Version May 2024
Anaphylaxis has been reported with the use of antithymocyte globulin (equine). Antithymocyte globulin (equine) can cause potentially life-threatening anaphylaxis when injected intravenously. Monitor patients for signs and symptoms of anaphylaxis during infusion and for at least 24 hours after infusion.
Note: Test dose: While a skin test is recommended prior to administration of the initial dose, anaphylaxis may still occur in patients who display negative skin tests. Consider testing initially with an epicutaneous prick of undiluted antithymocyte globulin (ATG); if no wheal in 10 minutes, then use 0.02 mL intradermally of a 1:1,000 dilution of ATG in normal saline along with a separate saline control of 0.02 mL; observe in 10 minutes. A positive skin reaction consists of a wheal with the initial prick test (undiluted) or ≥3 mm in diameter larger than the saline control with the diluted intradermal test. Alternatively, a 0.1 mL test dose (5 mg/mL concentration) may be administered intradermally along with a separate saline control; erythema larger than 5 mm in diameter (compared to the control) is considered a positive test (Ref). A positive skin test is suggestive of an increased risk for systemic allergic reactions with an infusion and alternative forms of treatment should be considered. Allergic reactions, including anaphylaxis, have occurred in patients with negative skin tests; skin testing does not show risk of delayed hypersensitivity reactions, including serum sickness.
Consider premedication with an antihistamine, corticosteroids, and/or an antipyretic. Concomitant immunosuppressants should also be administered.
Aplastic anemia, moderate to severe: IV: 10 to 20 mg/kg once daily for 8 to 14 days, then if needed, may administer every other day for 7 more doses for a total of 21 doses in 28 days or
Aplastic anemia, severe (off-label dosing): IV: 40 mg/kg once daily for 4 days (in combination with cyclosporine) (Ref) or 40 mg/kg once daily for 4 consecutive days (in combination with cyclosporine and eltrombopag) (Ref).
Lung transplant, induction therapy (off- label use): IV: 5 to 15 mg/kg daily for the first 3 days after transplant (Ref). Additional data may be necessary to further define the role of antithymocyte globulin (equine) in this condition.
Myelodysplastic syndromes, refractory, lower-risk disease (off-label use): IV: 40 mg/kg once daily for 4 days; an intradermal test dose was administered prior to treatment (Ref).
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
There are no dosage adjustments provided in the manufacturer's labeling.
There are no dosage adjustments provided in the manufacturer's labeling.
American Society for Blood and Marrow Transplantation practice guideline committee position statement on chemotherapy dosing in adults with a BMI ≥30 kg/m2: Utilize actual body weight to calculate weight-based dosing for hematopoietic cell transplant conditioning regimens (Ref).
Anaphylaxis: Discontinue infusion immediately; administer epinephrine. May require corticosteroids, respiration assistance, and/or other resuscitative measures. Do not resume infusion.
Hemolysis (severe and unremitting): May require discontinuation of treatment.
Refer to adult dosing. Begin at the lower end of dosing ranges.
(For additional information see "Antithymocyte globulin (horse derived, Atgam): Pediatric drug information")
Test dose: While a skin test is recommended prior to administration of the initial dose, anaphylaxis may still occur in patients who display a negative skin test. Consider testing initially with an epicutaneous prick of undiluted antithymocyte globulin (ATG); if no wheal in 10 minutes, then use 0.02 mL intradermally of a 1 mg/mL dilution of ATG in normal saline along with a separate saline control of 0.02 mL; observe in 10 minutes. A positive skin reaction consists of a wheal with the initial prick test (undiluted) or ≥3 mm in diameter larger than the saline control with the diluted intradermal test. A positive skin test is suggestive of an increased risk for systemic allergic reactions with an infusion, although anaphylaxis may occur in patients who display negative skin tests. If ATG treatment is deemed appropriate following a positive skin test, the first infusion should be administered in a controlled environment with intensive life support immediately available. A systemic reaction precludes further administration of the drug. Note: Consider premedication with an antihistamine, corticosteroids, and/or an antipyretic.
Aplastic anemia, moderate to severe when no HLA-matched sibling donor:
Manufacturer's labeling: Children and Adolescents: IV: 10 to 20 mg/kg/dose once daily for 8 to 14 days; then if needed, may administer every other day up to a total of 21 doses in 28 days
Alternate dosing (in combination with cyclosporine): Limited data available: Children ≥2 years and Adolescents: IV: 40 mg/kg/dose once daily for 4 days (Ref)
Renal transplantation rejection, treatment: Children and Adolescents: IV: 10 to 15 mg/kg/dose once daily for 14 days, then if needed, may administer every other day up to a total of 21 doses in 28 days
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
There are no dosage adjustments provided in the manufacturer’s labeling.
There are no dosage adjustments provided in the manufacturer’s labeling.
The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified.
>10%:
Dermatologic: Skin rash (26%)
Hematologic & oncologic: Leukopenia (18%), thrombocytopenia (22%)
Nervous system: Chills (27%)
Neuromuscular & skeletal: Arthralgia (17%)
Miscellaneous: Fever (40%)
1% to 10%:
Cardiovascular: Arteriovenous fistula site complication (thrombosis) (1%), bradycardia (2%), chest pain (3%), edema (2%), hypertension (3%), hypotension (3%), tachycardia (1%), thrombophlebitis (3%)
Dermatologic: Pruritus (5%), urticaria (9%)
Gastrointestinal: Diarrhea (3%), nausea (4%), upper abdominal pain (3%), vomiting (3%)
Hematologic & oncologic: Lymphadenopathy (1%)
Hepatic: Abnormal hepatic function tests (1%)
Infection: Infection (3%; including bacterial infection, fungal infection, viral infection)
Local: Infusion-site pain (2%)
Nervous system: Dizziness (1%), headache (5%)
Neuromuscular & skeletal: Back pain (2%)
Respiratory: Dyspnea (1%)
<1%:
Cardiovascular: Venous thrombosis (iliac)
Dermatologic: Allergic dermatitis, night sweats, toxic epidermal necrolysis
Endocrine & metabolic: Hyperglycemia
Gastrointestinal: Hiccups, stomatitis
Genitourinary: Proteinuria
Hypersensitivity: Anaphylaxis, serum sickness
Infection: Herpes simplex infection
Nervous system: Agitation, asthenia, encephalitis, malaise, paresthesia, seizure
Neuromuscular & skeletal: Laryngospasm
Ophthalmic: Periorbital edema
Renal: Renal artery thrombosis, renal function test abnormality
Respiratory: Pleural effusion, pulmonary edema
Miscellaneous: Wound dehiscence
Postmarketing:
Cardiovascular: Deep vein thrombosis, heart failure, syncope, vasculitis
Dermatologic: Hyperhidrosis
Gastrointestinal: Abdominal pain, gastrointestinal hemorrhage, gastrointestinal perforation, mouth pain
Hematologic & oncologic: Anemia, eosinophilia, granulocytopenia, hemolysis, hemolytic anemia, neutropenia, pancytopenia, pure red cell aplasia
Hepatic: Viral hepatitis
Hypersensitivity: Cytokine release syndrome, infusion-related reaction
Infection: Opportunistic infection, sepsis
Local: Infusion-site reaction (erythema, swelling)
Nervous system: Confusion, disorientation, pain, tremor
Neuromuscular & skeletal: Dyskinesia, limb pain, muscle rigidity, myalgia
Renal: Flank pain, nephrotoxicity (including acute kidney injury, kidney enlargement, kidney rupture)
Respiratory: Apnea, cough, epistaxis, oropharyngeal pain
History of anaphylactic reaction during prior administration of antithymocyte globulin (equine) or any other equine gamma globulin preparation.
Canadian labeling: Additional contraindications (not in US labeling): Hypersensitivity to antithymocyte globulin (equine) or any components of the formulation.
Concerns related to adverse effects:
• Anaphylaxis: Anaphylaxis (sometimes life-threatening) has been reported; generalized rash, dyspnea, hypotension, and tachycardia may be signs of anaphylactic reaction. Have epinephrine and emergency equipment available for acute allergic reaction. Skin testing is recommended prior to administration of the initial ATG dose. A positive skin test is suggestive of clinical hypersensitivity and an increased risk for systemic allergic reactions (including anaphylaxis) with an infusion, although anaphylaxis may occur in patients who display negative skin tests. If a positive skin test occurs, strongly consider alternative forms of therapy. Skin testing is not predictive for later development of serum sickness.
• Cytokine release syndrome: Cytokine release syndrome (sometimes fatal) has been reported. Symptoms may include chest pain, chills, dyspnea, edema, fever, headache, hypotension, and tachypnea.
• Hematologic toxicity: Thrombocytopenia and neutropenia may occur; consider platelet transfusion support in patients developing thrombocytopenia. Discontinue if severe and unremitting neutropenia or thrombocytopenia occur.
• Hepatic function: Abnormal hepatic function tests have been observed in patients with aplastic anemia and other hematologic disorders receiving ATG.
• Infection: Opportunistic infections (eg, bacterial, fungal, and viral) and sepsis have been reported due to immunosuppressant effect. An increased risk of viral reactivation (eg, cytomegalovirus, Epstein-Barr virus, herpes simplex virus) has been reported.
• Infusion reactions: Severe infusion reactions (eg, dyspnea, hypotension, generalized rash, tachycardia) have been reported.
• Renal function: Abnormal renal function tests have been observed in patients with aplastic anemia and other hematologic disorders receiving ATG.
• Serum sickness: Serum sickness, a delayed hypersensitivity/immune reaction, has occurred with use. Symptoms may include arthralgia, chills, fever, and pain.
Concurrent drug therapy issues:
• Immunizations: Live viral vaccines may not replicate and antibody response may be reduced if administered during ATG treatment. Patients should not be immunized with attenuated live viral vaccines prior to planned ATG treatment, during, and after treatment.
Other warnings/precautions:
• Administration: Administer via central line due to chemical phlebitis that may occur with a peripheral vein. Dose must be administered over at least 4 hours; patient may need to be pretreated with an antipyretic, antihistamine, and/or corticosteroid. Should be administered with concomitant immunosuppressants.
• Disease transmission: Product of equine and human plasma; may have a risk of transmitting disease, including viruses and Creutzfeldt-Jakob disease. Report any suspected infections to the manufacturer at 1-800-438-1985.
• Potency: Product potency and activity may vary from lot to lot.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Injectable, Intravenous [preservative free]:
Atgam: 50 mg/mL (5 mL) [thimerosal free]
No
Injection (Atgam Intravenous)
50 mg/mL (per mL): $914.52
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Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Injectable, Intravenous:
Atgam: 50 mg/mL (5 mL)
IV: For IV use only. Infuse over at least 4 hours through a 0.2 to 1 micron inline filter. Allow solution to reach room temperature prior to infusion. Infusion must be completed with 24 hours of preparation. Administration through a central line is recommended; high flow veins are preferred to reduce phlebitis (infuse into vascular shunt, arterial venous fistula, or high-flow central vein). May cause vein irritation (chemical phlebitis) if administered peripherally (peripheral administration is not recommended).
Monitor closely throughout the infusion and for at least 24 hours after the infusion for anaphylaxis. Appropriate resuscitative equipment should be nearby during administration. May require premedication with an antipyretic, antihistamine, and/or a corticosteroid to prevent reactions. Discontinue infusion for anaphylaxis or respiratory distress. Administer epinephrine, corticosteroids, antihistamines, and/or antipyretics as indicated to manage reactions.
Due to possible infusion-related reactions, it may be preferable to avoid initiating treatment late in the day or on weekends; consider withholding beta-blockers prior to administration to avoid suppressing compensatory responses to anaphylaxis (Ref).
IV: Infuse dose over at least 4 hours through a 0.2 to 1 micron in-line filter. May need to slow rate of infusion if patient experiences fever or chills during infusion (Ref). Allow solution to reach room temperature prior to infusion. Infusion must be completed with 24 hours of preparation. May cause vein irritation (chemical phlebitis) if administered peripherally; infuse into a vascular shunt, arterial venous fistula, or high-flow central vein. Any severe systemic reaction to the skin test, such as generalized rash, tachycardia, dyspnea, hypotension, or anaphylaxis, should preclude further therapy. Epinephrine and resuscitative equipment should be nearby. Patient may need to be pretreated with an antipyretic, antihistamine, and/or corticosteroid. Mild itching and erythema can be treated with antihistamines.
Aplastic anemia, moderate to severe: Treatment of moderate-to-severe aplastic anemia in patients not considered suitable candidates for bone marrow transplantation.
Limitations of use: The usefulness of antithymocyte globulin (equine) has not been demonstrated in patients with aplastic anemia who are suitable candidates for transplantation, or in aplastic anemia secondary to neoplastic disease, storage disease, myelofibrosis, Fanconi syndrome, or in patients with known prior treatment with myelotoxic agents or radiation therapy.
Acute graft-versus-host disease (treatment); Lung transplant (induction therapy); Myelodysplastic syndromes, refractory, lower-risk disease
Antithymocyte globulin equine (Atgam) may be confused with antithymocyte globulin rabbit (Thymoglobulin)
Atgam may be confused with Ativan
The Institute for Safe Medication Practices (ISMP) includes this medication among its list of drugs that have a heightened risk of causing significant patient harm when used in error.
None known.
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 Lexicomp drug interactions program by clicking on the “Launch drug interactions program” link above.
5-Aminosalicylic Acid Derivatives: May enhance the myelosuppressive effect of Myelosuppressive Agents. Risk C: Monitor therapy
Abrocitinib: May enhance the immunosuppressive effect of Immunosuppressants (Therapeutic Immunosuppressant Agents). Risk X: Avoid combination
Anti-CD20 B-Cell Depleting Therapies: May enhance the adverse/toxic effect of Antithymocyte Globulin (Equine). Specifically, these effects may be unmasked if the dose of anti-CD20 B-cell depleting therapy is reduced. Anti-CD20 B-Cell Depleting Therapies may enhance the immunosuppressive effect of Antithymocyte Globulin (Equine). Specifically, infections may occur with greater severity and/or atypical presentations. Risk C: Monitor therapy
Baricitinib: Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the immunosuppressive effect of Baricitinib. Risk X: Avoid combination
BCG (Intravesical): Myelosuppressive Agents may diminish the therapeutic effect of BCG (Intravesical). Risk X: Avoid combination
BCG Products: Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the adverse/toxic effect of BCG Products. Specifically, the risk of vaccine-associated infection may be increased. Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect of BCG Products. Risk X: Avoid combination
Belatacept: Antithymocyte Globulin (Equine) may enhance the adverse/toxic effect of Belatacept. Specifically, the risk for venous thrombosis of the renal allograft may be increased. Belatacept may enhance the immunosuppressive effect of Antithymocyte Globulin (Equine). Management: A 12-hour interval between administration of these 2 agents is suggested if used concomitantly. Monitor for venous thrombosis of the renal allograft, infections, and if the belatacept dose is reduced, monitor for unmasking of antithymocyte reactions. Risk D: Consider therapy modification
Brincidofovir: Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect of Brincidofovir. Risk C: Monitor therapy
Brivudine: May enhance the adverse/toxic effect of Immunosuppressants (Therapeutic Immunosuppressant Agents). Risk X: Avoid combination
Chikungunya Vaccine (Live): Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the adverse/toxic effect of Chikungunya Vaccine (Live). Specifically, the risk of vaccine-associated infection may be increased. Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect of Chikungunya Vaccine (Live). Risk X: Avoid combination
Chloramphenicol (Ophthalmic): May enhance the adverse/toxic effect of Myelosuppressive Agents. Risk C: Monitor therapy
Chloramphenicol (Systemic): Myelosuppressive Agents may enhance the myelosuppressive effect of Chloramphenicol (Systemic). Risk X: Avoid combination
Cladribine: May enhance the myelosuppressive effect of Myelosuppressive Agents. Risk X: Avoid combination
Cladribine: Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the immunosuppressive effect of Cladribine. Risk X: Avoid combination
CloZAPine: Myelosuppressive Agents may enhance the adverse/toxic effect of CloZAPine. Specifically, the risk for neutropenia may be increased. Risk C: Monitor therapy
Coccidioides immitis Skin Test: Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the diagnostic effect of Coccidioides immitis Skin Test. 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
Corticosteroids (Systemic): May enhance the adverse/toxic effect of Antithymocyte Globulin (Equine). Specifically, these effects may be unmasked if the dose of systemic corticosteroid is reduced. Corticosteroids (Systemic) may enhance the immunosuppressive effect of Antithymocyte Globulin (Equine). Specifically, infections may occur with greater severity and/or atypical presentations. Risk C: Monitor therapy
COVID-19 Vaccine (Adenovirus Vector): Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect of COVID-19 Vaccine (Adenovirus Vector). Management: Administer a 2nd dose using an mRNA COVID-19 vaccine (at least 4 weeks after the primary vaccine dose) and a bivalent booster dose (at least 2 months after the additional mRNA dose or any other boosters). Risk D: Consider therapy modification
COVID-19 Vaccine (Inactivated Virus): Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect of COVID-19 Vaccine (Inactivated Virus). Risk C: Monitor therapy
COVID-19 Vaccine (mRNA): Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect 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 diminish the therapeutic effect of COVID-19 Vaccine (Subunit). Risk C: Monitor therapy
COVID-19 Vaccine (Virus-like Particles): Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect of COVID-19 Vaccine (Virus-like Particles). Risk C: Monitor therapy
Deferiprone: Myelosuppressive Agents may enhance the neutropenic effect 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 enhance the adverse/toxic effect of Dengue Tetravalent Vaccine (Live). Specifically, the risk of vaccine-associated infection may be increased. Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect of Dengue Tetravalent Vaccine (Live). Risk X: Avoid combination
Denosumab: Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the immunosuppressive effect 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 enhance the immunosuppressive effect of Immunosuppressants (Therapeutic Immunosuppressant Agents). Risk X: Avoid combination
Dipyrone: May enhance the adverse/toxic effect of Myelosuppressive Agents. Specifically, the risk for agranulocytosis and pancytopenia may be increased Risk X: Avoid combination
Efgartigimod Alfa: May diminish the therapeutic effect of Fc Receptor-Binding Agents. Risk C: Monitor therapy
Etrasimod: May enhance the immunosuppressive effect of Immunosuppressants (Therapeutic Immunosuppressant Agents). Risk X: Avoid combination
Fexinidazole: Myelosuppressive Agents may enhance the myelosuppressive effect of Fexinidazole. Risk X: Avoid combination
Filgotinib: May enhance the immunosuppressive effect of Immunosuppressants (Therapeutic Immunosuppressant Agents). Risk X: Avoid combination
Immunosuppressants (Cytotoxic Chemotherapy): May enhance the adverse/toxic effect of Antithymocyte Globulin (Equine). Specifically, these effects may be unmasked if the dose of cytotoxic chemotherapy is reduced. Immunosuppressants (Cytotoxic Chemotherapy) may enhance the immunosuppressive effect of Antithymocyte Globulin (Equine). Specifically, infections may occur with greater severity and/or atypical presentations. Risk C: Monitor therapy
Immunosuppressants (Miscellaneous Oncologic Agents): May enhance the adverse/toxic effect of Antithymocyte Globulin (Equine). Specifically, these effects may be unmasked if the dose of immunosuppressive therapy is reduced. Immunosuppressants (Miscellaneous Oncologic Agents) may enhance the immunosuppressive effect of Antithymocyte Globulin (Equine). Specifically, infections may occur with greater severity and/or atypical presentations. Risk C: Monitor therapy
Immunosuppressants (Therapeutic Immunosuppressant Agents): May enhance the adverse/toxic effect of Antithymocyte Globulin (Equine). Specifically, these effects may be unmasked if the dose of immunosuppressive therapy is reduced. Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the immunosuppressive effect of Antithymocyte Globulin (Equine). Specifically, infections may occur with greater severity and/or atypical presentations. Risk C: Monitor therapy
Inebilizumab: Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the immunosuppressive effect of Inebilizumab. Risk C: Monitor therapy
Influenza Virus Vaccines: Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect 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 enhance the immunosuppressive effect 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
Methotrexate: May enhance the adverse/toxic effect of Antithymocyte Globulin (Equine). Specifically, these effects may be unmasked if the dose of methotrexate is reduced. Methotrexate may enhance the immunosuppressive effect of Antithymocyte Globulin (Equine). Specifically, infections may occur with greater severity and/or atypical presentations. Risk C: Monitor therapy
Mumps- Rubella- or Varicella-Containing Live Vaccines: Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the adverse/toxic effect of Mumps- Rubella- or Varicella-Containing Live Vaccines. Specifically, the risk of vaccine-associated infection may be increased. Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect of Mumps- Rubella- or Varicella-Containing Live Vaccines. Risk X: Avoid combination
Nadofaragene Firadenovec: Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the adverse/toxic effect of Nadofaragene Firadenovec. Specifically, the risk of disseminated adenovirus infection may be increased. Risk X: Avoid combination
Natalizumab: Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the immunosuppressive effect of Natalizumab. Risk X: Avoid combination
Ocrelizumab: Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the immunosuppressive effect of Ocrelizumab. Risk C: Monitor therapy
Ofatumumab: Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the immunosuppressive effect of Ofatumumab. Risk C: Monitor therapy
Olaparib: Myelosuppressive Agents may enhance the myelosuppressive effect of Olaparib. Risk C: Monitor therapy
Pidotimod: Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect of Pidotimod. Risk C: Monitor therapy
Pimecrolimus: Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the immunosuppressive effect of Pimecrolimus. Risk X: Avoid combination
Pneumococcal Vaccines: Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect of Pneumococcal Vaccines. Risk C: Monitor therapy
Poliovirus Vaccine (Live/Trivalent/Oral): Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the adverse/toxic effect of Poliovirus Vaccine (Live/Trivalent/Oral). Specifically, the risk of vaccine-associated infection may be increased. Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect of Poliovirus Vaccine (Live/Trivalent/Oral). Risk X: Avoid combination
Polymethylmethacrylate: Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the potential for allergic or hypersensitivity reactions to 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 enhance the myelosuppressive effect of Myelosuppressive Agents. Risk C: Monitor therapy
Rabies Vaccine: Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect 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 enhance the immunosuppressive effect of Ritlecitinib. Risk X: Avoid combination
Ropeginterferon Alfa-2b: Myelosuppressive Agents may enhance the myelosuppressive effect 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 diminish the therapeutic effect of Fc Receptor-Binding Agents. Risk C: Monitor therapy
Ruxolitinib (Topical): Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the immunosuppressive effect of Ruxolitinib (Topical). Risk X: Avoid combination
Sipuleucel-T: Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect 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
Tacrolimus (Topical): Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the immunosuppressive effect of Tacrolimus (Topical). Risk X: Avoid combination
Talimogene Laherparepvec: Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the adverse/toxic effect 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 combination
Tertomotide: Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect of Tertomotide. Risk X: Avoid combination
Tofacitinib: Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the immunosuppressive effect 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 combination
Typhoid Vaccine: Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the adverse/toxic effect of Typhoid Vaccine. Specifically, the risk of vaccine-associated infection may be increased. Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect of Typhoid Vaccine. Risk X: Avoid combination
Ublituximab: Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the immunosuppressive effect of Ublituximab. Risk C: Monitor therapy
Upadacitinib: Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the immunosuppressive effect of Upadacitinib. Risk X: Avoid combination
Vaccines (Inactivated/Non-Replicating): Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect of Vaccines (Inactivated/Non-Replicating). Management: Give inactivated vaccines at least 2 weeks prior to initiation of immunosuppressants when possible. Patients vaccinated less than 14 days before initiating or during therapy should be revaccinated at least 2 to 3 months after therapy is complete. Risk D: Consider therapy modification
Vaccines (Live): Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the adverse/toxic effect of Vaccines (Live). Specifically, the risk of vaccine-associated infection may be increased. Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect of Vaccines (Live). Risk X: Avoid combination
Yellow Fever Vaccine: Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the adverse/toxic effect of Yellow Fever Vaccine. Specifically, the risk of vaccine-associated infection may be increased. Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect of Yellow Fever Vaccine. Risk X: Avoid combination
Patients who may become pregnant should use effective contraception during therapy and for at least 10 weeks after the last dose of antithymocyte globulin (equine).
Antithymocyte globulin (equine) is a purified immunoglobulin G. Human IgG crosses the placenta. Fetal exposure is dependent upon the IgG subclass, maternal serum concentrations, placental integrity, newborn birth weight, and gestational age, generally increasing as pregnancy progresses. The lowest exposure would be expected during the period of organogenesis and the highest during the third trimester (Clements 2020; Palmeira 2012; Pentsuk 2009).
Outcome data related to the use of antithymocyte globulin (equine) during pregnancy are limited (Aitchison 1989; Miller 1995; Pajor 1992). Antithymocyte globulin (equine) is not recommended for the treatment of aplastic anemia in pregnancy (Killick 2016).
The 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.
It is not known if antithymocyte globulin (equine) is present in breast milk.
Antithymocyte globulin (equine) is a purified immunoglobulin G. Human IgG is present in breast milk; concentrations are dependent upon IgG subclass and postpartum age (Anderson 2021).
Due to the potential for serious adverse reactions in the nursing infant, the manufacturer recommends a decision be made to discontinue nursing or to discontinue the drug, considering the importance of treatment to the mother.
Complete blood count with differential and platelet count. Hepatic and renal function tests as clinically indicated. Monitor vital signs during administration; monitor for signs/symptoms of anaphylaxis during infusion and for at least 24 hours after the infusion; monitor for signs/symptoms of cytokine release syndrome; monitor for infusion reactions; monitor for signs/symptoms of infection; monitor for signs/symptoms of serum sickness.
Solid organ transplant: Absolute CD3 count (cells/µL) monitoring and CD3 based-dosing has been considered in renal 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 (Krasinska 2002).
Immunosuppressant involved in the elimination of antigen-reactive T lymphocytes (killer cells) in peripheral blood or alteration in the function of T-lymphocytes, which are involved in humoral immunity and partly in cell-mediated immunity; induces complete or partial hematologic response in aplastic anemia
Distribution: Poor into lymphoid tissues; binds to circulating lymphocytes, granulocytes, platelets, bone marrow cells
Half-life elimination: 5.7 ± 3 days
Excretion: Urine (~1%)
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