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The Delaware Valley DRUG METABOLISM DISCUSSION GROUP
Drug Metabolism and Pharmacokinetics of Immunosuppressive Agents: Implications for the Transplant Patient Suppression of the immune response is the cornerstone of Transplant Medicine. Most crucial to its success has been the introduction of several generations of immunosuppressants (for example cyclosporin A, Tacrolimus, microphenolate, or rapamycin), accompanied by a thorough understanding of their metabolism, their pharmacokinetics, and pharmacodynamics. However, striking the right balance between too much medication, with increased risks of serious side effects, and too little medication, with the risk of organ rejection, constitutes still a major fundamental challenge in Transplant Medicine. Learning from the experience of many investigators both in the clinical and pre-clinical arenas worldwide, our efforts to establish a "critical dose" of immunosuppressant agents, and to deliver this dose to the individual patient in the hospital, continue to be a major challenge. This has necessitated the development and application of sensitive and specific analytical techniques in the clinical laboratory (including HPLC and HPLC-MS) for detection and quantitation of the immunosuppressants and their metabolites, for accurate measurements of free drug levels, and for determination of kinetic and pharmacodynamic parameters - in studies on individual patients as well as on suitable cohorts. Parallel investigations have to be carried out in cell cultures for the assessment of drug effects on cell proliferation, and the characterization of suitable markers for mmunosuppression and outcome experiments in animal models. Today, patients with many different forms of life-threatening disease have a much brighter prospect of life as the result of the many major strides made over the past 40 years. Nevertheless, the search for new strategies and how to use the existing drugs for optimal effect will continue as a standard part of our daily clinical work. This - and the continued search for newer, better, and safer immunosuppressive agents - remains a high priority in the list of therapeutic goals in Transplant Medicine.
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