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Sirolimus is a macrolide antibiotic, isolated from Streptomyces hygroscopicus, with potent effects including suppression of T- and B-cell proliferation and antineoplastic and antifungal activity. It inhibits the protein kinase mTOR to arrest the cell cycle; it has no effects on calcineurin and, therefore, can be used in addition to cyclosporine or tacrolimus, or as a substitute in patients intolerant to these drugs. Sirolimus is metabolized by CYP3A4, thus, blood concentrations are affected by drugs that inhibit or induce this enzyme. The pharmacokinetic interaction between sirolimus and cyclosporine or tacrolimus increases both therapeutic immunosuppression and the toxicity of these agents; lower doses are required with combined use. Adverse effects of sirolimus are generally concentration dependent, making therapeutic drug monitoring essential.
Trough sirolimus concentrations are generally measured every 5 days. Target concentrations vary depending on concomitant therapy, time posttransplant, the desired degree of immunosuppression, and adverse effects. When given with cyclosporine or tacrolimus, the therapeutic range for sirolimus is generally between 4 and 12 ng/mL with minimal added benefit for concentrations >10 ng/mL. When sirolimus is given without calcineurin inhibitors, higher trough levels are needed; usually 12 to 20 ng/mL, but occasionally up to 20 to 30 ng/mL.
Monitoring whole blood sirolimus concentration during therapy, particularly in individuals coadministered CYP3A4 substrates, inhibitors, or inducers
Adjusting dose to optimize immunosuppression while minimizing toxicity
Evaluating patient compliance
Most individuals display optimal response to sirolimus with trough whole blood levels 4 to 20 ng/mL. Preferred therapeutic ranges may vary by transplant type, protocol, and comedications.
Therapeutic ranges are based on specimens drawn at trough (ie, immediately before a scheduled dose). Blood drawn at other times will yield higher results.
The assay is specific for sirolimus; it does not cross-react with cyclosporine, cyclosporine metabolites, tacrolimus, tacrolimus metabolites, or sirolimus metabolites. Results by liquid chromatography with detection by liquid chromatography-tandem mass spectrometry are approximately 30% less than by immunoassay.
The recommended therapeutic range applies to trough specimens drawn immediately before a dose. Blood drawn at other times will yield higher results.
4-20 ng/mL (Trough)
Target steady-state trough concentrations vary depending on the type of transplant, concomitant immunosuppression, clinical/institutional protocols, and time post-transplant. Results should be interpreted in conjunction with this clinical information and any physical signs/symptoms of rejection/toxicity.
1. Kahan BD: Ten years of mTOR inhibitor therapy. Transplant Proc 2003;35(3A):3S-240S
2. Yakupoglu YK, Kahan BD: Sirolimus: a current perspective. Exp Clin Transplant 2003;1:8-18
3. Groth CG, Backman L, Morales JM, et al: Sirolimus (rapamycin)-based therapy in human renal transplantation: similar efficacy and different toxicity compared with cyclosporine. Sirolimus European Renal Transplant Study Group. Transplantation 1999 April;67(7):1036-1042