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Pediatric Cardiac Intensive Care Society 2014 Consensus Statement: Pharmacotherapies in Cardiac Critical Care Immune Therapy

Singh, Rakesh K. MD, MS; Humlicek, Timothy PharmD; Jeewa, Aamir MD; Fester, Keith PharmD, BCPS

doi: 10.1097/PCC.0000000000000626

Objective: In this Consensus Statement, we review the etiology and pathophysiology of inflammatory processes seen in critically ill children with cardiac disease. Immunomodulatory therapies aimed at improving outcomes in patients with myocarditis, heart failure, and transplantation are extensively reviewed.

Data Sources: The author team experience and along with an extensive review of the medical literature were used as data sources.

Data Synthesis: The authors synthesized the data in the literature to present current immumodulatory therapies. For each drug, the physiologic rationale, mechanism of action, and pharmacokinetics are synthesized, and the evidence in the literature to support the therapy is discussed.

Conclusions: Immunomodulation has a crucial role in the treatment of certain pediatric cardiac diseases. Immunomodulatory treatments that have been used to treat myocarditis include corticosteroids, IV immunoglobulin, cyclosporine, and azathioprine. Contemporary outcomes of pediatric transplant recipients have improved over the past few decades, partly related to improvements in immunomodulatory therapy to prevent rejection of the donor heart. Immunosuppression therapy is commonly divided into induction, maintenance, and acute rejection therapy. Common induction medications include antithymocyte globulin, muromonab-CD3, and basiliximab. Maintenance therapy includes chronic medications that are used daily to prevent rejection episodes. Examples of maintenance medications are corticosteroids, cyclosporine, tacrolimus, sirolimus, everolimus, azathioprine, and mycophenolate mofetil. Rejection of the donor heart is diagnosed either by clinically or by biopsy and is treated with intensification of immunosuppression.

1Division of Pediatric Cardiology, Department of Pediatrics, Rady Children’s Hospital San Diego, UC San Diego School of Medicine, San Diego, CA.

2Department of Pharmacy, Texas Children’s Hospital, Houston, TX.

3Division of Cardiology, Department of Pediatric Medicine, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX.

4Department of Pharmacy, Morgan Stanley Children’s Hospital of New York-Presbyterian, Columbia University Medical Center, New York, NY.

Dr. Humlicek disclosed off-label product use: The pharmacotherapy in article includes discussion on medications not specifically labeled for the patient population. The remaining authors have disclosed that they do not have any potential conflicts of interest.

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©2016The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies