Anti-Rejection Medications

What are anti-rejection medications?

After an organ transplant, the body sees the “new” organ as foreign and tries to attack it. Anti-rejection medications - also called immunosuppressive medications - help prevent this. These medications work by lowering (or suppressing) the effect of the immune system so that it doesn’t harm the transplanted organ. 

What’s important to know?

• Their main job is protection. Anti‑rejection medications keep the immune system from attacking the transplanted organ. By calming the immune response, these medications help the transplanted organ stay healthy and work properly.
• Regular lab tests are part of life after transplant. Your care team will check medication levels and how well the transplanted organ is working. They will let you know how often your teen needs to get labs. Your teen should understand that going for lab work is a normal and important part of their ongoing care.
• Consistency matters. As your teen becomes more responsible for taking their own medications, encourage them to take every dose exactly as prescribed and at around the same time each day. The right dose at the right time helps protect the transplanted organ.
• These medications are lifelong. Your teen will need to take anti‑rejection medications every day for the rest of their lifetime. The specific medications or doses may change over time as the transplant team works to prevent rejection while also reducing side effects.

Types of Anti-Rejection Medications

There are several types of anti-rejection medications and each works in its own way. Sometimes they are used in combination to best protect the transplanted organ. 

• Calcineurin Inhibitors:  tacrolimus (Prograf™, Astagraf™, Envarsus™) and cyclosporine (Neoral™, Sandimmune™).
  • How they work: These medications block signals that trigger the immune system to attack the transplanted organ. They reduce or suppress the activation of T-cells (a type of immune cell) that can cause organ rejection.
  • Important to know: These medications can affect kidney function, so regular blood tests are needed to monitor drug levels and check how well the kidneys are working.
     
• Steroids: prednisone, methylprednisolone, budesonide (Entocort™)
  • How they work: Steroids reduce inflammation and immune activity in the body to help prevent rejection.
  • Important to know: Long-term use of steroids can lead to side effects like weight gain, high blood pressure, high blood sugar levels, and osteoporosis (weak bones). Your teen’s transplant team will use the lowest effective dose of steroids to minimize these side effects.
     
• Antimetabolites: mycophenolate mofetil (CellCept™), azathioprine (Imuran™)
  • How they work: These medications help decrease the number of immune cells that can attack the transplanted organ. They work by interfering with the DNA (the “instructions” your cells have to help your body perform all its functions) of immune cells. This prevents the immune cells from growing, then attacking the transplanted organ.
  • Important to know: Mycophenolate can cause pregnancy loss and birth defects. Teens and young adults must have contraception counseling if they are taking this medication. Patients are advised to use two forms of birth control, including a barrier method, because mycophenolate may decrease the effectiveness of oral contraceptives (the “pill”). 
     
• mTOR Inhibitors:  sirolimus (Rapamune™), everolimus (Zortress™)
  • How they work: These medications block the pathways that normally activate certain immune cells (T-cells) which could cause rejection.
  • Important to know: Wound healing may take longer if your teen is on this type of medication. If your teen is going to have an elective procedure or surgery, be sure to tell your transplant team. Your transplant doctor may lower or hold this medication for a short time before and after the procedure. 

Side Effects of Anti-Rejection Medications

Anti-rejection medications are needed to prevent rejection, but they may lead to side effects. Your teen’s transplant team will routinely check on how well their immunosuppression is working and if they have any side effects from the medications. Blood tests show how well the transplanted organ, as well as other organs in the body, are working. These results also report drug levels, detect signs of infection, and provide information about hydration, electrolyte levels, and nutrition. Routine physical exams are also helpful in assessing side effects.

Some common side effects include:

• Increased risk of infection: Immunosuppressive medications weaken the immune system, making it harder for the body to fight infections. Teens should understand the importance of frequent hand washing, particularly before preparing food or eating, and after using the bathroom. Avoiding people who are sick, and staying out of crowded places – especially during cold and flu season – can also help lower the risk of getting ill.
• High blood pressure and diabetes: Some medications can cause high blood pressure or affect blood sugar levels. This most often happens early on after transplant or when being treated for rejection when their immunosuppression levels are higher. If this occurs, your teen will be prescribed medications to lower blood pressure or to keep their blood sugar level in a healthy range.
• Kidney problems: Some anti-rejection drugs can affect how well your teen’s kidneys are functioning. Labs that monitor kidney function will be checked routinely. This is very important for patients who have had kidney transplants, as well as other organ transplant recipients.
• Weight gain, mood changes, or bone health issues: Long-term use of steroids may cause your teen to gain weight or may affect their mood. Over time, steroids can also cause bones to weaken (osteoporosis), placing your teen at risk for bone fractures.
• Interactions with other medications: Some anti-rejection medications may interact with other medicines your teen is prescribed, such as some antibiotics, acne treatments, or antidepressants. When taken together, your teen may experience certain side effects. It is important to check with your transplant team before your teen takes any new medications that have not been prescribed by their transplant team so that they can check on possible interactions. 

Talk to your teen about these helpful tips:

• Take your meds on time every day. The right dose at the right time – every day! It's critical that anti-rejection medications be taken daily and on time. Skipping doses can increase the risk of rejection or cause complications. Encourage your teen to use a weekly pill container and alarms to help them remember to take their meds. Help them learn how to organize their pill container then gradually increase their responsibility to do this on their own.
• Be aware of signs of infection. Because the immune system is suppressed, infections may occur more easily than in someone who has not had a transplant. Encourage your teen to let you know if they are not feeling well. They should understand the importance of calling the transplant team if they have a fever, cough, or any other signs of illness.
• Keep a list of your medications. Your teen should have access to an up-to-date list of all prescribed medications. This list should be checked with your transplant team routinely and reviewed with their other healthcare providers. Remind your teen that it is a good idea to have this list on their phone so it is always with them.  
• Getting labs: It is important to get regular blood tests to check medication levels and ensure that the transplanted organ and kidneys are functioning well. Your team will let you know the frequency of labs. Your teen will need to do this more often if it is early on after transplant or if they have been ill or had rejection. For patients who are doing well, labs are usually every one to three months.
• Follow-up appointments: Transplant care includes attending clinic and all scheduled appointments with the transplant team. Many transplant centers send reminders through the hospital portal for these appointments, and they can also be added to the calendar on your phone.

Anti-rejection medications are a vital part of transplant care, helping to ensure the success of your teen's transplant. Although these medications may cause side effects, routine monitoring of how well your teen is doing - and their awareness of their health - can minimize complications and promote a long and healthy life after transplant.

If you have any questions or concerns about your teen’s anti-rejection medications, reach out to your transplant team. They will help you understand how these medications are managed and support you and your teen every step of the way.