Post-Transplant Medications
Maintenance immunosuppression, usually with a calcineurin inhibitor, is used to prevent graft rejection. Tacrolimus, sirolimus, or cyclosporin are most commonly prescribed. These medications are usually taken every 12 hours to maintain a therapeutic level. The level may be affected by some foods (grapefruit, starfruit, pomegranate) and other medications (fluconazole, erythromycin). Some patients are also prescribed prednisone, particularly early on after transplant or during treatment for rejection. Additional agents include azathioprine, mycophenolate mofetil or sirolimus. The dose of the medication is adjusted based on graft function, trough levels, and concomitant rejection or infection.
Infection prophylaxis is used to prevent transplant-related infections, particularly in the early post-transplant period or during treatment for rejection. These agents include antiviral medications (valganciclovir), antifungal medications (nystatin, fluconazole), and antibiotics (trimethoprim-sulfamethoxazole, Pen VK). Antibiotics for prophylaxis against urinary tract infection may be indicated for some patients.
Post-Transplant Medications
Maintenance immunosuppression, usually with a calcineurin inhibitor, is used to prevent graft rejection. Tacrolimus, sirolimus, or cyclosporin are most commonly prescribed. These medications are usually taken every 12 hours to maintain a therapeutic level. The level may be affected by some foods (grapefruit, starfruit, pomegranate) and other medications (fluconazole, erythromycin). Some patients are also prescribed prednisone, particularly early on after transplant or during treatment for rejection. Additional agents include azathioprine, mycophenolate mofetil or sirolimus. The dose of the medication is adjusted based on graft function, trough levels, and concomitant rejection or infection.
Infection prophylaxis is used to prevent transplant-related infections, particularly in the early post-transplant period or during treatment for rejection. These agents include antiviral medications (valganciclovir), antifungal medications (nystatin, fluconazole), and antibiotics (trimethoprim-sulfamethoxazole, Pen VK). Antibiotics for prophylaxis against urinary tract infection may be indicated for some patients.
It may be helpful for providers to review common side effects and adverse events with patients, as well as significant drug interactions. Some common examples are included here:
| Drug | MOA | Dosing | Adverse effects | Interactions | Pearls | |||||
| Calcineurin inhibitors (CNIs) | ||||||||||
Tacrolimus (FK) Prograf™ Envarsus™ Astagraf™ Cyclosporine (CSA) Neoral™ Sandimmune™ |
Inhibit T-cell proliferation | Typically administered PO 1-2 times daily, 12 hours apart Dosed to target trough concentration: Tacro levels: 5-15 CSA levels: 100-300 |
| Cytochrome P450 3A4 inhibitors: azole antifungals, non-dihydropyridine CCB, macrolides, protease inhibitors,Letermovir Inducers: carbamazepine, barbiturates, phenytoin, rifampin, St John’s Wort | Target concentration depends on organ type, other IS medications, time from transplant, history of rejection, history of infections | |||||
| Corticosteroids | ||||||||||
| Prednisone Methylprednisolone | Varies by organ, center and patient population |
| ||||||||
Antiproliferatives | ||||||||||
Mycophenolate mofetil (MMF) Cellcept™
Mycophenolate Sodium (MPA) Myfortic™
| Decreases purine synthesis | Typical doses: MMF 1000 mg PO/IV BID
MPA 720 mg PO BID
|
| Bile acid sequestrants, sevelamer
| MMF/MPA: teratogenicity; birth control recommended in women of child-bearing age
| |||||
| Azathioprine (AZA) Imuran™ | Decreases purine synthesis | 1-3 mg/kg daily |
| Xanthine oxidase inhibitors: Allopurinol, febuxostat | AZA: lack of TPMT function increases risk of myelosuppression | |||||
mTOR inhibitors | ||||||||||
Sirolimus Rapamune™
Everolimus Zortress™ | Rapamune: once daily dosing Everolimus: twice daily dosing
Dosed to target trough concentration: Everolimus 3-8 | hyperlipidemia hypertriglyceridemia proteinuria bone marrow suppression stomatitis/mucositis delayed wound healing peripheral edema thrombotic complications | Similar drug interactions to CNIs | |||||||
| Costimulation blocker | ||||||||||
| Belatacept Nulojix™ | Typical maintenance dose: 5 mg/kg IV every 4 weeks | |||||||||
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