Immunosuppression

Immunosuppression is a condition where your body’s natural defense system doesn’t work as well as it should, making it harder to fight off infections and diseases. This can happen because of certain illnesses, medications, or medical treatments like organ transplants.

Table of contents

• What is immunosuppression?
• What causes immunosuppression?
• When immunosuppressants are used
• Types of immunosuppressant medications
• Risks and side effects
• Living with immunosuppression

What is immunosuppression?

Immunosuppression is described as a condition of temporary or permanent immune system weakness. Your immune system is normally an infection-fighting machine that targets intruders like viruses, bacteria and cancerous cells^[1]. When the immune system is suppressed, it means it isn’t working properly and is weakened, making it harder to fight infections as easily as it should^[4].

The term “immunosuppression” can refer to two different situations. First, it describes a condition where your immune system is naturally weakened by certain diseases or health problems. Second, it refers to the deliberate suppression of the immune system using medications called immunosuppressants^[5].

When someone is immunocompromised or immunosuppressed, this dysfunction emerges from damage to the immune system cells, causing their activity against harmful germs to become compromised^[5]. Being immunocompromised is also called having a weakened immune system^[4].

What causes immunosuppression?

Many different factors can cause your immune system to become suppressed. These include diseases, medications, and medical procedures^[4].

Diseases and conditions that can weaken your immune system include primary immunodeficiency (any condition you’re born with that weakens your immune system), HIV (human immunodeficiency virus), cancer (especially leukemia, lymphoma and multiple myeloma), diabetes, autoimmune diseases, sickle cell disease, liver cirrhosis, and viral hepatitis^[4].

Certain conditions can also cause immunosuppression, including cellular immune deficiencies such as severe combined immunodeficiency, 22q11 deficiency/DiGeorge syndrome, and Wiskott-Aldrich syndrome. People who have received bone marrow transplants or stem cell transplants in the past 24 months may also have ongoing immunosuppression. Additionally, those with no spleen or a dysfunctional spleen are at increased risk^[6].

When immunosuppressants are used

Healthcare providers prescribe immunosuppressants to treat autoimmune diseases. People who have organ transplants or stem cell transplants also receive immunosuppressants so their immune systems don’t attack the transplanted organ or stem cells^[1].

Autoimmune diseases

If you have an autoimmune disease, it means your immune system stops protecting your body from invaders and starts attacking healthy tissue and cells. Immunosuppressants hold back your immune system, helping prevent further cell damage and inflammation. These drugs minimize symptoms and can even put some autoimmune diseases into remission, where you have no signs of the disease^[1].

You may need immunosuppressants if you have one of these autoimmune diseases: alopecia areata, inflammatory bowel disease (including Crohn’s disease and ulcerative colitis), lupus, multiple sclerosis, psoriasis or psoriatic arthritis, or rheumatoid arthritis^[1].

Stem cell transplants

Sometimes, people with blood cancers, blood disorders or bone marrow issues have allogeneic stem cell transplants. These transplants use donated stem cells to replace unhealthy stem cells so your body can start building a new immune system. Healthcare providers treat many conditions with stem cell transplants, including blood cancers like leukemia, lymphoma and multiple myeloma, blood disorders like sickle cell disease and thalassemia, and bone marrow issues like aplastic anemia^[1].

This new immune system may view your body as foreign and start attacking your healthy tissues and organs. This is called graft-versus-host disease (GvHD). Immunosuppressants can lower the chances of GvHD and are used to help prevent and treat it. You may receive different immunosuppressants for several days, weeks or months during and after a stem cell transplant. You may need to take immunosuppressants for years until your new immune system settles down^[1].

Organ transplants

If you need an organ transplant, immunosuppressants reduce the risk that your body will reject the transplanted organ. Organ rejection happens because your immune system knows the transplanted organ is new to your body and will treat it like an intruder that should be destroyed. Immunosuppressants protect newly transplanted organs by keeping your immune system’s response managed^[1].

The field of organ transplantation has advanced greatly over the past 50 years, and many people around the world have been saved. Improved treatment strategies have been associated with better patient and survival rates. The kidney was the first complex organ to be successfully transplanted, with the first human pancreas transplantation performed in 1966 and the first successful heart-lung transplant carried out in 1981^[3].

Types of immunosuppressant medications

Immunosuppressant drugs are designed to suppress or reduce part of the immune system. Many were originally developed to prevent organ rejection in transplant patients, but some are now also used to treat cancer and autoimmune diseases^[10].

Immunosuppressive drugs can be classified into several main groups: glucocorticoids (such as prednisone and dexamethasone), cytostatics, antibodies, drugs acting on immunophilins, and other drugs^[7].

How immunosuppressants work

Glucocorticoids suppress cell-mediated immunity by inhibiting the production of substances called cytokines, including Interleukin 1, IL-2, IL-3, IL-4, IL-5, IL-6, IL-8, and TNF-alpha. This decrease in cytokine production reduces T cell growth. Glucocorticoids also suppress the production of antibodies^[7].

The development of immunosuppression medications has progressed significantly over time. With the development of 6-mercaptopurine, followed by azathioprine in the early 1960s, drug-based immunosuppression became the standard of care. Introduced in the 1980s, cyclosporine was used in combination with azathioprine and steroids and was credited with a dramatic improvement in transplant survival. The next advance came in 1994 with the introduction of mycophenolate mofetil^[3].

How immunosuppressants are taken

You may receive immunosuppressants as a pill, liquid, injection or intravenously (through a vein). Depending on your situation, you may need immunosuppressants for several months up to a year, or longer. For example, people with autoimmune disease may take immunosuppressants indefinitely. People with organ or stem cell transplants take immunosuppressants long term, according to the advice of their healthcare provider^[1].

Risks and side effects

Immunosuppressants slow or stop your immune system’s attack on healthy cells, but they also weaken your immune system, increasing your risk of viral, bacterial and fungal infections^[1].

These drugs increase the risk of infection, cancers and specific side effects particular to each medication in patients, particularly in pregnant women and regarding fertility issues^[5]. However, glucocorticoids do not prevent an infection and also inhibit later healing processes^[7].

Getting sick a lot or having unusually long-lasting infections are the most common signs of having a compromised immune system. Being immunocompromised can mean you get illnesses most people fight off without getting sick, illnesses that mildly affect most people make you severely sick, illnesses linger or it takes a longer time to recover from being sick, and you’re more likely to develop complications than others^[4].

Immunosuppressed people are at greater risk of contracting infections and having severe disease than people with normally functioning immune systems. Vaccines are critical factors in decreasing the prevalence and severity of contagious diseases in the general population. However, people who are immunocompromised can have a weaker response and therefore less protection against infections^[20].

Living with immunosuppression

If you are immunosuppressed, you are more likely to experience severe illness as a result of certain infections, and extra precautions are recommended. You are also potentially at risk of a worsening of your condition. The risk may differ depending on your degree of immune suppression^[6].

General precautions

Maintaining health starts with basic cleanliness practices. Wash your hands for 20 seconds with soap and water at mealtime and when contact is made with other people. Use hand sanitizer and bacterial wipes in between. Avoid touching your eyes, nose, and mouth. Shower and bathe regularly. Brush your teeth and keep up with dentist visits^[22].

To further prevent exposure, wear a mask, physically distance yourself from others, and avoid enclosed spaces without good ventilation for prolonged periods. Masking has been used for decades as a physical barrier to prevent infection and slow community transmission of many types of diseases. Studies have found that when patients were wearing masks during their exposures they were much more likely to have mild disease^[22].

Food and water safety

A weak immune system makes you vulnerable to food poisoning and can make it more serious if you get it. Raw fish, as well as uncooked meats like steak tartare, are not safe. Other foods to avoid include uncooked or undercooked eggs, rare burgers and steaks, soft cheeses like brie and Camembert as well as blue-veined cheese, uncooked deli meats like bologna and turkey breast, and self-serve buffets and salad bars^[18].

Fresh fruits and vegetables can spread foodborne illnesses. Wash any produce you plan to eat raw with running water. Peel fruits before you eat them. Use a brush to scrub hard-skinned items like potatoes and carrots. Don’t soak produce in the sink, which may harbor bacteria. In particular, stay away from raw or lightly cooked sprouts, like alfalfa sprouts^[18].

Even chlorinated water and saltwater can contain harmful germs. Never swallow water when you swim in a pool, lake, river, or ocean. Don’t drink from springs or private wells. Depending on water quality in your area, even tap water and ice made with it could be risky. It may be best to drink only bottled water or use a filter^[18].

Staying healthy

Taking care of yourself doesn’t have to be complicated. Eat well. Get enough sleep. Exercise. And find a doctor you can depend on. Physical activity and a healthy diet can help prevent unwanted side effects^[12].

Moving your body, raising your heart rate, and working up a sweat is a great way to help support your immune system as well as your body and mind. Any activity that increases your heart rate is a good exercise option^[19].

Eating healthy overall can include increasing your water intake, decreasing processed sugar, and reaching for fresh fruits and vegetables as part of each meal. There are many fruits and vegetables that can naturally boost your immune system and it may be a good idea to incorporate those into your daily diet as well^[19].

One aspect of life that is known to reduce your immune response and can hinder your ability to stay healthy is stress. Finding ways to reduce and manage stress when you can will help you keep your immune system healthy, as well as help you maintain good mental health. Setting up good daily routines is one way to reduce stress, as well as making time for self-care^[19].

Avoiding infections

Bug spray isn’t the only protection you need when you head out to work in your yard. Soil contains bacteria and mold that could lead to fungal infections. Wear gardening gloves to guard against cuts and scrapes to your hands, which give bacteria a way to enter your body. Long pants and long sleeves help too^[18].

Mosquitoes and ticks spread infections that can be serious for those with weak immune systems. Before heading outdoors, use bug repellent with effective ingredients, wear protective clothing, and avoid wooded and brushy areas. Check pets and yourself for ticks on your return^[18].

Pet waste may carry parasites that can infect anyone, but immunocompromised people are more likely to get seriously ill. Wear gloves to clean the litter box or cage, or ask someone else to do it. Afterward, wash your hands thoroughly. Stay away from reptiles, amphibians, and farm animals^[18].

Travel considerations

Pre-travel planning is essential. Immunosuppressed individuals should discuss their travel plans carefully with their hospital specialist and primary care doctor, ideally before booking travel. All travelers should obtain comprehensive travel health insurance. Immunosuppressed travelers should declare their full medical history to the insurers^[6].

Travelers who are immunosuppressed should be stable, know how to manage their condition, be prepared to manage minor illnesses, and know when and how to seek medical advice abroad^[6].

Medical monitoring

Although your eye doctors or specialists are the people who supervise and guide your treatment, you have a very important part to play in it. You are the person who needs to take charge of your overall health. This includes not only making sure that the regular blood and other tests ordered by your doctors are done as requested, but also paying more attention to your general health^[21].

You have to take the lead in organizing this aspect of your care. Depending on your age, blood pressure and general fitness, you may need to organize extra tests with your primary care doctor^[21].