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

Ther Drug Monit. 2020 Jun;42(3):360-368. doi: 10.1097/FTD.0000000000000761.


Background: 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.

Publication types

  • Review

MeSH terms

  • Adenosine Monophosphate / analogs & derivatives
  • Alanine / analogs & derivatives
  • Antibodies, Monoclonal, Humanized
  • Antiviral Agents / adverse effects*
  • Antiviral Agents / therapeutic use
  • Betacoronavirus
  • COVID-19
  • Coronavirus Infections / drug therapy*
  • Drug Interactions
  • Drug Monitoring*
  • Glucocorticoids
  • Humans
  • Hydroxychloroquine
  • Immunosuppressive Agents / adverse effects*
  • Immunosuppressive Agents / therapeutic use
  • Pandemics
  • Pneumonia, Viral / drug therapy*
  • Protease Inhibitors
  • SARS-CoV-2
  • Transplant Recipients*


  • Antibodies, Monoclonal, Humanized
  • Antiviral Agents
  • Glucocorticoids
  • Immunosuppressive Agents
  • Protease Inhibitors
  • remdesivir
  • Adenosine Monophosphate
  • Hydroxychloroquine
  • tocilizumab
  • Alanine