Requirements for therapeutic drug monitoring of sirolimus, an immunosuppressive agent used in renal transplantation

Background: On September 15, 1999, sirolimus received approval from the US Food and Drug Administration (FDA) for marketing as an immunosuppressive ag ent. As with any chronically administered medication, the question arises w hether therapeutic drug monitoring (TDM) is required for optimal therapy. I n the case of sirolimus, there are data to suggest that TDM may be benefici al in some patients. Objective: To assess the need for monitoring sirolimus concentrations, this paper reviews the following factors influencing the usefulness of TDM: wid e pharmacokinetic variability; toxicity; suspected noncompliance; suspected drug interactions; and specific demographic characteristics. Data supporti ng the correlation between sirolimus concentration and immunosuppressive ef ficacy are also discussed. Results: The available literature on sirolimus suggests that TDM may be req uired in some cases. Studies have shown that there is wide interindividual variability in the pharmacokinetic behavior of drugs in transplant patients ; that there is a relationship between blood concentrations of sirolimus an d adverse events; and that coadministration of cyclosporine alters the phar macokinetics of sirolimus. Additionally, the correlation between sirolimus concentration and immunosuppressive efficacy in phase III trials suggests a benefit in transplant patients when sirolimus concentrations reach appropr iate levels, Finally, noncompliance is a common occurrence in the transplan t population, and monitoring is often necessary in suspected noncompliers. Conclusion: Although additional clinical studies are needed, it appears tha t TDM is an important aspect of treatment with sirolimus.