Table 3. Specific recipient Drug Interactions used in potential LTx recipients that require modification of Maintenance Immunosuppression.

Medication/therapy	Examples	Method of Interaction	Recommendation
Azole antifungals	Voriconazole	Strong CYP3A4 inhibitor	Avoid loading with CNI prior to surgery
	Posaconazole	Increases serum levels of CNIs	Consider use of induction agents e.g., basiliximab
	Itraconazole		Initiation of CNI at a lower dose within a few days
	Fluconazole (Moderate)		Not routinely continued post LTx. Brief washout period recommended prior to initiating CNI
	Isavuconazole (Moderate)
Endothelin receptor antagonists	Bosentan	Bosentan – Moderate CYP3A4, 2C9 Inducer	As above
	Ambrisentan	Ambrisentan – Minimal CYP3A4, 2C9 inducer	Ceased post LTx
	Macitentan	Macitentan – Lower potential for interactions
Gene Modifiers	Ivacaftor	Ivacaftor – Weak CYP3A4 inhibitor	As above
	Lumacaftor-Ivacaftor	Lumacaftor – Strong CYP3A4 induction – Net overall induction with the combination	Ceased post LTx
Antibiotics	Clarithromycin	Strong CYP3A4 inhibitors	As above
	Erythromycin	Increased serum levels of CNIs	Consider alternative agents post LTx
	Rifampicin	Strong CYP3A4 inducer
		Decreased serum levels of CNIs
Calcium channel blockers	Diltiazem	Moderate CYP3A4 inhibitors	Consider alternative agents post LTx
	Verapamil
Xanthine oxidase	Allopurinol	Inhibits metabolism of xanthine oxidase – Increasing risk of myelosuppression	Use mycophenolate instead of azathioprine
HIV Protease inhibitors	Ritonavir	Strong CYP3A4 Inhibitors	Consider modifying regimen prior to LTx to a non-interacting regimen e.g., HIV-1 Integrase inhibitor based
	Cobicistat
	Saquinavir
	Nevirapine	Strong CYP3A4 Inducers
	Efavirenz
Anticonvulsants	Phenytoin	Strong CYP3A4 inducers	Consider modifying regimen prior to LTx to a non-interacting regimen e.g., levetiracetam
	Carbamazepine
	Phenobarbitone

LTx, lung transplantation. CNI, calcineurin inhibitor.