Quest for Lower Immunosuppression in Cardiac Transplantation: an Analysis of the TICTAC Trial

Evaluation of: Baran DA, Zucker MJ, Arroyo LH et al.: A prospective, randomized trial of single versus dual drug immunosuppression in heart transplantation: the Tacrolimus in Combination, Tacrolimus Alone Compared (TICTAC) trial. Circ. Heart Fail. 4(2), 129-137 (2011). Success in cardiac transplantation has been attributed to improved immunosuppressive regimens. Conventionally, patients are treated with a triple regimen following transplantation, consisting of a calcineurin inhibitor (cyclosporine or tacrolimus), antiproliferative agent (mycophenolate mofetil) and corticosteroids. These agents, however, are associated with a significant morbidity which has prompted a quest for minimization of immunosuppressive regimens; a challenging goal, given the potential for allograft rejection particularly early after transplantation. This article reviews a recent study by Baran and colleagues who boldly challenged the notion that triple immunosuppression is a prerequisite for success after cardiac transplantation. The authors successfully demonstrate the feasibility of weaning corticosteroids and mycophenolate mofetil early after cardiac transplantation, maintaining patients solely on monotherapy with tacrolimus. This evaluation focuses on the findings and limitations of the study and provides the historical background which led to this promising clinical trial.