Risiken und Nebenwirkungen von Immunsuppressiva in der Therapie chronisch entzündlicher Darmerkrankungen

Kernaussagen

Indikationen

• Die klassischen Immunsuppressiva Azathioprin, 6-Mercaptopurin, Methotrexat sowie die Calcineurininhibitoren Cyclosporin und Tacrolimus stellen auch in Zeiten der Biologika einen wichtigen Bestandteil der Therapiepyramide bei chronisch entzündlichen Darmerkrankungen dar.

• Die Thiopurine und Methotrexat haben ihren Stellenwert in der Remissionserhaltung beider Erkrankungen, während die Calcineurininhibitoren der Remissionsinduktion beim steroidrefraktären Schub der Colitis ulcerosa vorbehalten sind.

Nebenwirkungen

• Das Toxizitätsprofil muss entsprechend dem Indikationsspektrum der jeweiligen Immunsuppressiva eingeordnet werden.

• Bei den Thiopurinpräparaten stehen neben der idiosynkratischen Pankreatitis in erster Linie dosisabhängige Nebenwirkungen wie gastrointestinale Beschwerden, Hepatotoxizität und Knochenmarktoxizität im Vordergrund, die in aller Regel gut beherrscht bzw. überwacht werden können.

• Bei Methotrexat machen die gastrointestinalen Beschwerden und die Stomatitis den Großteil der Nebenwirkungen aus.

• Die Calcineurininhibitoren weisen eine recht hohe Rate an – allerdings meist komplett reversibler – Nephrotoxizität und Neurotoxizität auf. Weiterhin ist das Risiko für opportunistische Infektionen erhöht. Allerdings sind diese (Reserve-)Medikamente auch schwer kranken Patienten vorbehalten, bei denen die hohe Effektivität den Nachteil der Toxizität aufhebt.

Stellenwert

• Insbesondere angesichts der hohen Rate an Wirkungsverlust der Anti-TNF-Antikörper und der äußerst beschränkten Therapiealternativen stellen die klassischen Immunsuppressiva weiterhin einen ganz wesentlichen Baustein der Therapie chronisch entzündlicher Darmerkrankungen dar.

• Literatur

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