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Reducing Medications for Heart Transplant Patients Improves Side Effects Without Affecting Survival

Reducing the number of medications taken by heart transplant patients can eliminate unpleasant and unhealthy side effects without increasing the risk of organ rejection, reported Timothy Oaks, M.D., of Wake Forest University Baptist Medical Center (WFUBMC) at today''s meeting of the Southern Thoracic Surgical Association.

"There''s increasing evidence that steroids may not be required long-term in heart transplant patients, yet 70 percent of patients in the United States are still taking the drugs three years after transplant," said Oaks, director of cardiothoracic transplantation at WFUBMC.

Heart transplant patients normally take three drugs to prevent organ rejection. Oaks said one of the drugs, the steroid prednisone, can be safely eliminated in many patients. Prednisone''s side effects can include high blood pressure, high cholesterol, diabetes, kidney problems, weight gain, osteoporosis and cataracts. The other two drugs usually prescribed are cyclosporine and azathioprine.

Oaks reported that of 57 adult transplant patients at WFUBMC, 80 percent were successfully weaned off prednisone within two years of surgery. The patients did not have higher rates of rejection or infection as compared to national averages. Their survival rates were 98 percent after one year and 93 percent after three years, exceeding nationwide survival rates of 85 percent at one year and 77 percent at three years.

"Our study lends further support to the idea that patients can be safely weaned off steroids," said Oaks. "It can be done and it should be done."

At Wake Forest, doses of prednisone are gradually tapered off beginning at 6 months after transplant.

"We believe that steroids should be given during the time when rejection is most likely, namely the first six months," said Oaks.

In a review of professional journals, Oaks found that other centers have reported success weaning patients off steroids, or not prescribing them in the first place.

"Our success with steroid weaning is similar to previous published reports," said Oaks. "These studies clearly demonstrate that steroid-free immunosuppression is possible in at least half of patients and may reduce some of the long-term complications of steroids."

In addition to unpleasant side effects, steroids can cause high blood pressure and high cholesterol levels that are risk factors for atherosclerosis, the buildup of fatty deposits in the blood vessels. By eliminating steroids, many patients reduce these risk factors and can eliminate blood pressure and cholesterol-lowering medications.

Oaks said future advances in transplantation will likely come from increased understanding of immunosuppressant drugs and their long-term risks and benefits.

"The surgical procedure has changed little in the past 30 years," he said. "The success of heart transplantation is primarily related to achieving a perfect balance of suppressing the immune system to prevent rejection yet also avoiding infections and other complications."

Oaks called for large, randomly controlled research studies to provide definitive answers about the safest and most effective therapy after heart transplantation. About 2,200 heart transplants are performed every year in the United States.

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