The Role of Therapeutic Monitoring of Everolimus in Solid Organ Transplantation

Everolimus is a novel proliferation signal inhibitor used in immunosuppressive therapies for the prevention of acute and chronic rejection. A role for everolimus drug monitoring has been suggested because of the potential for improving efficacy and reducing adverse effects. Everolimus has proven efficacy for prevention of rejection in adult de novo renal and cardiac transplant recipients. Similar effects have been shown in pediatric renal transplant patients. Several analytic methods are available to quantify everolimus concentrations. A good relationship exists between everolimus concentration and pharmacological response. Mere clinical monitoring of efficacy is insufficient because clinical presentations of graft rejection vary for each patient and are nonspecific. Thus, the authors have used a previously published 9-step decision-making algorithm to evaluate the utility of therapeutic drug monitoring for everolimus. The recommended therapeutic range for everolimus is a trough concentration of 3 to 8 ng/mL, as concentrations over 3 ng/mL have been associated with a decreased incidence of rejection, and concentrations >8 ng/mL with increased toxicity. Everolimus exhibits interindividual pharmacokinetic variability. African American patients have higher apparent clearance, whereas patients with hepatic dysfunction or those on concomitant medications with potent cytochrome P450 (CYP) 3A4 inhibitor or inducer properties have lower or higher apparent clearance, respectively. Solid organ transplant recipients will likely be maintained on immunosuppressant therapy for the life of the graft and/or recipient and thus are likely to benefit from clinical pharmacokinetic monitoring. Based on the available evidence, therapeutic drug monitoring for everolimus may provide additional information on efficacy and safety than sound clinical judgment alone. Patients on everolimus who have problems with absorption, who take concurrent cytochrome P450 inhibitors or inducers, or are noncompliant will attain the greatest benefit from drug monitoring.