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Post-Transplant

Medications

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Section 1: Immunosuppression

Tacrolimus (Prograf)


What it Does: Helps prevent the body from rejecting the transplanted organ.

How is it Given:

  • Give tacrolimus at the same time every day, usually 12 hours apart (8 hours apart for small children). Please refer to your transplant team or pharmacist for dosing instructions for your child.
  • Give tacrolimus either with food or without food. Give it the same way every day, since changes in food intake can affect how much tacrolimus passes from your child’s stomach into their bloodstream.
  • Make sure that you always have the same brand of tacrolimus. Call your transplant team if you notice that the capsules or liquid tacrolimus look different from what your child normally takes.

Common Side Effects:

  • Decreased magnesium in the blood.
  • Increased potassium in the blood.
  • Increased blood sugar (some children develop diabetes).
  • Increased blood pressure.
  • Damage to the kidneys (usually if blood levels of tacrolimus are too high, but long-term damage at “normal” doses is also possible).
  • Shakiness of the hands/feet (tremor).
  • Upset stomach, vomiting (throwing up), or diarrhea (watery stools).
  • Mild headache.
  • Seizures (if blood levels of tacrolimus are too high).
  • Leg cramps.

Other Important Information:

  • Never give your child grapefruit juice or any juices that contain grapefruit. These products raise the tacrolimus level in your child’s bloodstream. This can lead to more side effects. Read the labels of mixed fruit juices (front and back!) carefully.
  • Never let your child eat grapefruit (even when mixed in a fruit salad).




Prednisone


What is It: Can be used to prevent and treat episodes of rejection. If used for rejection treatment, usually it is given by IV.

How it is Given:

  • Given IV if used for treatment of rejection episodes.
  • If used for maintenance immunosuppression, can be given by mouth.

Common Side Effects:

  • Increased blood pressure.
  • Higher blood sugar levels.
  • Upset stomach, vomiting (throwing up), or diarrhea (watery stools).
  • More appetite (hunger).
  • Weight gain.
  • Edema (puffiness) and rounded face.
  • Mood swings, irritability.
  • Difficulty sleeping.
  • More sweating (more often at night).
  • Mild headache.
  • Acne (pimples).
  • Slow wound healing.
  • Stretch marks.

Long Term Use Side Effects:

  • Weaker bones
  • Slower growth (height)
  • Cataracts (a gel-like glaze over the eye(s))




Mycophenolate Mofetil (CellCept)


What is It: May be used in addition to prograf as a secondary immunosuppressive agent to help prevent rejection of the newly transplanted organ.

How is it Given:

  • Give mycophenolate at the same times every day, 12 hours apart, or as instructed by your transplant team.
  • Give mycophenolate with food or without food. Give it the same way every day, since changes in food intake can affect how much mycophenolate passes from your child’s stomach into their bloodstream.
  • Giving mycophenolate with food may lessen stomach upset (such as cramps or diarrhea).

Common Side Effects:

  • Stomach cramps, diarrhea (watery stools).
  • Nausea (upset stomach), heartburn or vomiting (throwing up).
  • Low platelet counts (platelets help stop bleeding).
  • Low white blood cell counts (white blood cells help fight infection).
  • Low red blood cell (hemoglobin) counts (hemoglobin provides energy to the body).
  • Mild headache.
  • Birth defects and risk of malformations in an unborn fetus (girls should change to another agent while pregnant or trying to).




Sirolimus (Rapamune)


What is It: Can be used as a primary or secondary immunosuppressive to help prevent the body from rejecting the newly transplanted organ.

How it is Given:

  • Give sirolimus once a day, at the same time every day. Your child’s doctor may want your child to take it twice a day if they are on a high dose. Please refer to your transplant team or pharmacist for dosing instructions for your child.
  • Give sirolimus with food or without food, but give it the same way every day. Food does not have a big effect how much sirolimus passes from your child’s stomach into their bloodstream

Common Side Effects:

  • Upset stomach, vomiting (throwing up), or diarrhea (watery stools).
  • Mild headache.
  • High cholesterol and/or triglyceride levels.
  • Low white blood cell counts (white blood cells help fight infection).
  • Mouth sores or ulcers.
  • Low red blood cell (hemoglobin) counts (hemoglobin provides energy to the body).
  • Low platelet counts (platelets help stop bleeding).
  • High blood pressure.
  • Delayed wound healing.
  • Acne (pimples).
  • Increased protein in the urine.
  • Swelling.
  • Increase in liver function tests.
  • Leg cramps.
  • Lung inflammation (swelling).

Other important information

  • Never give your child grapefruit juice or any juices that contain grapefruit. These products raise the level in your child’s bloodstream. This can lead to more side effects. Read the labels of mixed fruit juices (front and back!) carefully.
  • Never let your child eat grapefruit (even when mixed in a fruit salad).




Thymoglobulin


Thymoglobulin is an anti-human thymocyte immunoglobulin that is derived from rabbits and functions in the immunosuppression of a particular type of immune cell in the body called T cells. If your child is in acute rejection, your child's transplant team may choose to use thymoglobulin as an addition to his or her maintenance immunosuppression to help save the graft. Thymoglobulin is given intravenously.

Common Side Effects:

  • High blood pressure (hypertension)
  • Joint or muscle pain
  • Abdominal pain
  • Increased levels of potassium in the blood
  • Low counts of platelets and white blood cells
  • Headache
  • Fever and/or chills
  • Shortness of breath




General Signs of Infection


For all immunosuppressive medications, be aware of the signs of infection, and notify your child's transplant team right away:

  • Pain, tenderness, redness, or swelling
  • Sweats or chills
  • Wound or cut that won’t heal
  • Red, warm, or draining sore
  • Sore throat, scratchy throat
  • Sinus drainage, nasal congestion
  • Persistent dry or moist cough lasting more than two days
  • Nausea, vomiting, diarrhea
  • Flue like symptoms (chills, aches, fatigue)
  • Trouble urinating
  • Bloody, cloudy or foul-smelling urine
  • Black, tarry stools




What are immunosuppression medications (aka anti-rejection medications)?


  • When your child receives an organ transplant, his or her body senses the new organ as foreign and the body's immune system attacks it.
  • Immunosuppressive medication helps reduce the risk of your child's body rejecting the new organ by lowering your immune response.
  • Since your child has a lowered immune response, this also means that your child is more susceptible to all types of infections.
  • Your child will have to take these medications for the rest of his or her life and it is very important for the survival and longevity of his or her transplant.




Cyclosporine (Neoral, Sandimmune)


What it Does: May also be used as a primary immunosuppressive agent to prevent your child’s body from rejecting the newly transplanted organ.

How is it Given:

  • Give cyclosporine at the same times every day, usually 12 hours apart (8 hours apart for small children). Please refer to your transplant team or pharmacist for dosing instructions for your child.
  • Give cyclosporine either with food or without food. Give it the same way every day, since changes in food intake can affect how much cyclosporine passes from your child’s stomach into their bloodstream.
  • Make sure that you always have the same brand of cyclosporine. Call your transplant team if you notice that the capsules or liquid cyclosporine look different from what your child normally takes.

Common Side Effects:

  • Decreased magnesium in the blood.
  • Increased potassium in the blood.
  • Increased blood pressure.
  • Increased blood sugar (some children develop diabetes).
  • Damage to the kidneys (usually if blood levels of cyclosporine are too high).
  • Headache.
  • Tremors (shakiness of the hands or feet).
  • Upset stomach, vomiting (throwing up) or diarrhea (watery stools).
  • Increased body hair growth.

Other Important Info:

  • Never give your child grapefruit juice or any juices that contain grapefruit. These products raise the level in your child’s bloodstream. This can lead to more side effects. Read the labels of mixed fruit juices (front and back!) carefully.
  • Never let your child eat grapefruit (even when mixed in a fruit salad).





Section 3: Other Medications

Pantoprazole (Protonix)


This is a common medication that your child may have been on before transplant. The function of this medication is to treat acid reflux by reducing the amount of acid the stomach produces and is known as a proton-pump inhibitor (PPI). It usually comes in tablet form.

Common Side Effects:

  • Headache
  • Dizziness
  • Abdominal pain
  • Nausea and/or vomiting




Metoclopramide (Reglan)


The purpose of this medication is to speed up the emptying of the stomach and the movement of the upper portion of the small intestines. Your child's transplant team may prescribe this to your child if he or she is having trouble with slow motility or nausea after transplant. It usually comes in the form of a tablet.

Common Side Effects:

  • Tiredness
  • Trouble sleeping
  • Agitation
  • Headache
  • Diarrhea
  • Dizziness




Loperamide (Lomotil)


This medication functions to treat diarrhea by slowing down the movement of the gut. It comes in the form of tablets. Your child's transplant team might suggest this medication if they are having high output from their ostomy and frequent bouts of dehydration.

Common Side Effects:

  • Dizziness
  • Tiredness
  • Constipation




Warfarin (Coumadin)


This medication functions to prevent and treat blood clots by lowering the activity of clotting proteins in your child's blood. It comes in the form of a tablet. This medication requires close monitoring and usually will require your child to have his or her blood drawn on a regular basis. You also need to be aware that your child can bleed easily on this medication, so you should be careful if your child becomes injured.

Common Side Effects:

  • Nausea, vomiting, stomach pain.
  • Bloating, gas.
  • Altered sense of taste.
  • Easy bruising, purple or red pinpoint spots on skin.

Important Tips and Special Instructions:

  • Interacts with many drugs, should check to see if any of your child's medications will interact.




Enoxaparin (Lovenox)


This medication functions to prevent and treat blood clots by lowering the activity of clotting proteins in your child's blood. It comes in the form of a subcutaneous (under the skin) injection. This medication requires close monitoring and usually will require your child to have his or her blood drawn on a regular basis. You also need to be aware that your child can bleed easily on this medication, so you should be careful if your child becomes injured.

Common Side Effects:

  • Pain, bruising, swelling at the injection site
  • Nausea
  • Diarrhea
  • Swelling in hands or feet
  • Fever

Important Tips and Special Instructions:

  • Use extra caution with sharp objects to avoid getting cut, bruised, or injured.
  • Avoid contact sports.




Other Possible Medications


  • After transplant, your child may be on a variety of other medications depending upon his or her individual needs.
  • Often times a large surgery like transplant may affect blood pressure, so the transplant team may need to use medications to either help raise or lower their blood pressure.
  • Medications may also be used to help with acid reflux if your child complains of heart burn post-transplant.
  • As your child transitions from parenteral nutrition to enteral feeds, supplements with vitamins and minerals may be required and will be determined by your transplant team and dieticians.
  • It is not uncommon for children to need to take a multivitamin or supplements of calcium, magnesium, iron, potassium, or other vitamins and minerals.





Section 2: Prophylaxis

What are prophylactic medications?


Your child’s transplant team may place your child on a variety of other medications after transplant depending on his or her specific needs. Many medications, called prophylactic medications, are medications that are given in order to prevent infection from occurring.

There are a number of anti-fungal, antiviral, and antibacterial prophylactic medications that transplant patients are often given post-transplant. Each treatment plan will be individualized based on your child’s immune status.

Examples of Prophylactic Medications Include:

  • Acyclovir (antiviral)
  • Nystatin (antifungal)
  • Clotrimazole (antifungal)
  • Sulfamethoxazole/ Trimethoprim (Bactrim) (antibiotic)
  • Pentamidine (alternative to Bactrim)
  • Valganciclovir (antiviral)




Valganciclovir (Valcyte)


Antiviral used to treat or prevent cytomegalovirus (CMV). It comes in tablet form and should be taken with food or on a full stomach for full absorption.

Common Side Effects:

  • Headache

  • Diarrhea

  • Nausea

  • Vomiting

  • Upset stomach

  • Low white blood cells

  • Low platelets

Important Tips and Special Instructions:

  • Store at room temperature, away from excess heat, moisture, and direct sunlight.

  • Missed Dose: If missed take as soon as possible; if close to the next dose do not take a double dose.




Acyclovir (Zovirax)


Prophylactically used as an antiviral to prevent and treat infections caused by viruses, particularly herpes virus; also used to treat chicken pox and shingles. It comes in the form of tablets, capsules, or liquid suspension.

Common Side Effects:

  • Tiredness
  • Lightheadedness
  • Headache
  • Nausea or vomiting
  • Abdominal pain
  • Skin reactions
  • Kidney problems

Important Tips and Special Instructions:

  • Most effective when taken as soon as possible after you notice symptoms of herpes infection (i.e. pain, burning, blisters).
  • Does not prevent the spread of herpes virus.




Sulfamethoxazole/ Trimethoprim (Bactrim)


Prophylactic antibiotic used to prevent a type of pneumonia caused by Pneumocystis jiroveci and comes in the form of a tablet.

Common Side Effects:

  • Anemia
  • Sensitivity to sunlight
  • Dizziness
  • Diarrhea
  • Headache
  • Loss of appetite
  • Nausea, vomiting
  • Skin rash

Important Tips and Special Instructions:

  • Take exactly as prescribed with a full glass of water.
  • Drink enough fluids throughout the day.
  • Missed Dose: If missed take as soon as possible; if close to the next dose do not take a double dose.




Pentamidine (NebuPent)


Antibiotic used to prevent a type of pneumonia caused by Pneumocystis jiroveci used for patients with a sulfa allergy or who cannot tolerate oral Bactrim. It is inhaled into the body via a breathing treatment.

Common Side Effects:

  • Dizziness
  • Metallic taste
  • Fatigue
  • Loss of appetite
  • Diarrhea
  • Cough
  • Upset stomach
  • Congestion

Important Tips and Special Instructions:

  • Store in room temperature, away from excess heat, moisture, and direct sunlight.
  • Missed Dose: If missed take as soon as possible; if close to the next dose do not take a double dose.





Section 4: Additional Resources

Helpful Download from Transplant Unwrapped


Sign-Up or Log-In to Access: Medication Table: Listing of common post-transplant medications in a printable format.




Past Webinars


View our past webinars to hear more about post-transplant medications: 1. Overview of Intestinal and Multivisceral Transplant by Dr. Jafri 2. Post-Transplant Life by Alyssa Burnham RPA-C




Helpful Websites: Medication Assistance


Medication Assistance Programs: Listing of sites such as RxAssist to help with prescription costs.




Page References


References here.