Universal check-list for immunosuppressant use::

•  Hep B/C screening?

• TB Quantiferon? Dual testing advised, IGRA favored over TST by ID

• Annual flu vaccine?

•  Pneumonia vaccine every 5 years?

• Shingrex vaccine?

• COVID-19 vaccinations/boosters:

• Live Vaccines?

• Pregnant/Breastfeeding? N/A

• Cancer history?

• Infections?

• Switching Immunosuppressant? Give at least 1 month 'holiday' after discontinuing one prior to starting new agent

Prednisone

• Start Date?

• Dose?

• CBC with differential monitoring?

• CMP monitoring? (look for hypokalemia)?

• PCP prophylaxis with Bactrim? If prednisone > 15 mg by mouth daily or corticosteroid sparing agent or if ALC < 0.8 or CD4 lymph count <200-400.

• DEXA?

• Calcium 1200mg daily

• Vitamin D 800 units daily

• HbA1c?

• Hypertensive? Blood pressure checks at home?

• Cataracts? Annual eye exam

• GI bleeding? ASA and NSAIDs increase risk:

• GI prophylaxis? Taking PPI

• Allopurinol or NSAID use?

• Lasix use? worsens hypokalemia

IVIG

• Start date:

• Dosing (g/kg)?

• Infusion frequency? Weekly

• Infusion given at infusion center/home?

• Monthly CBC?

• Leukopenia? Last WBC?

• Hemolytic anemia? Last Hgb normal

• Monthly BUN / Cr?

• Planned frequency or dose reduction?

• Thrombosis? DVT, stroke, MI, history of PE

• Anticoagulation:

• Skin rash?

• Headache? Prophylaxis? Abortive?

Methotrexate

• Start Date

• Dose 25 mg weekly

• CBC weekly for 1mo then Q1mo for 3mo then Q3mo thereafter (last check)? Checking

• Absolute Neutrophil Count < 1.0?

• Absolute lymphocyte count <0.6?

• WBC <3?

• MCV > 100? predictor of folate depletion

• BUN/Cr Q1mo then Q3mo (last check)?

• LFTs monthly for 3 month then Q3mo?

• Hepatotoxicity/fibrosis history?

• Annual PFTs? Interstitial Lung Disease / pneumonitis? ILD is contraindication to MTX

•  Cutaneous rash? usually within days of dose > reduce dose, if no improvement, discontinue.

• Stomatitis? if present, increase folic acid to 2mg daily

• Folic acid Supplementation?

• Do not give Folic acid  at same time as MTX (lowers effect)

• NSAID use? Myelosuppression and AKI more common with concomitant use.

• Down syndrome? increased risk BM suppression (esp with MTX)