: Avoid

Efgartigimod Alfa: May decrease therapeutic effects of Fc Receptor-Binding Agents. Risk C: Monitor

Etrasimod: May increase immunosuppressive effects of Immunosuppressants (Therapeutic Immunosuppressant Agents). Risk X: Avoid

Fexinidazole: Myelosuppressive Agents may increase myelosuppressive effects of Fexinidazole. Risk X: Avoid

Filgotinib: May increase immunosuppressive effects of Immunosuppressants (Therapeutic Immunosuppressant Agents). Risk X: Avoid

Inebilizumab: Immunosuppressants (Therapeutic Immunosuppressant Agents) may increase immunosuppressive effects of Inebilizumab. Risk C: Monitor

Influenza Virus Vaccines: Immunosuppressants (Therapeutic Immunosuppressant Agents) may decrease therapeutic effects of Influenza Virus Vaccines. Management: Administer influenza vaccines at least 2 weeks prior to initiating immunosuppressants if possible. If vaccination occurs less than 2 weeks prior to or during therapy, revaccinate 2 to 3 months after therapy discontinued if immune competence restored. Risk D: Consider Therapy Modification

Leflunomide: Immunosuppressants (Therapeutic Immunosuppressant Agents) may increase immunosuppressive effects of Leflunomide. Management: Increase the frequency of chronic monitoring of platelet, white blood cell count, and hemoglobin or hematocrit to monthly, instead of every 6 to 8 weeks, if leflunomide is coadministered with immunosuppressive agents. Risk D: Consider Therapy Modification

Linezolid: May increase myelosuppressive effects of Myelosuppressive Agents. Risk C: Monitor

Mumps- Rubella- or Varicella-Containing Live Vaccines: Immunosuppressants (Therapeutic Immunosuppressant Agents) may decrease therapeutic effects of Mumps- Rubella- or Varicella-Containing Live Vaccines. Immunosuppressants (Therapeutic Immunosuppressant Agents) may increase adverse/toxic effects of Mumps- Rubella- or Varicella-Containing Live Vaccines. Specifically, the risk of vaccine-associated infection may be increased. Risk X: Avoid

Nadofaragene Firadenovec: Immunosuppressants (Therapeutic Immunosuppressant Agents) may increase adverse/toxic effects of Nadofaragene Firadenovec. Specifically, the risk of disseminated adenovirus infection may be increased. Risk X: Avoid

Natalizumab: Immunosuppressants (Therapeutic Immunosuppressant Agents) may increase immunosuppressive effects of Natalizumab. Risk X: Avoid

Nipocalimab: May decrease therapeutic effects of Fc Receptor-Binding Agents. Risk C: Monitor

Ocrelizumab: Immunosuppressants (Therapeutic Immunosuppressant Agents) may increase immunosuppressive effects of Ocrelizumab. Risk C: Monitor

Ofatumumab: Immunosuppressants (Therapeutic Immunosuppressant Agents) may increase immunosuppressive effects of Ofatumumab. Risk C: Monitor

Olaparib: Myelosuppressive Agents may increase myelosuppressive effects of Olaparib. Risk C: Monitor

Pidotimod: Immunosuppressants (Therapeutic Immunosuppressant Agents) may decrease therapeutic effects of Pidotimod. Risk C: Monitor

Pimecrolimus: Immunosuppressants (Therapeutic Immunosuppressant Agents) may increase immunosuppressive effects of Pimecrolimus. Risk X: Avoid

Pneumococcal Vaccines: Immunosuppressants (Therapeutic Immunosuppressant Agents) may decrease therapeutic effects of Pneumococcal Vaccines. Risk C: Monitor

Poliovirus Vaccine (Live/Trivalent/Oral): Immunosuppressants (Therapeutic Immunosuppressant Agents) may decrease therapeutic effects of Poliovirus Vaccine (Live/Trivalent/Oral). Immunosuppressants (Therapeutic Immunosuppressant Agents) may increase adverse/toxic effects of Poliovirus Vaccine (Live/Trivalent/Oral). Specifically, the risk of vaccine-associated infection may be increased. Risk X: Avoid

Polymethylmethacrylate: Immunosuppressants (Therapeutic Immunosuppressant Agents) may increase hypersensitivity effects of Polymethylmethacrylate. Management: Use caution when considering use of bovine collagen-containing implants such as the polymethylmethacrylate-based Bellafill brand implant in patients who are receiving immunosuppressants. Consider use of additional skin tests prior to administration. Risk D: Consider Therapy Modification

Promazine: May increase myelosuppressive effects of Myelosuppressive Agents. Risk C: Monitor

Rabies Vaccine: Immunosuppressants (Therapeutic Immunosuppressant Agents) may decrease therapeutic effects of Rabies Vaccine. Management: Complete rabies vaccination at least 2 weeks before initiation of immunosuppressant therapy if possible. If combined, check for rabies antibody titers, and if vaccination is for post exposure prophylaxis, administer a 5th dose of the vaccine. Risk D: Consider Therapy Modification

Ritlecitinib: Immunosuppressants (Therapeutic Immunosuppressant Agents) may increase immunosuppressive effects of Ritlecitinib. Risk X: Avoid

Ropeginterferon Alfa-2b: Myelosuppressive Agents may increase myelosuppressive effects of Ropeginterferon Alfa-2b. Management: Avoid coadministration of ropeginterferon alfa-2b and other myelosuppressive agents. If this combination cannot be avoided, monitor patients for excessive myelosuppressive effects. Risk D: Consider Therapy Modification

Rozanolixizumab: May decrease therapeutic effects of Fc Receptor-Binding Agents. Risk C: Monitor

Ruxolitinib (Topical): Immunosuppressants (Therapeutic Immunosuppressant Agents) may increase immunosuppressive effects of Ruxolitinib (Topical). Risk X: Avoid

Sipuleucel-T: Immunosuppressants (Therapeutic Immunosuppressant Agents) may decrease therapeutic effects of Sipuleucel-T. Management: Consider reducing the dose or discontinuing the use of immunosuppressants prior to initiating sipuleucel-T therapy. Risk D: Consider Therapy Modification

Sphingosine 1-Phosphate (S1P) Receptor Modulators: May increase immunosuppressive effects of Immunosuppressants (Therapeutic Immunosuppressant Agents). Risk C: Monitor

Tacrolimus (Topical): Immunosuppressants (Therapeutic Immunosuppressant Agents) may increase immunosuppressive effects of Tacrolimus (Topical). Risk X: Avoid

Talimogene Laherparepvec: Immunosuppressants (Therapeutic Immunosuppressant Agents) may increase adverse/toxic effects of Talimogene Laherparepvec. Specifically, the risk of infection from the live, attenuated herpes simplex virus contained in talimogene laherparepvec may be increased. Risk X: Avoid

Tertomotide: Immunosuppressants (Therapeutic Immunosuppressant Agents) may decrease therapeutic effects of Tertomotide. Risk X: Avoid

Tofacitinib: Immunosuppressants (Therapeutic Immunosuppressant Agents) may increase immunosuppressive effects of Tofacitinib. Management: Coadministration of tofacitinib with potent immunosuppressants is not recommended. Use with non-biologic disease-modifying antirheumatic drugs (DMARDs) was permitted in psoriatic arthritis clinical trials. Risk X: Avoid

Typhoid Vaccine: Immunosuppressants (Therapeutic Immunosuppressant Agents) may decrease therapeutic effects of Typhoid Vaccine. Immunosuppressants (Therapeutic Immunosuppressant Agents) may increase adverse/toxic effects of Typhoid Vaccine. Specifically, the risk of vaccine-associated infection may be increased. Risk X: Avoid

Ublituximab: Immunosuppressants (Therapeutic Immunosuppressant Agents) may increase immunosuppressive effects of Ublituximab. Risk C: Monitor

Upadacitinib: Immunosuppressants (Therapeutic Immunosuppressant Agents) may increase immunosuppressive effects of Upadacitinib. Risk X: Avoid

Vaccines (Live): Immunosuppressants (Therapeutic Immunosuppressant Agents) may decrease therapeutic effects of Vaccines (Live). Immunosuppressants (Therapeutic Immunosuppressant Agents) may increase adverse/toxic effects of Vaccines (Live). Specifically, the risk of vaccine-associated infection may be increased. Risk X: Avoid

Vaccines (Non-Live/Inactivated/Non-Replicating): Immunosuppressants (Therapeutic Immunosuppressant Agents) may decrease therapeutic effects of Vaccines (Non-Live/Inactivated/Non-Replicating). Management: Give non-live/inactivated/non-replicating vaccines at least 2 weeks prior to starting immunosuppressants when possible. Patients vaccinated less than 14 days before or during therapy should be revaccinated at least 2 to 3 months after therapy is complete. Risk D: Consider Therapy Modification

Yellow Fever Vaccine: Immunosuppressants (Therapeutic Immunosuppressant Agents) may decrease therapeutic effects of Yellow Fever Vaccine. Immunosuppressants (Therapeutic Immunosuppressant Agents) may increase adverse/toxic effects of Yellow Fever Vaccine. Specifically, the risk of vaccine-associated infection may be increased. Risk X: Avoid

Zoster Vaccine (Live/Attenuated): Immunosuppressants (Therapeutic Immunosuppressant Agents) may increase adverse/toxic effects of Zoster Vaccine (Live/Attenuated). Specifically, the risk of vaccine-associated infection may be increased. Immunosuppressants (Therapeutic Immunosuppressant Agents) may decrease therapeutic effects of Zoster Vaccine (Live/Attenuated). Risk X: Avoid

Reproductive Considerations

Females of reproductive potential should use effective contraception during and for at least 3 months following treatment.

Antithymocyte globulin (rabbit) has been used as for the induction of immunosuppression in patients undergoing uterine transplant; a minimum interval of 3 months between uterine transplant and embryo transfer is suggested (Johannesson 2019; Jones 2019).

Pregnancy Considerations

Antithymocyte globulin (rabbit) is a purified immunoglobulin G. Placental transfer of human IgG is dependent upon the IgG subclass, maternal serum concentrations, newborn birth weight, and gestational age, generally increasing as pregnancy progresses. The lowest exposure would be expected during the period of organogenesis (Palmeira 2012; Pentsuk 2009).

Information related to the use of antithymocyte globulin (rabbit) during pregnancy is limited (Balaha 2019; Kutzler 2016; López 2014; Massenkeil 2016).

Transplant Pregnancy Registry International (TPR) is a registry that follows pregnancies that occur in maternal transplant recipients or those fathered by male transplant recipients. The TPR encourages reporting of pregnancies following solid organ transplant by contacting them at 1-877-955-6877 or https://www.transplantpregnancyregistry.org.

Breastfeeding Considerations

It is not known if antithymocyte globulin (rabbit) is present in breast milk.

Because other immunoglobulins are present in breast milk, the manufacturer recommends that breastfeeding be discontinued during antithymocyte globulin (rabbit) therapy.

Monitoring Parameters

Lymphocyte count (total lymphocyte and/or T-cell subset), CBC with differential and platelet count; vital signs during administration; signs and symptoms of infection

Solid organ transplant: Absolute CD3 count (cells/µL) monitoring and CD3 based dosing has been considered in kidney and heart transplant recipients. It may be beneficial in certain patient populations but is not routinely recommended or utilized. Dose adjustments have been recommended based on the CD3 count (Krasinskas 2002; Peddi 2002; Uber 2004).

Mechanism of Action

Antithymocyte globulin (rabbit) is a polyclonal antibody which appears to cause immunosuppression by acting on T-cell surface antigens and depleting CD4 lymphocytes

Pharmacokinetics (Adult Data Unless Noted)

Onset of action (T-cell depletion): Within 24 hours (Hardinger 2006)

Duration: Lymphopenia may persist for up to 1 year (Hardinger 2006)

Half-life elimination: 2 to 3 days

Brand Names: International
International Brand Names by Country
For country code abbreviations (show table)

  • (AE) United Arab Emirates: Thymoglobuline;
  • (AT) Austria: Thymoglobuline;
  • (AU) Australia: Atg rabbit;
  • (BE) Belgium: Thymoglobuline;
  • (BG) Bulgaria: Thymoglobuline;
  • (BR) Brazil: Thymoglobuline;
  • (CH) Switzerland: Atg | Thymoglobuline;
  • (CN) China: Anti human t lymphocyte rabbit immunoglobulin | Rabbit anti human thymocyte immunoglobulin | Thymoglobuline;
  • (CO) Colombia: Timoglobulina;
  • (CZ) Czech Republic: Atg | Thymoglobulin;
  • (DE) Germany: Atg | Thymoglobulin | Thymoglobuline;
  • (EC) Ecuador: Timoglobulina;
  • (EE) Estonia: Thymoglobuline;
  • (EG) Egypt: Thymoglobulin | Thymoglobuline;
  • (ES) Spain: Timoglobulina;
  • (FI) Finland: Thymoglobuline;
  • (FR) France: Thymoglobuline;
  • (GB) United Kingdom: Thymoglobuline;
  • (GR) Greece: Thymoglobuline;
  • (HK) Hong Kong: Thymoglobuline;
  • (HR) Croatia: Thymoglobuline;
  • (HU) Hungary: Thymoglobulin;
  • (IE) Ireland: Thymoglobuline;
  • (IT) Italy: Thymoglobuline;
  • (JO) Jordan: Thymoglobulin;
  • (JP) Japan: Thymoglobulin | Thymoglobuline;
  • (KR) Korea, Republic of: Thymoglobulin;
  • (KW) Kuwait: Thymoglobuline;
  • (LB) Lebanon: Thymoglobuline;
  • (LT) Lithuania: Atg;
  • (LV) Latvia: Thymoglobuline;
  • (MX) Mexico: Timoglobulina;
  • (MY) Malaysia: Thymoglobuline;
  • (NL) Netherlands: Thymoglobuline;
  • (NZ) New Zealand: Thymoglobuline;
  • (PE) Peru: Timoglobulina;
  • (PK) Pakistan: Thymoglobuline;
  • (PL) Poland: Thymoglobuline;
  • (PT) Portugal: Timoglobulina;
  • (QA) Qatar: Thymoglobuline;
  • (RU) Russian Federation: Atg-Fresenius S | Thymoglobulin;
  • (SA) Saudi Arabia: Thymoglobulin;
  • (SE) Sweden: Thymoglobuline;
  • (SI) Slovenia: Thymoglobulin;
  • (SK) Slovakia: Thymoglobuline;
  • (TH) Thailand: Thymoglobuline;
  • (TN) Tunisia: Thymoglobuline;
  • (TR) Turkey: Thymoglobuline;
  • (TW) Taiwan: Thymoglobuline;
  • (UY) Uruguay: Timoglobulina;
  • (ZA) South Africa: Thymoglobuline
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