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Transplant patients take medications each day to prevent organ rejection. Because the patient's immune system recognizes the transplanted organ as a foreign tissue, it is normal for the immune system to try to reject it. Patients are prescribed a combination of immunosuppressive drugs to help suppress the immune system and prevent or reverse rejection. All anti-rejection drugs can increase the risk of infection because they suppress the immune system. The aim is to prescribe the right balance for each patient – enough to prevent rejection, but not too much which could increase side effects like infections.
Other medications can affect how well the anti-rejection drugs work. Patients should not use herbal medications while taking anti-rejection medications, and they should check with a pharmacist before taking non-prescription ("over the counter") medications, such as cold capsules, aspirin, cough syrups and vitamins. It is also strongly recommended that patients do not eat or drink products with grapefruit due to drug interactions. For these and other helpful tips, read Medication Tips.
Although researchers continue to study new drugs, these are the most common drugs used by transplant patients:
- tacrolimus extended release (Advagraf®)
- tacrolimus regular release (Prograf®)
- mycophenolate sodium (Myfortic®)
- mycophenolate mofetil (CellCept®)
- prednisone (Novo Prednisone®, Apo Prednisone®)
- sirolimus (Rapamune®)
- antilymphocyte globulin (Thymoglobulin®)
- basiliximab (Simulect®)
Tacrolimus (Advagraf® or Prograf®)
Tacrolimus is often combined with mycophenolate and prednisone to prevent rejection. It may also be used to treat rejection episodes. There are two kinds of tacrolimus: Prograf® and Advagraf®. Prograf® is taken every 12 hours as an oral medication while Advagraf® is specially designed to be taken only once a day (every 24 hours). They cannot be interchanged. Not all community pharmacies stock tacrolimus so it’s important to contact your pharmacy and re-order as soon as your medication begins to run low.
Whether you are on Prograf or Advagraf, the tacrolimus level in the blood is measured so that appropriate dosage changes can be made. The aim is to ensure enough drugs are given to prevent rejection, but not too much in order to minimize potential side effects. Side effects may include headache, tremors, elevated potassium in the blood, high blood pressure, and decreased kidney function. Tacrolimus also makes some patients more sensitive to touch, causes numbness or tingling especially around the mouth, and can elevate blood sugar levels.
Tacrolimus interacts with many other medications. Patients need to check with their doctor or pharmacist before taking any new prescribed or over-the-counter medications to ensure that their anti-rejection drugs will not be affected. LHSC's Pharmacy provides more detailed information about Prograf (tacrolimus regular release) and Advagraf (tacrolimus extended release).
Mycophenolate (Myfortic® or CellCept®)
Mycophenolate is another immunosuppressant. Mycophenolate must be given with other anti-rejection drugs, for example, tacrolimus and prednisone. There are two kinds of mycophenolate: Myfortic® and CellCept®. Mycophenolate is taken orally every 12 hours, either with or without food as long as it is done consistently.
Stomach upset and diarrhea are the most common side effects so taking with food may help patients tolerate the medication. Patients may also experience heartburn, acne, tremors, constipation, or headache. This drug may lower some blood cell counts, especially white blood cells. It's important that patients have their blood checked regularly and keep all clinic appointments. Many transplant patients have had healthy babies while taking anti-rejection drugs. Mycophenolate, however, may be harmful to the unborn baby. Pregnancy and breastfeeding are not advised while taking this medication so speak with the transplant team regarding pregnancy.
Also, patients should not take antacids containing magnesium or aluminum (such as Mylanta, Maalox, Amphogel) at the same time as they take mycophenolate because antacids may make this drug less effective. Tums (calcium carbonate) is okay to use because it has no effect on mycophenolate. LHSC's Pharmacy provides more detailed information about CellCept (mycophenolate mofetil) and Myfortic (mycophenolate sodium).
Prednisone continues to be an integral part of anti-rejection drug treatment. Prednisone doses are usually high after the transplant, and are slowly tapered to a lower dose. The body produces its own form of prednisone called cortisol. When prednisone is taken, the body produces less cortisol. Cortisol is necessary to help the body deal with stress such as infections or rejection. Prednisone doses are slowly lowered to allow the body to adjust and produce more cortisol.
Patients should not stop taking prednisone suddenly or they may become very ill. Prednisone may cause some stomach irritation, so it is best taken with food. Other side effects may include moodiness, round face ("cushingoid"), fluid retention or ankle swelling, weight gain, acne, thin skin, easy bruising, poor wound healing, cataracts, high blood sugar, and weakening of the bones (osteoporosis). Transplant teams are aware of these side effects and they attempt to reduce prednisone over time to as low a dose as possible while still preventing rejection.
Prednisone may also be given intravenously (methylprednisolone) immediately after transplant or to treat specific rejection episodes. This IV treatment usually lasts between 2-5 days. LHSC's Pharmacy provides more detailed information about prednisone.
Sirolimus, also known as Rapamune, is another immunosuppressant that is combined with other anti-rejection drugs. Sirolimus is usually taken once a day, preferably at the same time every day.
Side effects may include nausea, diarrhea, tremors, dizziness, high blood pressure, high cholesterol and triglycerides, unusual heartbeat, certain types of cancers (e.g., skin cancer) or mouth sores. Several medications do not mix well with sirolimus, and they may affect the level of sirolimus. For example, drugs that are used to treat high cholesterol and triglycerides may become more potent when taken with sirolimus.
Medication should be stored at room temperature, away from excessive heat and humidity. Sirolimus is a very specialized drug and may not be readily available at every pharmacy so it's important for patients to keep enough on hand so they don't run out. LHSC's Pharmacy provides more detailed information about sirolimus.
Antilymphocyte globulin (Thymoglobulin) may be used during and after transplant to prevent rejection or to treat acute rejection episodes. It is given intravenously, usually for 4-10 days. LHSC’s Pharmacy provides more detailed information about antilymphocyte globulin.
Basiliximab (Simulect) may be used during and after transplant to prevent rejection or to treat acute rejection episodes. It is given intravenously on the day of transplant and again on postoperative day 4. LHSC’s Pharmacy provides more detailed information about basiliximab.