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Antithymocyte globulin (rabbit derived, Thymoglobulin): Drug information

Antithymocyte globulin (rabbit derived, Thymoglobulin): Drug information
(For additional information see "Antithymocyte globulin (rabbit derived, Thymoglobulin): Patient drug information" and see "Antithymocyte globulin (rabbit derived, Thymoglobulin): Pediatric drug information")

For abbreviations, symbols, and age group definitions used in Lexicomp (show table)
ALERT: US Boxed Warning
Experienced physician:

Anti-thymocyte globulin should only be used by physicians experienced in immunosuppressive therapy in transplantation.

Brand Names: US
  • Thymoglobulin
Brand Names: Canada
  • Thymoglobulin
Pharmacologic Category
  • Immune Globulin;
  • Immunosuppressant Agent;
  • Polyclonal Antibody
Dosing: Adult

Note: Premedicate with corticosteroids, acetaminophen, and/or an antihistamine 1 hour prior to infusion to reduce the incidence and severity of infusion-related reactions. Administer antifungal and antibacterial prophylaxis therapy if clinically indicated. Antiviral prophylaxis is recommended in patients who are CMV-seropositive at the time of transplant and for CMV-seronegative patients scheduled to receive a kidney from a CMV-seropositive donor.

Renal transplant, acute rejection treatment

Renal transplant, acute rejection treatment: IV: 1.5 mg/kg/day for 7 to 14 days.

Renal transplant, induction therapy

Renal transplant, induction therapy: IV: 1.5 mg/kg/day for 4 to 7 days; the first dose should be administered prior to reperfusion of the donor kidney

Off-label induction dosing: IV: 1.5 mg/kg once daily for 5 to 7 days (Brennan 1999; Brennan 2006; Hardinger 2008) or 1 mg/kg once daily for 3 to 6 days (Goggins 2003); alternative dosing strategies with higher doses for shorter durations such as 2 mg/kg once daily for 3 days have also been recommended (Hardinger 2010); dosing based on peripheral blood CD3+ lymphocyte counts has also been described with an initial dose of 1.5 mg/kg followed by repeat doses when CD3+ count is >20 cells/mm3 (Peddi 2002)

Chronic graft-versus-host disease, prevention

Chronic graft-versus-host disease, prevention (off-label use): IV: 0.5 mg/kg administered 2 days prior to transplant and 2 mg/kg administered 1 day before and 1 day after transplant (Walker 2016) or 2.5 mg/kg once daily for 3 days beginning 3 days prior to transplant (Ruutu 2013).

Heart transplant, induction therapy

Heart transplant, induction therapy (in high risk patients) (off-label use): IV: 1 to 1.5 mg/kg once daily for up to 7 days (Zuckermann 2015)

Heart transplant, acute cellular rejection, treatment

Heart transplant, acute cellular rejection, treatment (off-label use): IV: 0.75 to 1.5 mg/kg/day for 5 to 14 days (ISHLT [Costanzo 2010])

Intestinal and multivisceral transplantation, induction therapy

Intestinal and multivisceral transplantation, induction therapy (off-label use): IV: 2 mg/kg/day on postoperative days 0, 2, 4, 6, and 8 (in combination with rituximab) (Vianna 2008). Additional trials data may be necessary to further define the role of antithymocyte globulin (rabbit) in this condition.

Lung transplant, induction therapy

Lung transplant, induction therapy (off-label use): IV: 1.5 mg/kg/day for 3 days; the first dose was administered within 24 hours of transplantation (Palmer 1999; Hartwig 2008). Additional trails may be necessary to further define the role of antithymocyte globulin (rabbit) for prevention of rejection after lung transplant.

Lung transplant, persistent acute cellular rejection, treatment

Lung transplant, persistent acute cellular rejection, treatment (off-label use): IV: Pulse treatments have been used to manage persistent acute cellular rejection (Martinu 2000). Additional data may be necessary to further define the role of antithymocyte globulin (rabbit) in treatment of acute cellular rejection after lung transplantation.

Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Dosing: Kidney Impairment: Adult

There are no dosage adjustments provided in the manufacturer's labeling.

Dosing: Hepatic Impairment: Adult

There are no dosage adjustments provided in the manufacturer's labeling.

Dosing: Pediatric

(For additional information see "Antithymocyte globulin (rabbit derived, Thymoglobulin): Pediatric drug information")

Note: Premedicate with corticosteroids, acetaminophen, and/or an antihistamine 1 hour prior to infusion to reduce the incidence and severity of infusion-related reactions. Administer antifungal and antibacterial prophylaxis therapy if clinically indicated. For use in solid organ transplantation (ie, kidney), antiviral prophylaxis is recommended in patients who are CMV-seropositive at the time of transplant and for CMV-seronegative patients scheduled to receive a kidney from a CMV-seropositive donor.

Aplastic anemia; refractory

Aplastic anemia; refractory: Limited data available: Children and Adolescents: IV: 3.5 mg/kg/day once daily for 5 days in combination with cyclosporine (Di Bona 1999; Scheinberg 2006; Takahashi 2013); Note: Consistent with observations in adult patients, rabbit-antithymocyte globulin is less effective than horse-antithymocyte globulin when either combined with cyclosporine in children and adolescents for initial treatment of severe aplastic anemia (Marsh 2009; Scheinberg 2011; Yoshimi 2013)

Hematopoietic stem cell transplant; graft-versus-host disease prevention

Hematopoietic stem cell transplant; graft-versus-host disease (GVHD) prevention: Limited data available; regimens and protocols variable; refer to institutional protocols: Infants, Children, and Adolescents: IV: Usual reported TOTAL dose range: 4.5 to 15 mg/kg total divided into 3 to 5 once daily doses administered pretransplant; usual regimen is 3 to 4 doses on consecutive days in combination with chemotherapy or radiation (Admiraal 2015; Aversa 2005; Horn 2006; Kang 2016; Locatelli 2017; Soni 2014; Willemsen 2015). In adolescents ≥16 years, a lower total dose and timing approach has been successfully used: IV: 0.5 mg/kg/day 2 days before transplantation, 2 mg/kg/day 1 day before transplantation, and 2 mg/kg/day 1 day after transplantation (total dose: 4.5 mg/kg; in addition to standard GVHD prophylaxis) (Walker 2016)

Solid organ transplantation

Solid organ transplantation: Note: Doses and timing may vary; refer to institutional specific protocols:

Kidney transplantation: Infant, Children, and Adolescents:

Induction, prophylaxis: IV: 1.5 mg/kg/dose once daily for 4 to 10 doses initiated at time of transplant prior to reperfusion of donor kidney; during variable and dependent on other immunosuppressive regimens (Khositseth 2005; Li 2010)

Acute rejection, treatment: IV: 1.5 mg/kg/dose once daily for 7 to 14 days

Heart/lung transplantation: Limited data available: Infant, Children, and Adolescents:

Induction, prophylaxis: Reported range: IV: 1 to 2 mg/kg/dose once daily infused over 12 hours for 5 days; dose dependent on baseline platelet count; in trials the following doses were used based on platelet count (Di Filippo 2003):

>150,000/mm3: IV: 2 mg/kg/dose

100,000 to 150,000/mm3: IV: 1.5 mg/kg/dose

50,000 to <100,000/mm3: IV: 1 mg/kg/dose

Acute rejection, treatment: IV: 2 mg/kg/dose once daily for 5 days (Di Filippo 2003)

Liver, intestinal, or multivisceral transplant: Limited data available: Infants, Children, and Adolescents:

Induction, prophylaxis: IV: Total dose of 5 mg/kg divided into separate pre- and post-op doses: 2 to 3 mg/kg over 6 to 8 hours before allograft reperfusion, followed by the remainder 2 to 3 mg/kg over 6 to 8 hours post-operative; used in combination with other immunosuppressives (Bond 2005; Reyes 2005)

Rejection: 1.5 mg/kg/dose once daily; duration variable (usually at least 4 to 5 days) based upon biopsy results (Schmitt 2010; Thangarajah 2013)

Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Dosing: Kidney Impairment: Pediatric

There are no dosage adjustments provided in the manufacturer's labeling.

Dosing: Hepatic Impairment: Pediatric

There are no dosage adjustments provided in the manufacturer's labeling.

Dosing: Older Adult

Refer to adult dosing.

Dosing: Obesity: Adult

American Society for Blood and Marrow Transplantation (ASBMT) practice guideline committee position statement on chemotherapy dosing in obesity: Utilize actual body weight (full weight) to calculate mg/kg dosing for hematopoietic stem cell transplant conditioning regimens (Bubalo 2014).

Dosing: Adjustment for Toxicity: Adult

Renal transplantation:

WBC count 2,000 to 3,000 cells/mm3 or platelet count 50,000 to 75,000 cells/mm3: Reduce dose by 50%.

WBC count <2,000 cells/mm3 or platelet count <50,000 cells/mm3: Consider discontinuing treatment.

Dosage Forms: US

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Solution Reconstituted, Intravenous:

Thymoglobulin: 25 mg (1 ea) [contains glycine, mannitol, sodium chloride]

Generic Equivalent Available: US

No

Dosage Forms: Canada

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Solution Reconstituted, Intravenous:

Thymoglobulin: 25 mg (1 ea)

Administration: Adult

IV: Infuse the first dose over at least 6 hours; subsequent doses may be infused over at least 4 hours. Infuse through a high-flow vein (central line). Administer through an in-line 0.22 micron filter. Premedication with corticosteroids, acetaminophen, and/or an antihistamine 1 hour prior to infusion may reduce the incidence and severity of infusion-related reactions. Reducing the infusion rate may minimize infusion reactions. Infusion rate may vary for off-label uses; refer to specific protocol.

In renal transplantation, administration through a peripheral vein has been reported with the addition of 1,000 units heparin and 20 mg hydrocortisone (in 500 mL NS only) to decrease the risk of thrombosis and phlebitis (Marvin 2003; Trofe-Clark 2012). The first 2 doses were infused over 6 hours and subsequent doses were infused over 4 hours (Trofe-Clark 2012).

Administration: Pediatric

Parenteral: Administer by slow IV infusion over 6 to 12 hours for the preconditioning/induction dose or over 6 hours for the initial acute rejection treatment dose; infuse over 4 hours for subsequent doses if first dose tolerated. Administer through an in-line filter with pore size of 0.22 microns via central line or high flow vein. Premedication with corticosteroids, acetaminophen, and/or an antihistamine may reduce infusion-related reactions.

Use: Labeled Indications

Renal transplant rejection: Prophylaxis and treatment of acute rejection in renal transplantation (in conjunction with concomitant immunosuppression)

Note: In a multicenter, double-blind, randomized trial, antithymocyte globulin (rabbit) was shown to be superior to antithymocyte globulin (equine) in reversing acute rejection and preventing subsequent episodes (Gaber 1998). Based on data from studies (including 10 years follow up) comparing ATG (rabbit) to ATG (equine) for induction, ATG (rabbit) has emerged as the T-cell lymphocyte depleting induction therapy of choice over ATG (equine) in adult kidney transplantation due to its improved efficacy and lower incidence of acute rejection (Brennan 1999; Hardinger 2008).

Use: Off-Label: Adult

Chronic graft-versus-host disease, prevention; Heart transplant, induction therapy; Heart transplant, acute cellular rejection, treatment; Intestinal and multivisceral transplantation, induction therapy; Lung transplant, induction therapy; Lung transplant, persistent acute cellular rejection, treatment

Medication Safety Issues
Sound-alike/look-alike issues:

Antithymocyte globulin rabbit (Thymoglobulin) may be confused with antithymocyte globulin equine (Atgam)

High alert medication:

The Institute for Safe Medication Practices (ISMP) includes this medication among its list of drugs that have a heightened risk of causing significant patient harm when used in error.

Adverse Reactions

The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified.

>10%:

Cardiovascular: Hypertension (18% to 37%), hypotension (10% to 16%), peripheral edema (20%), tachycardia (7% to 23%)

Dermatologic: Acne vulgaris (12%), diaphoresis (6% to 13%), skin rash (7% to 13%)

Endocrine & metabolic: Hyperkalemia (17% to 57%), hyperlipidemia (15%), hypokalemia (6% to 12%)

Gastrointestinal: Abdominal pain (8% to 38%), constipation (15% to 33%), diarrhea (6% to 20%), nausea (29% to 37%), vomiting (12% to 20%)

Genitourinary: Urinary tract infection (39% to 42%)

Hematologic & oncologic: Anemia (12% to 25%), leukocytosis (13%), leukopenia (21% to 63%), thrombocytopenia (9% to 37%)

Infection: Cytomegalovirus disease (6% to 13%), infection (17% to 76%; severe infection: 23%), sepsis (6% to 12%)

Nervous system: Anxiety (7% to 14%), chills (9% to 57%), headache (18% to 40%), insomnia (12% to 20%), malaise (9% to 13%), pain (26%)

Neuromuscular & skeletal: Arthralgia (15%), asthenia (13%), back pain (12%), myalgia (11% to 20%)

Respiratory: Dyspnea (15% to 28%), lower respiratory tract infection (≤13%), pulmonary disease (12%), upper respiratory tract infection (11%)

Miscellaneous: Fever (13% to 46%)

1% to 10%:

Cardiovascular: Chest pain (9%), edema (6%)

Dermatologic: Pruritus (6%)

Endocrine & metabolic: Acidosis (6% to 9%), hyperphosphatemia (6% to 7%), hypophosphatemia (6%)

Gastrointestinal: Anorexia (6%), dyspepsia (10%), gastritis (1%), intestinal candidiasis (5%), oral candidiasis (6%)

Hematologic & oncologic: Lymphoproliferative disorder (posttransplant: 2%), malignant neoplasm (4%)

Hypersensitivity: Serum sickness (1% to 2%)

Infection: Herpes simplex infection (5%), herpes zoster infection (5%)

Respiratory: Increased cough (7%), nasopharyngitis (5%)

<1%: Hypersensitivity: Anaphylactic shock

Frequency not defined: Miscellaneous: Infusion related reactions

Postmarketing:

Hematologic & oncologic: Disorder of hemostatic components of blood, disseminated intravascular coagulation, febrile neutropenia, malignant lymphoma, malignant solid tumor

Hepatic: Increased serum transaminases

Hypersensitivity: Anaphylaxis, cytokine release syndrome

Miscellaneous: Reactivation of disease

Contraindications

Hypersensitivity (allergy or anaphylaxis) to rabbit proteins or any component of the formulation; active acute or chronic infection which contraindicate additional immunosuppression

Documentation of allergenic cross-reactivity for drugs in this class is limited. However, because of similarities in chemical structure and/or pharmacologic actions, the possibility of cross-sensitivity cannot be ruled out with certainty.

Warnings/Precautions

Concerns related to adverse effects:

• Hematologic effects: Reversible leukopenia, neutropenia, thrombocytopenia, and lymphopenia may occur. Monitor blood counts. Leukopenia and/or thrombocytopenia may require dosage adjustment.

• Hypersensitivity: Hypersensitivity and fatal anaphylactic reactions have been reported. Stop infusion immediately if anaphylactic reaction occurs. Immediate treatment (including subcutaneous epinephrine and corticosteroids) should be available during infusion for management of hypersensitivity.

• Infection: Severe infections (bacterial, fungal, viral and/or protozoal) may develop following concomitant use of immunosuppressants with antithymocyte globulin. Reactivation of infections (particularly CMV) and sepsis have been reported. Appropriate antiviral, antibacterial, antiprotozoal, and/or antifungal prophylaxis is recommended. Monitor closely for infection.

• Infusion reactions: Release of cytokines by activated monocytes and lymphocytes may lead to cytokine release syndrome (CRS) during infusion; may cause serious cardiopulmonary events (sometimes fatal). Rapid infusion rates have been associated with CRS (case reports). Other infusion reaction symptoms, including flu-like symptoms (fever, chills, nausea, muscle/joint pain) may also occur. Local infusion site reactions (pain, swelling, skin redness) have been reported.

• Malignancy: Immunosuppressants, including antithymocyte globulins may increase the incidence of malignancies, including lymphoma, post-transplant lymphoproliferative disease (PTLD) or other malignancies; may be fatal.

Concurrent drug therapy issues:

• Immunizations: Patients should not be immunized with attenuated live viral vaccines during or shortly after treatment; safety of immunization following therapy has not been studied.

Disease-related concerns:

• Liver transplantation induction: Antithymocyte globulin (rabbit) has been associated with increased adverse effects when used for induction in liver transplantation and should be used cautiously in this population (Boillot 2009)

Other warnings/precautions:

• Administration: Initial dose must be administered over at least 6 hours into a high flow vein. Reducing the infusion rate (and prolonging the administration time) may minimize infusion reactions. May pretreat with an antipyretic, antihistamine, and/or corticosteroid.

• Experienced physician: [US Boxed Warning]: Should only be used by physicians experienced in immunosuppressive therapy in transplantation. Maintenance immunosuppression may require dosage reduction. Medical surveillance is required during the infusion. Should be administered in combination with other immunosuppressants.

• Product selection: Antithymocyte globulin (ATG) (rabbit) is available (based on region) in different product formulations, ATG-Thymoglobulin and ATG-Fresenius; the dosing differs among the formulations. Dosing of antithymocyte globulin (rabbit) also differs from dosing of other antithymocyte globulin products (eg, ATG [equine]); protein compositions and concentrations are different. Use caution to ensure dose prescribed is intended for product being administered.

Metabolism/Transport Effects

None known.

Drug Interactions

Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the Lexicomp drug interactions program by clicking on the “Launch drug interactions program” link above.

Abrocitinib: May enhance the immunosuppressive effect of Immunosuppressants (Therapeutic Immunosuppressant Agents). Risk X: Avoid combination

Baricitinib: Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the immunosuppressive effect of Baricitinib. Risk X: Avoid combination

BCG Products: Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the adverse/toxic effect of BCG Products. Specifically, the risk of vaccine-associated infection may be increased. Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect of BCG Products. Risk X: Avoid combination

Belatacept: Antithymocyte Globulin (Rabbit) may enhance the adverse/toxic effect of Belatacept. Specifically, the risk for venous thrombosis of the renal allograft may be increased. Management: A 12-hour interval between administration of these 2 agents is suggested if these agents are to be used concomitantly. Monitor for venous thrombosis of the renal allograft. Risk D: Consider therapy modification

Brincidofovir: Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect of Brincidofovir. Risk C: Monitor therapy

Cladribine: Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the immunosuppressive effect of Cladribine. Risk X: Avoid combination

Coccidioides immitis Skin Test: Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the diagnostic effect of Coccidioides immitis Skin Test. Management: Consider discontinuing therapeutic immunosuppressants several weeks prior to coccidioides immitis skin antigen testing to increase the likelihood of accurate diagnostic results. Risk D: Consider therapy modification

COVID-19 Vaccine (Adenovirus Vector): Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect of COVID-19 Vaccine (Adenovirus Vector). Management: Administer a 2nd dose using an mRNA COVID-19 vaccine (at least 4 weeks after the primary vaccine dose) and a bivalent booster dose (at least 2 months after the additional mRNA dose or any other boosters). Risk D: Consider therapy modification

COVID-19 Vaccine (Inactivated Virus): Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect of COVID-19 Vaccine (Inactivated Virus). Risk C: Monitor therapy

COVID-19 Vaccine (mRNA): Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect of COVID-19 Vaccine (mRNA). Management: Give a 3-dose primary series for all patients aged 6 months and older taking immunosuppressive medications or therapies. Booster doses are recommended for certain age groups. See CDC guidance for details. Risk D: Consider therapy modification

COVID-19 Vaccine (Subunit): Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect of COVID-19 Vaccine (Subunit). Risk C: Monitor therapy

COVID-19 Vaccine (Virus-like Particles): Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect of COVID-19 Vaccine (Virus-like Particles). Risk C: Monitor therapy

Dengue Tetravalent Vaccine (Live): Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the adverse/toxic effect of Dengue Tetravalent Vaccine (Live). Specifically, the risk of vaccine-associated infection may be increased. Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect of Dengue Tetravalent Vaccine (Live). Risk X: Avoid combination

Denosumab: Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the immunosuppressive effect of Denosumab. Management: Consider the risk of serious infections versus the potential benefits of coadministration of denosumab and immunosuppressants. If combined, monitor for signs/symptoms of serious infections. Risk D: Consider therapy modification

Deucravacitinib: May enhance the immunosuppressive effect of Immunosuppressants (Therapeutic Immunosuppressant Agents). Risk X: Avoid combination

Filgotinib: May enhance the immunosuppressive effect of Immunosuppressants (Therapeutic Immunosuppressant Agents). Risk X: Avoid combination

Inebilizumab: Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the immunosuppressive effect of Inebilizumab. Risk C: Monitor therapy

Influenza Virus Vaccines: Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect of Influenza Virus Vaccines. Management: Administer influenza vaccines at least 2 weeks prior to initiating immunosuppressants if possible. If vaccination occurs less than 2 weeks prior to or during therapy, revaccinate 2 to 3 months after therapy discontinued if immune competence restored. Risk D: Consider therapy modification

Leflunomide: Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the immunosuppressive effect of Leflunomide. Management: Increase the frequency of chronic monitoring of platelet, white blood cell count, and hemoglobin or hematocrit to monthly, instead of every 6 to 8 weeks, if leflunomide is coadministered with immunosuppressive agents. Risk D: Consider therapy modification

Natalizumab: Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the immunosuppressive effect of Natalizumab. Risk X: Avoid combination

Ocrelizumab: Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the immunosuppressive effect of Ocrelizumab. Risk C: Monitor therapy

Ofatumumab: Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the immunosuppressive effect of Ofatumumab. Risk C: Monitor therapy

Pidotimod: Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect of Pidotimod. Risk C: Monitor therapy

Pimecrolimus: Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the immunosuppressive effect of Pimecrolimus. Risk X: Avoid combination

Pneumococcal Vaccines: Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect of Pneumococcal Vaccines. Risk C: Monitor therapy

Poliovirus Vaccine (Live/Trivalent/Oral): Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the adverse/toxic effect of Poliovirus Vaccine (Live/Trivalent/Oral). Specifically, the risk of vaccine-associated infection may be increased. Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect of Poliovirus Vaccine (Live/Trivalent/Oral). Risk X: Avoid combination

Polymethylmethacrylate: Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the potential for allergic or hypersensitivity reactions to Polymethylmethacrylate. Management: Use caution when considering use of bovine collagen-containing implants such as the polymethylmethacrylate-based Bellafill brand implant in patients who are receiving immunosuppressants. Consider use of additional skin tests prior to administration. Risk D: Consider therapy modification

Rabies Vaccine: Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect of Rabies Vaccine. Management: Complete rabies vaccination at least 2 weeks before initiation of immunosuppressant therapy if possible. If combined, check for rabies antibody titers, and if vaccination is for post exposure prophylaxis, administer a 5th dose of the vaccine. Risk D: Consider therapy modification

Rubella- or Varicella-Containing Live Vaccines: Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the adverse/toxic effect of Rubella- or Varicella-Containing Live Vaccines. Specifically, the risk of vaccine-associated infection may be increased. Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect of Rubella- or Varicella-Containing Live Vaccines. Risk X: Avoid combination

Ruxolitinib (Topical): Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the immunosuppressive effect of Ruxolitinib (Topical). Risk X: Avoid combination

Sipuleucel-T: Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect of Sipuleucel-T. Management: Consider reducing the dose or discontinuing the use of immunosuppressants prior to initiating sipuleucel-T therapy. Risk D: Consider therapy modification

Sphingosine 1-Phosphate (S1P) Receptor Modulator: May enhance the immunosuppressive effect of Immunosuppressants (Therapeutic Immunosuppressant Agents). Risk C: Monitor therapy

Tacrolimus (Topical): Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the immunosuppressive effect of Tacrolimus (Topical). Risk X: Avoid combination

Talimogene Laherparepvec: Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the adverse/toxic effect of Talimogene Laherparepvec. Specifically, the risk of infection from the live, attenuated herpes simplex virus contained in talimogene laherparepvec may be increased. Risk X: Avoid combination

Tertomotide: Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect of Tertomotide. Risk X: Avoid combination

Tofacitinib: Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the immunosuppressive effect of Tofacitinib. Management: Coadministration of tofacitinib with potent immunosuppressants is not recommended. Use with non-biologic disease-modifying antirheumatic drugs (DMARDs) was permitted in psoriatic arthritis clinical trials. Risk X: Avoid combination

Typhoid Vaccine: Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the adverse/toxic effect of Typhoid Vaccine. Specifically, the risk of vaccine-associated infection may be increased. Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect of Typhoid Vaccine. Risk X: Avoid combination

Upadacitinib: Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the immunosuppressive effect of Upadacitinib. Risk X: Avoid combination

Vaccines (Inactivated/Non-Replicating): Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect of Vaccines (Inactivated/Non-Replicating). Management: Give inactivated vaccines at least 2 weeks prior to initiation of immunosuppressants when possible. Patients vaccinated less than 14 days before initiating or during therapy should be revaccinated at least 2 to 3 months after therapy is complete. Risk D: Consider therapy modification

Vaccines (Live): May enhance the adverse/toxic effect of Immunosuppressants (Therapeutic Immunosuppressant Agents). Specifically, the risk of vaccine-associated infection may be increased. Vaccines (Live) may diminish the therapeutic effect of Immunosuppressants (Therapeutic Immunosuppressant Agents). Risk X: Avoid combination

Yellow Fever Vaccine: Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the adverse/toxic effect of Yellow Fever Vaccine. Specifically, the risk of vaccine-associated infection may be increased. Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect of Yellow Fever Vaccine. Risk X: Avoid combination

Reproductive Considerations

Females of reproductive potential should use effective contraception during and for at least 3 months following treatment.

Antithymocyte globulin (rabbit) has been used as for the induction of immunosuppression in patients undergoing uterine transplant; a minimum interval of 3 months between uterine transplant and embryo transfer is suggested (Johannesson 2019; Jones 2019).

Pregnancy Considerations

Antithymocyte globulin (rabbit) is a purified immunoglobulin G. Placental transfer of human IgG is dependent upon the IgG subclass, maternal serum concentrations, newborn birth weight, and gestational age, generally increasing as pregnancy progresses. The lowest exposure would be expected during the period of organogenesis (Palmeira 2012; Pentsuk 2009).

Information related to the use of antithymocyte globulin (rabbit) during pregnancy is limited (Balaha 2019; Kutzler 2016; López 2014; Massenkeil 2016).

Transplant Pregnancy Registry International (TPR) is a registry that follows pregnancies that occur in maternal transplant recipients or those fathered by male transplant recipients. The TPR encourages reporting of pregnancies following solid organ transplant by contacting them at 1-877-955-6877 or https://www.transplantpregnancyregistry.org.

Breastfeeding Considerations

It is not known if antithymocyte globulin (rabbit) is present in breast milk.

Because other immunoglobulins are present in breast milk, the manufacturer recommends that breastfeeding be discontinued during antithymocyte globulin (rabbit) therapy.

Monitoring Parameters

Lymphocyte count (total lymphocyte and/or T-cell subset), CBC with differential and platelet count; vital signs during administration; signs and symptoms of infection

Solid organ transplant: Absolute CD3 count (cells/µL) monitoring and CD3 based dosing has been considered in renal and heart transplant recipients. It may be beneficial in certain patient populations but is not routinely recommended or utilized. Dose adjustments have been recommended based on the CD3 count (Krasinska 2002).

Mechanism of Action

Antithymocyte globulin (rabbit) is a polyclonal antibody which appears to cause immunosuppression by acting on T-cell surface antigens and depleting CD4 lymphocytes

Pharmacokinetics

Onset of action (T-cell depletion): Within 24 hours (Hardinger 2006)

Duration: Lymphopenia may persist for up to 1 year (Hardinger 2006)

Half-life elimination: 2 to 3 days

Pricing: US

Solution (reconstituted) (Thymoglobulin Intravenous)

25 mg (per each): $1,166.56

Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.

Brand Names: International
  • Thymoglobulin (DE);
  • Thymoglobuline (AT, AU, BE, BG, BR, CH, CN, CZ, DK, FI, FR, GB, GR, HK, HR, IE, IT, KR, LU, LV, MT, MY, NL, NO, PL, RO, SG, SI, TH, TW, ZA)


For country code abbreviations (show table)
  1. Admiraal R, van Kesteren C, Jol-van der Zijde CM, et al. Association between anti-thymocyte globulin exposure and CD4+ immune reconstitution in paediatric haemopoietic cell transplantation: a multicentre, retrospective pharmacodynamic cohort analysis. Lancet Haematol. 2015;2(5):e194-203. [PubMed 26688094]
  2. Aversa F, Terenzi A, Tabilio A, et al. Full haplotype-mismatched hematopoietic stem-cell transplantation: a phase II study in patients with acute leukemia at high risk of relapse. J Clin Oncol. 2005;23(15):3447-3454. [PubMed 15753458]
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