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Pharmacologic Treatment of Transplant Recipients Infected With SARS-CoV-2: Considerations Regarding Therapeutic Drug Monitoring and Drug–Drug Interactions

  • Elens, Laure1, 2
  • Langman, Loralie J.3
  • Hesselink, Dennis A.4
  • Bergan, Stein5
  • Moes, Dirk Jan A.R.
  • Molinaro, Mariadelfina6
  • Venkataramanan, Raman7
  • Lemaitre, Florian8
  • 1 Louvain Drug Research Institute (LDRI), Integrated Pharmacometrics, Pharmacogenomics and Pharmacokinetics (PMGK), Université catholique de Louvain (UCLouvain);
  • 2 Institut de Recherche Expérimentale et Clinique (IREC), Louvain Center for Toxicology and Applied Pharmacology (LTAP), Université catholique de Louvain (UCLouvain);
  • 3 Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, Minnesota;
  • 4 Rotterdam Transplant Group;
  • 5 Department of Pharmacology, Oslo University Hospital, Oslo, Norway;
  • 6 Clinical and Experimental Pharmacokinetics Lab, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy;
  • 7 School of Pharmacy and Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania;
  • 8 INSERM, Centre d'Investigation Clinique, CIC 1414, Rennes, France.
Published Article
Therapeutic drug monitoring
Publication Date
Apr 23, 2020
DOI: 10.1097/FTD.0000000000000761
PMID: 32304488
PMCID: PMC7188032
PubMed Central


COVID-19 is a novel infectious disease caused by the severe acute respiratory distress (SARS)-coronavirus-2 (SARS-CoV-2). Several therapeutic options are currently emerging but none with universal consensus or proven efficacy. Solid organ transplant recipients are perceived to be at increased risk of severe COVID-19 because of their immunosuppressed conditions due to chronic use of immunosuppressive drugs (ISDs). It is therefore likely that solid organ transplant recipients will be treated with these experimental antivirals. Methods: This article is not intended to provide a systematic literature review on investigational treatments tested against COVID-19; rather, the authors aim to provide recommendations for therapeutic drug monitoring of ISDs in transplant recipients infected with SARS-CoV-2 based on a review of existing data in the literature. Results: Management of drug–drug interactions between investigational anti-SARS-CoV-2 drugs and immunosuppressants is a complex task for the clinician. Adequate immunosuppression is necessary to prevent graft rejection while, if critically ill, the patient may benefit from pharmacotherapeutic interventions directed at limiting SARS-CoV-2 viral replication. Maintaining ISD concentrations within the desired therapeutic range requires a highly individualized approach that is complicated by the pandemic context and lack of hindsight. Conclusions: With this article, the authors inform the clinician about the potential interactions of experimental COVID-19 treatments with ISDs used in transplantation. Recommendations regarding therapeutic drug monitoring and dose adjustments in the context of COVID-19 are provided.

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