Download Immunosuppression in Thoracic Transplantation

Transplant Medications
Ed Horn, Pharm.D., BCPS
Clinical Pharmacy Specialist – Transplant
Allegheny General Hospital
Objectives
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By the end of this talk you should be able to:
– Know the different types of medications used in
transplant patients
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Anti-rejection
Anti-infection
– Know the side effects of transplant medications
– Understand the follow-up required when taking anti-
rejection medications
What Types of Medications Are
Used After Transplant?

Anti-rejection
– Prevent your body’s immune system from attacking
(rejecting) your new organ
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Tacrolimus (Progaf)
Cyclosporine (Neoral, Gengraf, Sandimmune)
Mycophenolate (CellCept, Myfortic)
Prednisone
Sirolimus (Rapamune, Rapamycin)
Anti-infection
– Prevent you from infection due to your body’s
decreased ability to fight infection
What Types of Medications Are
Used After Transplant?

Anti-infection
– Prevent you from infection due to your body’s
decreased ability to fight infection

Pneumonia
– Bactrim
– Dapsone

Fungal infections
– Clotrimazole (Mycelex Troches)
– Fluconazole (Diflucan)
– Voriconazole (Vfend)
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Viral infections
– Acyclovir
– Valganciclovir
– Ganciclovir
Balance is key. . .
Infection
Side Effects
Rejection
Immunosuppressive Strategies

Usually consists of 2-pronged approach:
– Induction
 Potent immunosuppressant given in the ICU
immediately after surgery
 Helps body accept newly transplanted organ easier
– Maintenance – MOST IMPORTANT
MEDICATONS

Usually a 1-3 drug combination to start
– Calcineurin inhibitor: PROGRAF or Cyclosporine
– Anti-metabolite: CELLCEPT
– Steroids: PREDNISONE
Anti-Rejection Medications
Maintenance
Immunosuppressive Strategies
Maintenance - PROGRAF
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Tacrolimus (PROGRAF)
– Works by preventing the immune system from
activating (“turning on”)
– Usually taken two times per day 12 hours apart
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Ex: 8:00 a.m. and 8:00 p.m.
If taken once daily, take at 8:00 a.m.
– Blood levels are drawn to determine how much Prograf
is in the body
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Usually need levels between 10-15
When having blood drawn, take Prograf AFTER
– Can be taken with or without food – just keep it
consistent!
Immunosuppressive Strategies
Maintenance - PROGRAF
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Tacrolimus (PROGRAF)
– Side Effects:
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Diabetes (high blood sugar)
Hypertension (high blood pressure)
Hyperlipidemia (high cholesterol and triglycerides, especially LDL bad cholesterol)
Renal insufficiency (decreased kidney function)
Tremors (shaking hands)
– Infection
– Malignancy (certain types of cancer or lymphoma)

Prograf has MANY drug interactions – do not take
new medications (prescription or over the counter)
before contacting your coordinator
Immunosuppressive Strategies
Maintenance - CYCLOSPORINE

Cyclosporine
– Works by preventing the immune system from
activating (“turning on”)
– Usually taken two times per day 12 hours apart

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Ex: 8:00 a.m. and 8:00 p.m.
If taken once daily, take at 8:00 a.m.
– Blood levels are drawn to determine how much
Cyclosporine is in the body
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Usually need levels between 200-300
When having blood drawn, take Cyclosporine AFTER
– Can be taken with or without food – just keep it
consistent!
Immunosuppressive Strategies
Maintenance – CYCLOSPORINE

Cyclosporine
– Side Effects:
Diabetes (high blood sugar)
 Hypertension (high blood pressure)
 Hyperlipidemia (high cholesterol and triglycerides, especially LDL bad cholesterol)
 Renal insufficiency (decreased kidney function)
 Unwanted hair growth
 Gum overgrowth
– Infection
– Malignancy (certain types of cancer or lymphoma)
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Cyclosporine has MANY drug interactions – do not take new
medications (prescirption or over the counter) before contacting your
coordinator
Cyclosporine has at least 3 brand/generic products! Make sure you are
always taking the same one
– Neoral
– Sandimmune
– GenGraf
Immunosuppressive Strategies
Maintenance - CELLCEPT

Mycophenolate (CellCept)
– Works by decreasing the number of certain
types of white blood cells that cause rejection
– Usually taken two times per day with doses
ranging from 1000mg-1500mg 2x/day

Dose may be lower if white blood cell count is low
or if infection is present
– Can take with Prograf or cyclosporine
– Do not crush tablets or open capsules
Immunosuppressive Strategies
Maintenance - CELLCEPT
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Mycophenolate – CELLCEPT
– Side effects:
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Decrease white blood count
– found in blood tests
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Infection
Nausea, vomiting, diarrhea
Malignancy (certain types of cancer or lymphoma)
Immunosuppressive Strategies
Maintenance - PREDNISONE
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Prednisone
– Works by many different ways in the immune system to
prevent rejection
– One of the first medications used to prevent rejection in
transplant patients
– Can be continued long-term or tapered off after
transplant
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Has many long term side effects
– Should not be stopped abruptly
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Adrenal crisis – severe drop in blood pressure, loss of
consciousness
Immunosuppressive Strategies
Maintenance - PREDNISONE
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Side effects
– Short term
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High blood pressure
Elevated cholesterol - triglycerides, LDL-bad cholesterol
Salt and fluid retention
Diabetes (steroid induced)
Poor wound healing
Mood swings (extreme elation or depression)
– Long Term
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Osteoporosis - weak bones
Stomach ulcers
Myopathy (muscle weakness)
Cosmetic effects (full moon face)
Thrush/fungal infections
Immunosuppressive Strategies
Maintenance - RAPAMUNE
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Sirolimus (RAPAMUNE, rapamycin)
– Works by preventing certain immune cells from
multiplying
– Used in combination with PROGRAF, Cyclosporine or
with CellCept
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Usually taken once daily
– Can be taken at the same time as PROGRAF
– Must be taken 4 hours apart from cyclosporine
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Levels are monitored similar to PROGRAF
Immunosuppressive Strategies
Maintenance - RAPAMUNE
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Side effects
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Increases cholesterol, triglycerides and LDL levels
Decreases white blood cell counts and hemoglobin
Poor wound healing
Mouth ulcers
Infection
Malignancy (certain types of cancer-lymphoma)
Drug interactions
– Similar to PROGRAF and cyclosporine
– Do not take any new medications before calling your coordinator
Infection Prevention

Aside from rejection, biggest risk to
transplant patients is infection
– Bacterial – pneumonia, blood stream infections
– Viral – gastritis, pneumonia, meningitis
– Fungal
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Risk of infection is highest in first 6-12
months after transplant
 Type of infection depends on the organ
transplanted
Rules To Live By . . .
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Do not take any new medications, even
ones prescribed by your PCP, before calling
your transplant coordinator
 Beware of herbal medications
– Many have effects on the immune system
 Activation
 Suppression
– May have interactions with anti-rejection
medications
Summary
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Immunosuppressive agents are used to
prevent rejection
 Balance between rejection, infection, and
side effects must be maintained
 Medication regimens are complex with
multiple drug interactions and side effects
 Proper monitoring of blood levels is
mandatory to adjust medications