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Transplant Patient Education Medications After Transplant Medicine Dos and Don'ts 1. Always take your medicines as directed. Medicines play an important role after transplant. Never stop, start or change your dose without Some of them will be taken for the rest of your approval from the transplant team. life to prevent your body from rejecting your new organ(s) and to treat any other medical health 2. If a doctor other than your transplant doctor issues you may have. Always take your medicines orders a medicine for you, check with your as directed. Never stop or start a medicine transplant team before taking that medicine.
or change a dose without approval from the transplant team. If you miss a dose of medicine, 3. Keep a current list of your medicines, the always let the transplant team know as soon as directions and the times you take them with you. Bring the current medicine list with you to each doctor appointment. Be sure to The following pages will describe the basics of update the list when a change is made.
some medicines that are commonly used after transplant. The information is meant to serve as a 4. If you miss a dose, do not double the next learning guide only and should not replace advice dose. Contact the transplant team for from your transplant doctor. Follow the "Dos and instructions. Remember, it is best to stay on Don'ts" that are listed on the next page. schedule with all your medicines.
Before Leaving The Hospital 5. Store all medicines away from extreme temperatures, direct light and moisture. Make sure that they are always kept away from • Names of your medicines children and pets.
• Purpose of each medicine • Dose of each medicine 6. Keep medicines with you in your carry-on bag • When to take each medicine when you travel, and always keep an updated • Possible side effects of your medicines medicine list with you that includes phone numbers for your transplant coordinator and For more information, call 800.401.4444 or go to www.nebraskamed.com/transplant Medications, continued 7. Contact your transplant team if you are Medicines to Prevent Rejection feeling too ill to take your medicines because of an upset stomach or are throwing up or Anti-rejection medicines are a group of drugs having loose stools. Do not take an extra used to keep your body from trying to reject dose without contacting the transplant team your new organ(s). They are vital to keep your for instructions.
newly transplanted organ(s) alive and functioning well. You will take a combination of medicines to 8. Do not run out of your medicines. Contact prevent rejection. your pharmacy ahead of the time for refills in case the medicine needs to be ordered.
9. Call the transplant team if you have any side effects, questions about the dose or concerns about why you are taking the medicine.
10. Do not take any over-the-counter medicines or herbal supplements without the approval of the transplant team. Some of these products interact with your transplant medicines or cause side effects, which may be harmful to you and your new organ.
11. Do not stop taking your medicines because of a lack of money. Call the transplant office during business hours as soon as you think that you may have a problem. We have social workers, pharmacy counselors and financial counselors who will work with you. They can find out if there are other choices to help get Please do not wait until Friday afternoon, or until you are out of medicines to contact us.

Transplant Patient Education Medications, continued Tacrolimus (Prograf, also called "Fk" or "Fk-506") Tacrolimus is dispensed in 0.5mg, 1mg and 5mg Possible Side Effects Of Tacrolimus • Shaking (tremors) • Numb or tingling hands/feet Tacrolimus is used to prevent or treat rejection. It blocks the • Trouble sleeping body's immune response to the transplanted organ(s).
• Increased risk of infection • High blood pressure • High blood sugar • Increase in cholesterol levels Tacrolimus is taken twice a day 12 hours apart. For • Decrease in magnesium levels example, if you take your morning dose at 8 a.m., you • Increase in potassium levels should take your evening dose at 8 p.m.
• Abnormal kidney function • Stomach discomfort Dose Changes And Lab Monitoring Tacrolimus doses will be changed based on your lab work including a tacrolimus level. Do not drink grapefruit juice or pomegranate juice because it can interfere with your tacrolimus level.
Do not take your tacrolimus dose before your blood is Check with the transplant team for any possible drug interactions before taking any new medicines, including We may change your tracrolimus dose based on the level herbal supplements.
of the drug in your system called a trough level. This occurs about 30 minutes before you take your next dose. This medicine should not be cut in half or opened. Take the ordered dose after your blood is drawn. The transplant coordinator will call you if you should change your dose.
For more information, call 800.401.4444 or go to www.nebraskamed.com/transplant Medications, continued Cyclosporine (Neoral, Sandimmune, Gengraf) Cyclosporine comes in 25mg, 50mg and 100 capsules. Possible Side Effects Neoral comes in 25mg and 100mg capsules.
• Headaches • Shaking, tremors Cyclosporine is used to prevent or treat rejection. It • Numb or tingling hands/feet blocks the body's immune response to the transplanted • Excessive hair growth • Swelling or overgrowth of gums • Trouble sleeping • Increased risk of infection • High blood pressure Cyclosporine is taken 2 times a day, 12 hours apart. For • High blood sugar example, if you take your morning dose at 8 a.m., you • Increase in cholesterol levels should take your evening dose at 8 p.m.
• Decrease in magnesium levels • Abnormal kidney function Dose Changes And Lab Monitoring • Stomach discomfort Your dose of cyclosporine will change based on your lab work including a cyclosporine level. Do not take your cyclosporine dose before your blood is drawn.
Do not drink grapefruit or pomegranate juice because it We may change your cyclosporine dose based on the can interfere with your cyclosporine level.
trough level. This occurs about 30 minutes before your next dose. Your pharmacy or insurance company may recommend a change to a generic form of cyclosporine. Notify Take your ordered dose after your blood is drawn. the transplant team if this change is recommended or A transplant coordinator will call with changes to your has been made. Check with the transplant team for cyclosporine dose.
any possible drug interactions before taking any new medicines, including herbal supplements.

Transplant Patient Education Medications, continued Prednisone (Deltasone) Prednisone comes in different strengths (1mg, 5mg, • Night sweats 10mg 20mg). Usually our patients receive 5mg tablets.
• Pimples • Purple or red bruising • Vision changes or cataracts • Weak or brittle bones • Increased risk of infection Prednisone is a steroid and is used to prevent or treat • Increase in cholesterol levels rejection. It lowers the body's immune response to the • High blood sugar transplanted organ(s). • Stomach irritation/ulcers Shortly after transplant, prednisone is usually taken once It is NOT safe to suddenly stop taking prednisone. Doses a day and should be taken with food. For example, you should be reduced per a doctor's instruction.
should take your morning dose with breakfast.
Be alert for infections and report any black tarry stools or Your prednisone dose will be decreased over time. In the Check with the transplant team for any possible drug event of rejection, your dose may be increased.
interactions before taking any new medicines, including herbal supplements.
Possible Side Effects Of Prednisone • Increase in appetite • Weight gain • Water retention (swelling in ankles/feet) • Round face or "chubby cheeks" • Mood changes or anxiety • Trouble sleeping For more information, call 800.401.4444 or go to www.nebraskamed.com/transplant

Medications, continued Mycophenolate Mofetil (Cellcept, Myfortic, Also Called "MMF ") Mycophenolate mofetil is dispensed in 250mg and 500mg gel tablets. Myfortic is dispensed in 180mg and 360mg tablets. Each tablet has a coating that helps Mycophenolate mofetil comes in gelatin capsules or tab- protect against stomach pain.
lets; these should not be opened or crushed. Wash with soap and water if contents of capsules come into contact Mycophenolate mofetil is used to prevent rejection. It may Women of childbearing age should use two forms of birth be added to help protect your kidney function or it may be control while taking mycophenolate mofetil and for 6 added if you have an episode of rejection. It lowers the body's weeks after stopping the medicine. Always check with the immune response to the transplanted organ(s). transplant team before planning a pregnancy. Check with the transplant team for any possible drug interactions before taking any new medicines, including herbal supplements.
Mycophenolate mofetil is taken twice a day. 12 hours apart. Contact the transplant office if you have upset stomach, vomiting or loose stools after starting this medicine. Your mycophenolate mofetil dose will generally not change unless you are having bad side effects. Your dose will be reviewed by your liver doctor at 3 months after transplant. If it is safe for you to stop taking this medicine at that time, we will contact you. Possible Side Effects of Mycophenolate Mofetil • Stomach discomfort • Loose stools • Upset stomach/throwing up • Decrease in platelets • Increase or decrease in white blood cells • Decrease in red blood cells • Increase risk of infection Liquid medication • Increase in cholesterol levels • Increase in blood sugar • Electrolyte abnormalities - a decrease in magnesium or calcium levels

Transplant Patient Education Medications, continued Everolimus (Zortress) Everolimus comes in 0.25mg, .50mg and .75mg tablets.
Possible Side Effects Of Everolimus • Increased cholesterol and triglyceride levels • Constipation Everolimus is used to prevent rejection. It may be given • Upset stomach as an added medicine to help prevent rejection and to • Loose stools help protect kidney function. It lowers the body's immune • Abnormal kidney function response to the transplanted organ(s).
• Impaired wound healing • Increased risk of infection • Water retention (swelling in ankles/feet) • High blood pressure • Abnormal blood counts (low iron, low platelet Everolimus is taken twice a day, 12 hours apart. counts, low white blood cell counts) • Mouth sores Dose Changes And Lab Monitoring Your dose of everolimus will change based on a blood level drawn by the lab, called an everolimus level. Do not Do not drink grapefruit juice or pomegranate juice take your dose before your blood is drawn for lab because it can interfere with your everolimus level.
Check with the transplant team for any possible drug We may change your everolimus dose based on the interactions before taking any new medicines, including level of the drug in your system called a trough level. herbal supplements.
This occurs about 30 minutes before you take your next dose. Take the ordered dose after your blood is drawn. A It is very important that you call the transplant team if transplant coordinator will call with changes to your levels. you are planning any surgery. This medicine will need to be stopped 4 weeks before surgery and replaced with another anti-rejection medicine.
For more information, call 800.401.4444 or go to www.nebraskamed.com/transplant Medications, continued Sirolimus (Rapamune) Sirolimus is dispensed in 0.5mg, 1mg, and 2mg tablets • Shaking, tremors • High blood pressure • Water retention - swelling in ankles/feet • Abnormal kidney function • Increased risk of infection Sirolimus is used to prevent rejection. It may be added • Increased cholesterol and triglyceride levels to protect kidney function or if you have had an episode of rejection. It lowers the body's immune response to the transplanted organ(s).
Do not drink grapefruit juice because it can interfere with your sirolimus level. Sirolimus is usually taken once a day. If you take tracrolimus, you can take sirolimus at the same time. Check with the transplant team for any possible drug interactions before taking any new medicines, including Dose Changes And Lab Monitoring herbal supplements.
Your dose of sirolimus will change based on a blood level It is very important that you call the transplant team if drawn by the lab, called a sirolimus (Rapamune) level. you are planning any surgery. This medicine will need Do not take your dose before your blood is drawn. to be stopped 4 weeks before surgery and replaced The transplant team wants to see the trough level, which with another anti-rejection medicine. occurs about 30 minutes before you would take your next dose. Take your ordered dose after your blood is drawn. A transplant coordinator will call with changes to your sirolimus dose. The transplant team may also change your dose based on other factors, such as other lab tests or possible side effects.
Possible Side Effects Of Sirolimus • Impaired wound healing • Stomach discomfort or heartburn • Upset stomach • Loose stools • Headaches Transplant Patient Education Medications, continued Trimethoprim/Sulfamethoxazole Single Strength (SS) (Bactrim SS, Septra SS, Smz-Tmp, Co-Trimazole, Cotrim) Trimethoprim/sulfamethoxazole is used to prevent bacte- • Do not take trimethoprim/sulfamethoxazole if you are rial infections, including Pneumocystis carinii pneumonia allergic to sulfa medicines. (PCP). The SS stands for single strength because Bactrim • Always take trimethoprim/sulfamethoxazole with a full is also available in a double strength formulation. Bactrim glass of water to protect your kidneys. SS is a sulfa drug; the transplant team will decide a differ- • Wear sunscreen to protect your skin from sunburn.
ent medicine for you if you are allergic to sulfa medicines.
Check with the transplant team for any possible drug interactions before taking any new medicines, including Trimethoprim/sulfamethoxazole is taken twice a day for 2 herbal supplements.
days of the week on Monday and Tuesdays only. You will continue this medicine for one year after the transplant.
Your trimethoprim/sulfamethoxazole dose will generally not change during the course of therapy.
Possible Side Effects Of • Upset stomach • Rash/Itching • Decrease in white blood cell count • Decrease in red blood cell count • Decrease in platelet count • Increase in sensitivity to sunlight For more information, call 800.401.4444 or go to www.nebraskamed.com/transplant Medications, continued Acyclovir (Zovirax) Possible Side Effects Of Acyclovir Acyclovir is used to prevent or treat viral infections, includ- ing herpes simplex viruses and shingles.
• Upset stomach/Throwing up • Loose stools • Dizziness/Weak • Confusion or mood changes Acyclovir is usually taken with food and should be • Decreased white blood cell count taken with plenty of water. Your dose and schedule will • May increase your sensitivity to sunlight - wear be decided by the transplant team, and there may be sunscreen while you take this medicine adjustments for patients with abnormal kidney function.
Check with the transplant team for any possible drug Your acyclovir dose will generally not change during the interactions before taking any new medicines, including course of therapy unless you are having painful side herbal supplements.
effects or your kidney function changes. Acyclovir may be stopped at 3 months after your transplant.
Transplant Patient Education Medications, continued Ganciclovir, Cytovene Ganciclovir (Cytovene) is used to prevent or treat viral • Your transplant team will watch your blood cell counts infections, including a virus called cytomegalovirus (CMV). while you take this medicine Transplant patients are more likely to get this infection if • Report any unusual bleeding or bruising they or their donors have had CMV in the past. Ganciclovir • Do not crush, chew or cut tablets before swallowing is also used to treat and/or prevent herpes simplex • Avoid direct contact of broken or crushed tablets with viruses and shingles.
the skin or mucous membranes• Ganciclovir may cause birth defects and impaired fertility; men and women of childbearing age should use birth control during, and for 90 days following Ganciclovir can be taken by mouth, usually with food. ganciclovir use It can also be given through the veins. Your dose and • May increase sensitivity to the sunlight. Must wear schedule will be decided by the transplant team, and there sunscreen while taking this drug may be adjustments for patients with abnormal kidney function.
Check with the transplant team for any possible drug interactions before taking any new medicines, including herbal supplements.
Your ganciclovir dose will generally not change during the course of therapy unless you are having bad side effects or your kidney function changes.
Possible Side Effects Of • Upset stomach, throwing up • Headache • Loose stools • Numbness or tingling in hands or feet • Decrease in white blood cell count • Decrease in red blood cell count • Decrease in platelet count • Increased risk for infection • Dizziness • Confusion or mood changes For more information, call 800.401.4444 or go to www.nebraskamed.com/transplant Medications, continued Valganciclovir (Valcyte) • May increase your sensitivity to sunlight - must wear sunscreen while taking this medicine Valganciclovir (Valcyte) is used to prevent viral infections, • May increase your kidney function tests - drink plenty including a virus called cytomegalovirus (CMV). Transplant patients are more likely to get this infection if they or their donors have had CMV in the past. Valganciclovir is also used to prevent and/or treat herpes simplex viruses and shingles.
• Your transplant team will watch your blood cell counts while you take this medicine • Report any unusual bleeding or bruising• Do not crush, chew or cut tablets before swallowing. Valganciclovir is usually taken once a day with food. • Avoid direct contact of broken or crushed tablets with However, the dose or schedule may be changed for the skin or mucous membranes patients with abnormal kidney function. The length of • Valganciclovir may cause birth defects and impaired therapy will be decided by your CMV status. fertility; men and women of childbearing age should use birth control during, and for 90 days following, valganciclovir use. Check with the transplant team for any possible drug Your valganciclovir dose will generally not change during interactions before taking any new medicines, including the course of therapy unless you are having bad side herbal supplements.
effects or your kidney function changes.
Possible Side Effects Of Valganciclovir • Upset stomach • Headache • Loose stools • Dizziness • Numbness or tingling in hands or feet • Decrease in white blood cell count • Decrease in red blood cell count • Decrease in platelet count • Increase risk for infection Transplant Patient Education Medications, continued Fluconazole (Difucan) Fluconazole is given to prevent or kill yeast or fungal • This medicine may affect your tacrolimus or infections. As a transplant patient you will be taking anti- cyclosporine (anti-rejection) medicine levels rejection medicine and other antibiotic medicines which • Your anti-rejection medicine dose may be decreased may result in fungal or yeast infection. while you are on fluconazole therapy• You may need to have your anti-rejection medicine levels drawn more frequently while you are on this medicine Fluconazole is given one time per day for 10 days to 2 • Please notify the transplant office if you are started on Fluconazole comes in 200mg tablets. Possible Side Effects Of • Headache • Drowsiness • Upset stomach, throwing up, loose stools – take medicine with food • Skin rash For more information, call 800.401.4444 or go to www.nebraskamed.com/transplant Medications, continued Furosemide (Lasix) Possible Side Effects Of Furosemide is given to help your body reduce excess fluid retention and make you urinate more. • Muscle cramps in legs • Upset stomach - take medicine with food • Decreased potassium levels • Low blood pressure Furosemide may be given once or twice per day. The schedule dose may change based on the amount of excess fluid you have and your kidney function. If you take this once a day, take it in the morning. If you take Watch your urine output. Notify the transplant office if you this drug twice a day, take one dose in the morning and one dose in the late afternoon so you will not be up at night going to the bathroom because of increased urine output.
Furosemide comes in 10mg, 20mg, 40mg and 80mg tablets. Be sure to check the label of Furosemide on your bottle so you know what dose of medicine you have. Transplant Patient Education Medications, continued High Blood Pressure Medications Multi-vitamins are used to supplement the diet so you The medicines you take to prevent rejection can cause receive the recommended daily nutritional requirements high blood pressure as a side effect. The transplant team of vitamins. Please do not take multi-vitamins with extra will decide if you need a medicine for high blood pressure ingredients such as energy boosters, weight loss, etc. and which one is right for you.
These extras can interfere with the absorption of your transplant medicines. We will have you take a multi- Possible Side Effects Of Blood Pressure vitamin daily.
Calcium (Calcium Gluconate, Calcium Carbonate, Tums Plus Vitamin D) • Dizziness if you stand up quickly Liver disease as well as taking prednisone in large doses • Headache - take Tylenol as needed and report to for an extended period of time can result in bone loss. transplant coordinator Calcium and vitamin D can help increase bone density. • Weakness or weak Follow the instructions provided by the transplant team on • Swelling in lower extremities • Shortness of breath - report to transplant coordinator • Upset stomach or constipation Headache or Muscle Aches or Pains • Chest pain, fast or pounding heartbeat - report to You may take Tylenol (acetaminophen) or a pain medicine transplant coordinator that is ordered by the transplant team. Do not take more High Blood Sugar Medicines than 3,000 mg of Tylenol per 24 hours, which is no more than 6 double-strength (500 mg) tablets or 9 The medicines you take to prevent rejection can also single strength (325mg) tablets.
cause high blood sugar levels. It is not unusual for a transplant patient to need medicines to lower their blood sugars on a temporary or more permanent basis. These • Motrin (ibuprofen) may include oral medications or insulin injections. You will • Advil (ibuprofen) or Aleve (naproxen) have teaching from our diabetes team if you need to be • Any other non-steroidal anti-inflammatory (NSAID) started on insulin.
Antacids, Anti-Ulcer Medicines These medicines can interact with your transplant These medicines are important because you are taking medicines or harm your kidneys.
many medicines that can cause stomach irritation. You will usually be ordered one of the following medicines to protect your stomach: esomeprazole (Nexium), lansoprazole (Prevacid), rabeprazole (Aciphex) or omeprazole (Prilosec). Other medicines that could be used are ranitidine (Zantac) or famotidine (Pepcid). These may be stopped once prednisone is reduced.
For more information, call 800.401.4444 or go to www.nebraskamed.com/transplant Medications, continued Indigestion and Heartburn You may take docusate (Colace), Fiber-Con or Miralax for constipation. Exercising, drinking plenty of water You may take ranitidine (Zantac), famotidine (Pepcid or and increasing fiber in your diet are other remedies to Pepcid AC), nizatidine (Axid) or Tums for heartburn or help relieve constipation. Contact the transplant team if indigestion. Do not take cimetidine (Tagamet) as this will constipation lasts. increase tacrolimus levels.
Pregnancy and Transplant Always drink enough fluids to prevent dehydration. Call the transplant team if you have more than 6 loose stools Most medicines used after transplant can pose a risk to in a 24-hour period. an unborn baby developing in the mother's womb. Always check with your transplant doctor before planning a Do not take an anti-diarrheal stool medicine such as pregnancy and contact your transplant doctor immediately Lomotil, Immodium, etc., until you talk to the transplant if you think you are pregnant. See the section on Activity team. The transplant team may order stool cultures to for further information about sexual activity.
decide the cause of the loose stools, and these should be obtained before taking medicine to stop the loose stools.
National Transplantation Allergy, Cold Symptoms Pregnancy Registry You may take dextromethorphan (Robitussin DM) for cough or guaifenesin to loosen thick secretions. You may take the following antihistamines for runny or stuffy nose and itchy or watery eyes: (Claritin, Alavert, Alegra Research Publication from the Zyrtec) or diphenhydramine (Benadryl). You may also National Transplantation Pregnancy use a saline nasal spray for nasal congestion. Do not use Afrin nasal spray. Avoid taking any cold products that have pseudoephedrine unless it has been approved by your local doctor. This drug may cause high blood pressure. Call your primary care doctor immediately if you have persistent cold symptoms, including cough, fever, increased shortness of breath or yellow/green drainage because you may have an infection that requires antibiotics. Notify the transplant team of any medicines your primary care doctor orders.

Source: http://nebhealthsys.org/transplant/info/liver/medications.pdf