Quick answer

Ask your pharmacist or doctor before combining. NIH and NCCIH document 2 supplements for immunosuppressants, echinacea and elderberry, which might reduce the effect of medicines that suppress the immune system. NIH's fact sheet names ginseng and omega-3 too. The concern is theoretical, and no source checked sets a severity of avoid.^1,2,3

Key facts

MedlinePlus describes immunosuppressants such as azathioprine as medicines that lower the activity of the immune system, used to prevent transplant rejection and for some conditions where the immune system attacks the body's own tissue.⁴
NIH says echinacea might make medicines that suppress the immune system work less well, and NCCIH describes the concern as theoretical.^1,3
NIH says elderberry might reduce the effect of immune-suppressing medicines, in both its professional and its consumer fact sheet.^2,5
NIH's immune function fact sheets also name ginseng, omega-3 and andrographis among supplements that might interact with immunosuppressants, none of which has an entry on this page.^1,6
NCCIH says evidence on echinacea and medicines that the liver breaks down is conflicting.³
Both entries are tagged ask first and expected: they rest on NIH and NCCIH reasoning from how the supplements work, and no medicine label is cited.^5,6

What do immunosuppressants do, and why would a supplement matter?

MedlinePlus uses azathioprine as its example of the class. The page says it is used with other medicines to prevent rejection of a transplanted kidney, and for severe rheumatoid arthritis after other treatments have not helped. Such medicines work by lowering the activity of the immune system so that it does not attack the transplanted organ or the joints.⁴

That is why the two supplements on this page are here: NIH says both may stimulate the immune system, and the medicine's job is to turn immune activity down. The sources checked name the class as a whole, so they do not tell you whether one particular medicine is more or less affected. Ask about your own.^1,2

Does echinacea interfere with immunosuppressants?

Ask your pharmacist or doctor first

Echinacea might make medicines that suppress the immune system work less well, because it may stimulate immune activity. NIH and NCCIH both name this as a possible interaction on theoretical grounds.^1,3,6

Expected from how the two work, not shown in studies

NCCIH calls the immunosuppressant concern theoretical and says evidence on echinacea and medicines the liver breaks down is conflicting. NIH adds that echinacea might lower levels of some medicines cleared by cytochrome P450 enzymes. The two ideas are separate: one is about immune activity, the other about how fast the body clears a medicine.^1,3

Does elderberry interfere with immunosuppressants?

Ask your pharmacist or doctor first

Because elderberry may stimulate the immune system, NIH says it might reduce the effect of medicines that suppress the immune system.^2,5

Expected from how the two work, not shown in studies

The elderberry card is the shorter one. NIH repeats it in two places, once for professionals and once for consumers, and both phrase it as a possibility. The same sheets say raw or unripe elderberry fruit and other parts of the plant can make people sick, and that safety in pregnancy is not known, which are separate cautions from this one.^2,5

What does expected mean, and why is there no avoid tag?

Both cards say ask first and expected. Expected is the tag for concerns that follow from how the products work, as opposed to concerns printed on a medicine label or seen in studies of people. Ask first is this page's plain-word tag for a request to raise the supplement with the prescriber, so that the choice is made with knowledge of your medicine, your transplant or condition and your other treatments.

A concern reasoned from mechanism is not a finding of harm either. It marks a question that nobody has tested, which is a reason to ask and not a reason to guess in either direction.

Does NIH name other supplements for immunosuppressants?

Yes, a few. The NIH fact sheets that name echinacea and elderberry also say ginseng might reduce the effectiveness of immunosuppressants, say omega-3s might interact with medicines that suppress the immune system, and say the same of andrographis. They describe each differently, and none has an entry on this page.^1,6

For a supplement that no source on this page names, the sources checked do not address it. That is not a finding either way, so ask your pharmacist.

Questions to ask your pharmacist or transplant team

Which immunosuppressant am I taking, and does my care team have a rule about supplements?
Does any product I use contain echinacea or elderberry, including teas, gummies, syrups and blends?
If I already take one of them, should I tell my team before my next visit?
What would a change in how my medicine works look like, and who should I call?

Questions people ask

What supplements should I avoid with immunosuppressants?

Official sources document echinacea and elderberry. NIH says both might reduce the effect of medicines that suppress the immune system, and NCCIH calls the echinacea concern theoretical. Ask your pharmacist or transplant team before starting or stopping either.^1,2,3

Which vitamins should not be taken with immunosuppressants?

No vitamin has an entry on this page: the 2 documented supplements are botanicals. The sources checked do not address vitamins for this class. That is not a finding either way, so ask your pharmacist.^5,6

Which supplements interact with immunosuppressants?

Echinacea and elderberry are the 2 documented on this page, both tagged ask first and expected. NIH and NCCIH reason that they may stimulate the immune system, and the NIH sheets also name ginseng, omega-3 and andrographis.^1,2,6

Is elderberry on the list of supplements to avoid with immunosuppressants?

NIH says elderberry might reduce the effect of medicines that suppress the immune system. It is a possibility rather than a finding from a study of people, so raise it with your pharmacist before using it.^2,5

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This page is information, not medical advice. Talk to your doctor or pharmacist about your own situation.