Transplant Medications, Henry Ford Hospital

General Medication Rules for Transplant Patients Do not take any prescribed or over-the-counter drugs without making sure these will not interact with the transplant medications. Do not take any herbal medications as their interactions with the transplant medications are unknown. Patients should always check with their transplant physician before any new medicine is taken.

Store all medications at room temperature unless otherwise indicated on the medication container. Since bathrooms have moisture, the bathroom medicine cabinet is not a good place to store medications. A kitchen cabinet may be better. Improper storage of medicine may result in loss of potency (strength). Always keep medications in their prescription bottles, as this will keep them fresher than any other container.

Keep medication bottles tightly closed because air can cause deterioration. Please protect these medications from children. When traveling, take special care of your medications. Do not pack medicine with luggage as the luggage compartment in airplanes can get too hot or too cold and result in a loss of potency. A padded camera case works well in organizing and transporting your medications.

Taking the prescribed medications must be made a part of every patient’s daily routine, just like eating and sleeping.

While in the hospital, transplant patients will attend special classes to learn all about the medications. Patients will begin to take their own medicines in the hospital (Self-Medication Program) to learn exactly how to take the medicines at home.

It is the responsibility of every transplant patient to contact the transplant coordinator before starting any new medicine. This is essential for two reasons:

We keep a record of all your medications. If we think this medicine will cause a harmful drug interaction, we will suggest a different medication. If vomiting or diarrhea occurs, call the local doctor, transplant surgeon, or transplant coordinator. Such symptoms can affect absorption of certain medications and result in lowering of the medicine in blood levels.

Common Transplant Medications The following medications may be used by transplant patients although other medications may be used that are not included in this list. Please note that certain medications pertain only to certain types of organ transplants. Each patient should talk with the transplant physician and team to obtain detailed information specific to the individual’s medications prescribed.

Tacrolimus (Prograf or FK506) Tacrolimus is one of the main drugs in making organ transplants more successful. It is used to prevent rejection of the new liver. Because Tacrolimus stays in the body for a specific amount of time, it should be taken every 12 hours. It is important to take the doses of Tacrolimus at the same time each day as prescribed by the transplant team.

Special Instructions about Tacrolimus Blood-work:

Tacrolimus is adjusted based on drug levels in the blood. Blood levels are measured prior to taking the morning dose.

Possible Side Effects of Tacrolimus:

Decrease in kidney function. Kidney function should be closely checked by lab tests. Having the correct Tacrolimus dose will keep the risk of this side effect to a minimum. Tremor of the hands. This usually stops as the Tacrolimus dose is reduced. The new onset of tremor may indicate the Tacrolimus blood level is too high. Increased blood sugars. This occurs in approximately 15-20% of patients and is usually worst immediately after transplant. Headaches. Tingling of the arms or legs. Increased risk of infection. Because this drug weakens the immune system, patients are more prone to infection. Patients should avoid anyone with an active infection and be careful not to injure themselves which may increase the chance of acquiring a wound infection. Stay away from anyone who has a cold, mumps, measles, or chickenpox or other communicable diseases.

Drug Interactions with Tacrolimus:

Many drugs can increase or decrease the amount of Tacrolimus in the body. It is important that every physician who takes care of a transplant patient is aware of the drug interactions involving Tacrolimus. The dosage of Tacrolimus may need adjusting when used with a possible interacting drug. Any doctor or dentist who cares for transplanted patients should be in close contact with the transplant physician. The following is a list of some drugs that decrease Tacrolimus blood levels:

Rifampin (antibiotic) Phenytoin (Dilantin seizure medication) Phenobarbital (seizure medication) Octreotide (Sandostatin) Some drugs that increase Tacrolimus blood levels:

Ketoconazole (antifungal medication) Erythromycin (antibiotic) Clarithromycin (antibiotic) Diltiazem (blood pressure medication) Diflucan (antifungal medication) These are only a few of the drugs that interact with Tacrolimus. Patients should not take any medication prescribed by any doctor unless they consult with their transplant doctor or pharmacist.

Cyclosporine A (Neoral or Generic Formulation) Cyclosporine is another immunuosuppressive drug that is used to prevent rejection of the new liver. Because Cyclosporine stays in the body for a specific amount of time, it should be taken every 12 hours. It is important to take the doses of Cyclosporine at the same time each day as prescribed by the transplant team.

Special Instructions about Cyclosporine Blood-work:

Cyclosporine is adjusted based on the lowest level in the blood.

Storing Cyclosporine:

Cyclosporine should be stored at room temperature. Too much heat or cold can destroy the potency of this medication. Cyclosporine liquid should not be exposed to direct sunlight.

Possible Side Effects of Cyclosporine:

Decrease in kidney function. Kidney function should be closely checked by lab tests. Having the correct Cyclosporine dose will keep the risk of this side effect to a minimum. Tremor of the hands. This usually stops as the Cyclosporine dose is reduced. The new onset of tremor may indicate the Cyclosporine level is too high. Increased growth of facial hair. Facial hair removers may be used to get rid of unwanted hair. Make sure it is non-irritating to the skin. Increased blood pressure. Medications to keep blood pressure under control can be used. Gum hyperplasia. Use a soft toothbrush and get good dental care. Attention to good daily dental care can help prevent this complication. Increased risk of infection. Because this drug weakens the immune system, patients are more prone to infection. Patients should avoid anyone with an active infection and be careful not to injure themselves which may increase the chance of acquiring a wound infection. Stay away from anyone who has a cold, mumps, measles, or chickenpox or other communicable diseases. Some of the less frequent side effects of Cyclosporine:

Acne Headache Flushing Tingling of the arms or legs Nasal congestion Drug Interactions with Cyclosporine: Many drugs can increase or decrease the amount of Cyclosporine in the body. It is important that every physician who takes care of a transplant patient is aware of the drug interactions involving Cyclosporine. The dosage of Cyclosporine may need adjusting when used with a possible interacting drug. Any doctor or dentist who cares for transplanted patients should be in close contact with the transplant physician. The following is a list of some drugs that decrease Cyclosporine blood levels:

Rifampin (antibiotic) Phenytoin (Dilantin seizure medication) Phenobarbital (seizure medication) Octreotide (Sandostatin) Some drugs that increase Cyclosporine blood levels:

Ketoconazole (antifungal medication) Erythromycin (antibiotic) Clarithromycin (antibiotic) Diltiazem (blood pressure medication) Diflucan (antifungal medication) These are only a few of the drugs that interact with Cyclosporine. Patients should not take any medication prescribed by any doctor unless they consult with their transplant doctor or pharmacist.

Differences Between Tacrolimus and Cyclosporine

Tacrolimus and Cyclosporine have similar mechanisms action and drug interactions. Patients may take either Cyclosporine or Tacrolimus, but never both. Some of the differences of Tacrolimus from Cyclosporine include:

Tacrolimus is much more potent (weight for weight) The incidence of high blood pressure is lower The incidence of high blood sugars (diabetes) is higher The incidence of neurotoxicity such as tremors, nightmares, headaches, etc., is higher

Methylprednisolone (Medrol, Prednisone) Methylprednisolone is a member of the family of drugs called “steroids.” It is taken to prevent the body from rejecting the liver. Methylprednisolone or some other steroid medication is a necessary ongoing part of daily medication for all transplant patients.

Possible Side Effects of Methylprednisolone:

Sodium (salt) and water retention. Ankles may become swollen. Fluid and salt intake may be restricted and diuretics (water pills) may be given to correct this. Stomach ulcers. Antacids relieve this side effect. When steroid dose is reduced, antacids need to be stopped, making it essential that steroids are taken after eating. The stools should be watched for presence of blood. A danger sign to watch for is black, tarry stools. “Moon Face.” This side effect is usually reduced as steroid dose is lowered. Also, taking steroids close to a person’s wake-up time can help to reduce “moon face.” The most important factor in preventing this side effect is avoiding weight gain from overeating. Muscle weakness. This happens primarily in the thighs and buttocks. Patients should be careful getting out of chairs and climbing stairs until they regain their strength. Walking and exercise maintains strength. Blurred vision. Blurred vision improves when the steroid dose is reduced. Cataracts. A patient’s eyes should be examined regularly by an ophthalmologist. Night sweats, nightmares. Difficulty sleeping. Easy bruising of the skin, slow wound healing. Mood swings. Some people feel happy one minute and depressed the next. Patients usually feel better once the steroid dose is reduced. Increase in hair growth. Hair removal preparation may be used. Darkened skin. This usually looks like a suntan. Facial blemishes (acne). Washing the face two to three times daily with soap and water may be helpful to reduce acne. Increased appetite. Some people have to “push” themselves away from the table to avoid weight gain. The steroids do not cause the weight gain; people gain when they eat too much while on steroids. Increased sensitivity to the sun. Use a lotion with a Sun Protectant Factor (SPF) of 25. Increased risk of infection. High blood sugar. Any signs of high blood sugar such as increased thirst or tiredness should be reported to the doctor. Diet may be adjusted to control blood sugar. If this problem develops and cannot be controlled by diet, then insulin or oral hypoglycemic medications may be needed. Most often, medications will not be required once the steroid dose is lowered to the normal maintenance level.

Mycophenolate Mofetil or Sodium (CellCept or Myfortic) Mycophenolate is an immunosuppressant used to prevent rejection of the transplant. Most patients take this medication two times a day.

Possible Side Effects of Mycophenolate:

Abdominal pain/cramping. If this occurs, take this medication with food. Vomiting/diarrhea. If these last more than one day, the doctor should be contacted. Headache. Decreased white blood cell (WBC) count and/or platelets. If either the WBC or platelet counts drop too low, the dose can be adjusted. Increased risk of infection. Because this drug weakens the immune system, patients are more prone to infection. Patients should avoid anyone with an active infection and be careful not to injure themselves which may increase the chance of acquiring a wound infection. Stay away from anyone who has a cold, mumps, measles, or chickenpox or other communicable diseases. Drug Interactions with Mycophenolate: Cholestyramine (Questran), a cholesterol-lowering drug, and antacids (Mylanta, Maalox, Tums, Riopan) decrease the levels of Mycophenolate.

Sirolimus (Rapamune) Sirolimus is an immunosuppressant used to prevent rejection of the transplant. This drug does not cause kidney damage and therefore patients will be switched to this medication from other drugs that cause kidney problems to preserve their kidney function. It is taken once daily.

Possible Side Effects of Sirolimus:

Increase in triglycerides and cholesterol. Decrease in wound healing post transplant. Decreased white blood cell (WBC) count and/or platelets. If either the WBC or platelet counts drop too low, the dose can be adjusted. Joint and bone pain. Increased risk of infection. Because this drug weakens the immune system, patients are more prone to infection. Patients should avoid anyone with an active infection and be careful not to injure themselves which may increase the chance of acquiring a wound infection. Stay away from anyone who has a cold, mumps, measles, or chickenpox or other communicable diseases. Drug Interactions with Sirolimus:

Many drugs can increase or decrease the amount of Sirolimus in the body. It is important that every physician who takes care of a transplant patient is aware of the drug interactions involving Sirolimus. The dosage of Sirolimus may need adjusting when used with a possible interacting drug. Any doctor or dentist who cares for transplanted patients should be in close contact with the transplant physician. The following is a list of some drugs that decrease Sirolimus blood levels:

Rifampin (antibiotic) Phenytoin (Dilantin seizure medication) Phenobarbital (seizure medication) Octreotide (Sandostatin) Some drugs that increase Sirolimus blood levels:

Ketoconazole (antifungal medication) Erythromycin (antibiotic) Clarithromycin (antibiotic) Diltiazem (blood pressure medication) Diflucan (antifungal medication) These are only a few of the drugs that interact with Sirolimus. Patients should not take any medication prescribed by any doctor unless they consult with their transplant doctor or pharmacist.

Azathioprine (Imuran) Imuran helps prevent rejection of the transplant. Although an Imuran pill looks like two pills stuck together, it is really one 50 milligram pill. Most people take Imuran at the same time every day. Take it after a meal or snack.

Possible Side Effects of Imuran:

Decreased white blood cell (WBC) count. Because white blood cells are important in fighting infection, Imuran can be adjusted if the WBC count is too low. Upset stomach. Take this medication after a meal or a snack, because it is less upsetting on a full stomach. Sore throat, mouth ulcers, blood in urine, dark tarry stools. A doctor should be contacted if any of these symptoms arise. Drug Interactions: Allopurinol (Zyloprim), a gout medication, should never be given together with Imuran. The combination may cause fatal bone marrow suppression if taken together.

Other Important Information: Dangers of the sun, such as skin cancer, are increased when taking Cyclosporine, Prednisolone, and Imuran. Patients should wear a sunscreen preparation to provide protection against the harmful rays of the sun. The sunscreen should contain a minimum 25 SPF. Wearing a broad-brimmed hat outdoors can aid sun protection. Sunbathing or using a tanning booth should never be done.

Imuran depresses the body’s resistance to infections. Patients should avoid others with an infection and be careful not to injure themselves, as this increases the risk of infection. Any sign of infection, such as fever, chills, swelling, redness, or pain should be reported to the doctor immediately. Take care to wash hands with soap and water before eating, as this kills many germs. Stay away from anyone who has mumps, measles, or chicken pox.

Thymoglobulin Thymoglobulin is a potent immunosuppressive drug that is used immediately after transplant to prevent rejection or to treat rejection episodes whenever they occur post transplantation. This medication is only available in the intravenous formulation and must be given while the patient is in the hospital.

Possible Side Effects of Thymoglobulin: Most of the side effects caused by Thymoglobulin occur after the first two or three doses only. These are similar to having the flu. They include:

Fever. Chills. Nausea. Vomiting. Diarrhea. Decreased white blood cell (WBC) count and/or platelets. If either the WBC or platelet counts drop too low, the dose can be adjusted. Increased risk of infection. Because this drug weakens the immune system, patients are more prone to infection. Patients should avoid anyone with an active infection and be careful not to injure themselves which may increase the chance of acquiring a wound infection. Stay away from anyone who has a cold, mumps, measles, or chickenpox or other communicable diseases. It is important to avoid all possible sources of infection such as pets, school-age children, flowers, and crowded, enclosed areas. Some patients have no side effects. Some patients get sick with the first two doses. Patients who have shortness of breath, wheezing, or chest pain should tell their doctor immediately.

Drug Interactions with Thymoglobulin: To date, there are no known drugs that interact with Thymoglobulin.

Muromonab CD3 (OKT3) OKT3 is an antibody that attaches to, and helps kill, the white blood cells that are involved in rejection of the transplanted organ. OKT3 is an effective drug that reverses rejection. It is given as an intravenous injection once a day for 7 to 14 days. It will be used if rejection does not respond to extra steroids or Thymoglobulin treatments.

Possible Side Effects of OKT3: Most of the side effects caused by OKT3 occur after the first two or three doses only. These are similar to having the flu. They include:

Fever. Chills. Nausea. Vomiting. Diarrhea. Increased risk of infection. Because this drug weakens the immune system, patients are more prone to infection. Patients should avoid anyone with an active infection and be careful not to injure themselves which may increase the chance of acquiring a wound infection. Stay away from anyone who has a cold, mumps, measles, or chickenpox or other communicable diseases. It is important to avoid all possible sources of infection such as pets, school-age children, flowers, and crowded, enclosed areas. Some patients have no side effects. Some patients get sick with the first two doses. Patients who have shortness of breath, wheezing, or chest pain should tell their doctor immediately.

Asthma-like wheezing or tightness when breathing is an uncommon but potentially dangerous side effect. Prior to each dose of OKT3, patients are given another drug to decrease these side effects. While on OKT3, patients are severely immunosuppressed (more than would be with other immunosuppressants).

Other Medications Nystatin (Mycostatin) Nystatin is used to prevent or treat yeast infection (thrush) in the mouth and the food pipe (esophagus). This is usually given when the patient is on a high-dose immunosuppressant and stopped when the steroid dose is reduced below 20 mg per day.

How to Take Nystatin Liquid:

Shake well before measuring the dose. Swish the dose around in the mouth for at least two minutes before swallowing. Allow the Nystatin to coat the mouth for as long as possible. Do not eat or drink anything for 30 minutes after taking the medication.

Sulfa Tablets, Bactrim, Septra, Cotrim (Sulfatrim) Sulfa tablets are used to prevent bacterial infections following transplantation. Sulfa tablets are usually taken as directed once every morning or one tablet three times a week (Monday, Wednesday, and Friday). Do not stop taking the sulfa tablets unless directed by a doctor. Sulfa tablets can make the skin more sensitive to sunlight. Use a lotion with a minimum of SPF 25 when in the sun.

Possible Side Effects of Sulfa Tablets, Bactrim, Septra, Cotrim (Sulfatrim):

Nausea, vomiting, abdominal cramping, diarrhea. If these side effects occur, take the medication with food. If the side effects last for more than one day, contact a doctor. Skin rash, itching, sore throat, fever, chills, mouth sores, or joint pain. If these side effects occur, contact a doctor immediately.

Nifedipine, Adalat, Procardia or Amlodipine (Norvasc) These medications are used to lower blood pressure. Patients usually take Procardia or Norvasc, but never both. Normally, these medicines will be taken once or twice a day. It is important to take the medication on a regular basis. Do not stop taking this medication unless instructed by a doctor.

Possible Side Effects of Procardia and Norvasc:

Dizziness, lightheadedness, or faintness when rising from lying or sitting. If these side effects occur, get up slowly. Headache, weakness, flushing, nausea, heartburn, muscle cramps, sore throat. If these side effects become severe, contact a doctor. Swelling of the feet or lower legs, breathing difficulty, sudden weight gain, irregular heartbeat or heart rate. If these side effects occur, contact a doctor immediately.

Atenolol (Tenormin) Atenolol is used to control high blood pressure. Atenolol must be taken regularly because it only controls high blood pressure — it does not cure it. Suddenly stopping this medication can make the condition worse and affect the heart. Patients sometimes are instructed to check their pulse (heart rate) daily. When the pulse is lower than 60, a doctor should be contacted.

Possible Side Effects of Atenolol:

Dizziness or fainting. Avoid sudden changes, such as quickly standing from a lying or sitting position. Change positions slowly. When getting out of bed, sit on the side of the bed for a few seconds before standing up. Fatigue, depression, breathing difficulty, swelling of hands or feet, slow or irregular pulse, and chest pains are uncommon side effects. Captopril (Capoten) Captopril is used to control high blood pressure. Captopril must be taken regularly because it doesn’t cure but only controls high blood pressure. For best results, Captopril should be taken on an empty stomach one hour before or at least two hours after a meal. While in the sun, a sunscreen with an SPF 25 should be used.

Possible Side Effects of Captopril:

Dizziness or lightheadedness when getting up from a lying or sitting position. Always get up slowly. Salty taste or change in taste. This usually goes away in time. Rash, mouth sores, sore throat, fever, irregular heartbeat, chest pains, swelling of the hands or feet, difficulty breathing. A doctor or transplant surgeon should be contacted if any of these symptoms occur. Diltiazem (Cardizem) Diltiazem is used to lower blood pressure. Diltiazem may be used to make Cyclosporine/Tacrolimus levels higher. Diltiazem does not cure high blood pressure but only controls it. Do not drink alcohol while taking Diltiazem. This will add to the blood pressure lowering effect.

Possible Side Effects of Dilitiazem:

Fatigue, nausea, headache. Contact a doctor if these side effects become severe. Lightheadedness or dizziness. When getting up from lying or sitting, stand or sit up slowly. Irregular heartbeat or increased heart rate. If these side effects occur, contact a doctor. Furosemide (Lasix) Furosemide is a diuretic (water pill). It helps the body rid itself of water and salt. It is used to control high blood pressure and to treat swelling and water retention. Patients who gain weight rapidly or whose hands or feet swell should call their doctor.

Possible Side Effects of Lasix:

Muscle cramps, weakness, or ringing in ears. Call a doctor or transplant surgeon if these symptoms occur. Dizziness, lightheadedness. When getting up from lying or sitting, change position slowly. If that does not help, then the dose may need to be reduced. Fever, sore throat, or skin rash. Call a doctor or transplant surgeon immediately if these side effects occur. Pantoprazole (Protonix), Omeparazole (Prilosec) This medicine is used to treat or prevent ulcers, heartburn, or indigestion. It protects the stomach from the harsh effects of Medrol and other drugs. Patients usually take this drug either once or twice a day as directed by a doctor. If a patient takes it only once a day, it should be taken at bedtime. For those taking it twice a day, this medicine should be taken in the morning and at night.

Precautions:

It may take several days for this medication to work. Do not take medicine with foods or drinks that irritate the stomach. These include citrus fruits or juices and carbonated drinks. Smoking may keep this medicine from working as well as it should. No transplant patient should smoke or use tobacco products. For ulcer pain that does not get better or gets worse, check with a doctor. Atrovastatin (Lipitor), Simvastatin (Zocor), and Pravastatin (Pravachol) Long-term use of Cyclosporine and Medrol may increase the cholesterol and fat levels in the blood. If this happens, patients need one of these medicines to decrease these levels and avoid further complications. Take this medication with a late meal. For patients taking more than one dose a day, it should be taken with meals or snacks.

Possible Side Effects:

Blurred vision. Fever. Muscle aches or cramps; unusual tiredness or weakness. Constipation or diarrhea. Dizziness or headache. Some side effects are not serious. A doctor should be contacted if the symptoms are bothersome.

Valganciclovir (Vacyte), Ganciclovir (Cytovene) One common virus that patients develop after transplantation is cytomegalovirus (CMS). If untreated, CMV can cause serious complications particularly in the liver, intestine, and lungs. The most effective treatment for CMV is intravenous Ganciclovir. If a patient develops CMV, the patient will be given intravenous Ganciclovir once or twice a day for 14-21 days. All patients will be given oral Ganciclovir or Valganciclovir to prevent the development of CMV disease post transplantation.

Calcium Carbonate (OSCAL-500, Tums) Calcium carbonate is used to supply calcium to the body. We recommend that calcium be taken one hour after meals.

Possible Side Effects:

Diarrhea, vomiting. Weakness. Drug Interactions: Calcium carbonate may affect the way the body responds to other medications. A doctor or pharmacist can instruct patients if certain medications should be separated from calcium carbonate.

Investigational Medications An investigational drug is one that has not yet been approved by the US Food and Drug Administration (FDA). All new drugs must be investigated and studied before the FDA will approve them for a particular use. Cyclosporine, for example, was classified as an investigational drug for five years before the FDA approved it in 1983. Few drugs are currently being studied in transplantation. However, some patients are asked to participate in studies. If approached, we encourage all patients to be involved in these studies since they help progress our knowledge and develop better ways to treat patients.

Transplant Medications, Henry Ford Hospital, Detroit, MI.

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