Overview of medications for preventing rejection and infection in post-organ transplant patients. Presented by Methodist Hospital, Houston, TX

1. WHAT DO I NEED TO KNOW
ABOUT MEDICATIONS AFTER
MY ORGAN TRANSPLANT?

2. Meet the Pharmacists
Leamon Samir Patel
Blanton
Kyle Dawson Jenny DeVos

3. This presentation will…
 Answer your questions on what medications
you will take after transplant
 Why these medications are important
 Proper ways of taking these medications
 Explain to you the side effects associated with
these medications

4. Medications that you will be taking
 Anti-rejection medications
 Anti-infection medications
 Medications to protect your stomach
 Blood pressure medications
 Medications for high blood sugars
 Supplements

5. Anti-Rejection Medications
Lungs Immune
System
Heart
Liver
Pancreas Kidney

6. Anti-Rejection Medications
 Prograf® (Tacrolimus)
 Neoral® / Gengraf® (Cyclosporine)
 CellCept® / Myfortic ® (Mycophenolate)
 Imuran® (Azathioprine)
 Rapamune® (Sirolimus)
 Steroids (Prednisone)

7. Anti-Infection Medications
Anti-Rejections drugs
weaken the immune
system
They increase your risk of
getting infections

8. Anti-Infection Medications
Immune Infections
System
Monitor anti-rejection Anti-infection
medications to balance medications help
between risk of rejection and prevent infection

9. Anti-Infection Medications
 Anti-fungal medications
 Fluconazole, Vfend®, nystatin, clotrimazole
 Anti-bacterial medications
 Bactrim®, pentamidine, dapsone, atovaquone
 Anti-viral medications
 Acyclovir, Valcyte®

10. Anti-Rejection Medications

11. Prograf® (Tacrolimus)
 Anti-rejection Medication
 Mostly used anti-rejection medication
Yellow = 0.5 mg
you are put on Prograf® OR
 Typically
Neoral® (Cyclosporine)
White = 1 mg  Do not allow pharmacy to substitute
without physician approval
 Many drug interactions
Red = 5 mg

12. Cyclosporine (Neoral®)
 Anti-rejection medication
 Neoral® or Prograf®
25 mg capsule  Also comes as Sandimmune®,
Gengraf®)
 Do not allow pharmacy to substitute
100 mg capsule without physician approval
 Store capsule in original package
 Many drug interactions

13. Prograf® (Tacrolimus),
Neoral® (Cyclosporine)
 Take every 12 hours at the same time every day
8:00 AM 8:00 PM
 Levels are checked before morning dose and the
dose may be changed according to the drug level
 On lab days, DO NOT take Prograf® or Neoral®
Instead, bring them with you and take after lab
work

14. Prograf® (Tacrolimus),
Neoral® (Cyclosporine)
Side Effects:
 Hand tremors  Water retention
 Headaches  High potassium
 Confusion  Low magnesium
 High blood sugar  Low phosphorus
 High blood pressure  Kidney problems

15. Prograf® (Tacrolimus),
Neoral® (Cyclosporine)
Side Effects:
 Hair Loss (Prograf®)  Hair Growth (Neoral®)

16. Prednisone
 Typically take once daily in the
morning
5 mg tablet  Best to take with food
10 mg tablet  Side effects of prednisone can get
20 mg tablet better as the dose decreases
40 mg tablet

17. Prednisone
Side effects:
 Fluid, salt retention  Facial puffiness
 High blood sugar  Increased appetite
 High blood pressure  Weak bones/bone
 Mood changes
loss
 Insomnia
 Weak muscles/loss
 Weight gain
 Stomach irritation
 Acne

18. Mycophenolate
(CellCept®, Myfortic®)
CellCept®  Anti-rejection medication
 You may take either CellCept®
250 mg 500 mg OR Azathioprine (Imuran®)
 Myfortic® is a “slower release”
Myfortic® form of CellCept®
 Take every 12 hours, same time
180 mg 360 mg every day

19. Azathioprine (Imuran®)
 Anti-rejection medicine
50 mg tablet  May take in place of CellCept
® or Myfortic®
 Once daily dosing
 Drug interaction with
allopurinol
 Decrease azathioprine dose by

20. Mycophenolate (CellCept®, Myfortic®),
Azathioprine (Imuran®)
Side effects:
CellCept ®, Myfortic® Azathioprine
 Nausea, cramping (Imuran®)
 Diarrhea  Decreased white
 Decreased white
blood cell count
blood cell count  Decreased red
blood cell count

21. Sirolimus (Rapamune®)
 Anti-rejection medication
 Take once daily, separate from
1mg tablet Cyclosporine (Neoral®) by 4 hours
Neoral® Rapamune®
8:00 AM 12:00 AM
2 mg tablet  Many drug interactions, ask
Also available as a solution
transplant team before taking any
new medication

22. Sirolimus (Rapamune®)
Side effects:
 Slow wound healing  Increase in
 Increase in
triglycerides
cholesterol  Decrease in red
 Decreased white
blood cell count
blood cell count  Stomach cramping
 Decrease in

23. Drug Interactions for
Prograf®, Neoral®, Rapamune®
Drug/Food Interactions:
 Blood pressure medications (diltiazem, verapamil)
 Seizure medications (phenytoin, carbamazepine)
 Anti-infection medications (voriconazole,
fluconazole)
 Grapefruit, careful of foods high in potassium
 ALWAYS ask transplant team BEFORE taking a
NEW medication or stopping an OLD medication if
it will affect your anti-rejection medication

24. Over-the-counter medications
to AVOID
 Anti-inflammtory drugs: ibuprofen, naproxen
(Aleve®, Advil®, Motrin®)
 Herbal supplements
 Decongestants (phenylephrine,
pseudoephedrine)
 Diet pills
 Cimetidine (Tagament®)

25. Over-the-counter medications
that are OK
 Zyrtec®, Claritin®, Benadryl® - Allergies
 Pepcid®, Zantac®, Prilosec® - Upset stomach
 Immodium® - Diarrhea
 Bisacodyl, Senna, Docusate Sodium –
Constipation
 Tylenol® - Headache, pain, fever

26. Anti-infection Medications

27. Risk of infection
 Lower immune system can increase risk of
infection
 Infection can come from germs in and around
the body, environment, animals or people,
food, insects
 Signs of infections: fever, fatigue, diarrhea,
symptoms of upper respiratory infection,
frequency/burning when urinating, red/irritated
skin

28. Kinds of infections after transplant
that we try to prevent against:
 Fungal infections:
 Oral “thrush”, fungal infection invading body
 Viral infections:
 Herpes (simplex, zoster), Cytomegalovirus (CMV)
 Bacterial infections:
 Pneumocystic jiroveci pneumonia (PCP)

29. Anti-fungal medications
Oral “thrush” medications:
 Nystatin swish and swallow 5 ml four
times daily
 Clotrimazole (Mycelex®) troches four
times daily
 Do not eat or drink for 15 minutes after

30. Anti-fungal medications
For invasive fungal infections:
 Fluconazole (Diflucan®)
 Itraconazole (Sporonox®)
 Voriconazole (Vfend®)

31. Anti-fungal medications
Key points:
 Clotrimazole, fluconazole, itraconazole and
voriconazole WILL affect Prograf®, Neoral®, and
Rapamune® levels
Always ask: What will happen to my anti-rejection
medicine?
 Itraconazole (Sporonox )
®
 Capsules should be taken WITH FOOD
 Solution should be taken on an EMPTY STOMACH
 Voriconazole (Vfend®)

32. Anti-viral medications
Herpes virus, Cytomegalovirus (CMV)
 Acyclovir (Zovirax®)
 200mg-800mg two to four times daily
 Valacyclovir (Valtrex®)
 500mg-1000mg one to two times daily
 Valgancyclovir (Valcyte®)
 450 mg one to two times daily

33. Anti-viral medications
Key points:
 Take medications WITH FOOD to help
increase absorption
 Valcyte can decrease red and white blood cell
counts and dose may be adjusted accordingly
 Thiscould lead to infections and feelings of
fatigue

34. Anti-PCP medications
Pneumocystis jiroveci pneumonia (PCP)
 Bactrim DS on MONDAYS, WEDNESDAYS,
FRIDAYS Bactrim SS daily
 Cannot take if you have an allergy to SULFA
 Increase sensitivity to sunlight
 Can decrease white blood cell counts

35. Anti-PCP medications
Other anti-PCP medications
 Pentamidine Inhalation Treatments
 Given once a month in a breathing treatment
 May cause coughing, irritation
 Dapsone
 100 mg tablet given once daily
 Atovoquone (Mepron®)
 Banana flavored liquid, 750 mg two times daily

36. Other Medications

37. Supplements
 NeutraPhos (Phosphorus)
 MagOxide (Magnesium)
 Multivitamin
 Calcium
 Vitamin D

38. Other medications
 Blood pressure medications
 Norvasc®, Metoprolol, Hydralazine
 Blood sugar lowering medications
 Insulin, Januvia®, Actos®
 Osteoporosis prevention/treatment medications
 Boniva®, Fosamax®, Actonel®
 Take with full glass of water and sit/stand upright for
30 minutes

39. Other medications
 Acetylcysteine (Mucomyst) for inhalation –
Lung
 Lung secretions
 Ursodiol (Actigal®) – Liver
 Prevention of bile stones
 Statins (pravastatin, simvastatin)
 Caution: May cause muscle pain
 Aspirin

40. Other medications
 Water pills (Lasix®)
 Ulcer prevention medications
 Prilosec®, Prevacid®, Nexium®, Pepcid®, Zantac®
 Pain medications
 Maycause: constipation, nausea, confusion,
drowsiness

41. Other information

42. Medication Calendar
PILL BOX SLOT: MORN NOON EVE BED
Used to treat / Noon / Supper / Special
Drug Name/Strength/Instructions 7-9 am Bedtime
prevent afternoon 7- 9 pm Instructions
***PROGRAF (TACROLIMUS); yellow = 0.5 mg
Take ____ MG in the morning and ____ MG in Rejection   white = 1 mg
the evening, 12 hours apart pink = 5 mg
CELLCEPT 500 MG (MYCOPHENOLATE); Take
_____ tablets twice daily every 12 hours (each Rejection  
dose = _____ MG)
PREDNISONE 5 MG; Take 5 tablets (25 mg)
Rejection  Steroid Sparing Protocol
once daily on 2/7
Last dose on:
VALCYTE 450 MG (VALGANCICLOVIR) take
Viral Infections  cmv d-/r+
one tablet every morning 05/03/10
CLOTRIMAZOLE 10 MG (MYCELEX); Take one Last dose on:
Fungal
tablet four times daily - do not eat/drink for 15    
Infections 05/03/10
min. after each dose
Last dose on:
BACTRIM SS (SULFAMETHOX-TMP); Take one
Pneumonia 
tablet everyday in the evening 05/03/10
PROTONIX 40 MG (PANTOPRAZOLE); Take Heartburn /

one tablet once daily Reflux

43. Medication Calendar
 ALWAYS follow directions on Calendar and
NOT on the pill bottle
 ALWAYS bring medication calendar to every
clinic, lab and hospital visit
 ALWAYS make changes to medication on the
calendar

44. NEVER stop taking your
medications
Reasons
 Changes in financial income, insurance policy,
etc
 Side effects from medications
 Laziness, forgetfulness
 Cost of medication

45. ALWAYS ask transplant
team when:
 A NEW medication is started
 An OLD medication is changed or stopped
 Make sure the change in therapy will NOT
affect your anti-rejection medications

46. Suggestions:
 Get to know your pharmacists
 Check medications before leaving the
pharmacy
 Use an alarm device to remind you to take
your medications
 Be proactive in your healthcare

47. Frequently Asked
Questions
 What do I do if I vomit after taking my
medication?
 What do I do if I forget to take my
medications?
 Is there a difference between brand and
generic medications?

48. Questions?