Patient Education. Transplant Services. Medications. For a liver transplant

Transcription

1 Patient Education Medications For a liver transplant When you have a transplant, you ll need to learn how to plan for your medication needs after transplant. You ll be taking medications every day for the rest of your life. You ll want to know as much as you can about your medications how they work, what the side effects are, how to pay for them and tips for always remembering to take your medicines at the right time in the right way.

2 Medications Page 8-2 Getting Started The medications are vital to your recovery and the success of the transplant operation. They include: Immunosuppressive drugs are taken to help prevent or treat rejection of the new organ. At first the doses will be high and then they will be tapered down slowly. You ll take these drugs as long as you have your transplanted organ(s). Antibiotics are needed during the first three to six months after surgery. The immunosuppressive drugs make you more susceptible to infections. Antacids are taken during the first two to three months after transplant to prevent stomach upset or injury. Laxatives are taken for two to three months to help avoid constipation after transplant. Aspirin may be prescribed in small doses to prevent blood clotting. Antihypertensive drugs are taken by some patients for high blood pressure.

3 Page 8-3 Medications Diuretics, also known as water pills, are sometimes taken to help treat swelling. Iron is sometimes taken to help treat anemia. A multivitamin is suggested to be taken by patients after transplant. Calcium and vitamin D supplements are taken to help prevent osteoporosis. In the first few months after surgery, you will take many medications. There is a potential for many side effects. Keep all of your appointments with your doctor and the transplant clinic so that proper adjustments to your medications and medication levels can be made when needed. Medications can cost as much as $1,000 per month or more. The costs may decrease over time as some of the medicines are stopped or your doctor lowers the dosages. Medicare, Medicaid and private insurers may cover part of the costs of medications. Be sure to verify your medical insurance coverage for transplant medications before your transplant. Contact your insurance representative, social worker, local

4 Medications Page 8-4 pharmacist or financial counselor where you will receive your follow-up care. Know what your expected co-pays or deductibles will be. Be sure to maintain your coverage post-transplant, as medication costs can be $12,000 to $15,000 per year. You should also know where you plan to get your prescriptions filled. Fill your prescriptions at a local pharmacy or use a mail-order pharmacy. It is a good idea to tell your pharmacy that you will be a transplant patient so that they may anticipate your medication needs and set up billing arrangements. If you will be staying temporarily in Seattle after the transplant, you will need to make pharmacy arrangements. Call your insurance company to obtain a list of participating pharmacies near where you plan to stay after discharge from the hospital. Always carry your prescription insurance card with you so you re ready to show it to any pharmacy. You may be asked to buy certain equipment to help monitor the effect of therapy, such as a blood pressure cuff, scale, thermometer, and blood glucose meter. It is a good idea to buy these items now and learn how to use them.

5 Page 8-5 Medications At the Hospital When you re called in for transplant, bring your medications with you along with a list of your current medications and dosages. This will provide the transplant team with accurate information about the medications that you take. Also, bring your transplant guide and any equipment you were asked to buy. By this time, you should have a pharmacy plan in place. After surgery, you will begin to learn about your medication regimen. You ll need to know the names, strengths, doses, purpose and side effects of each medicine you take. The pharmacist will begin teaching you about your medications about one to six days after surgery. At first, the number of medications may seem overwhelming, but they will be decreased over the next several months. Patients have told us that the best way to learn all of this information is to start taking the medications yourself while in the hospital. The pharmacist will give you a box (called a mediset ) that helps you organize your medicines. It s a really good idea for family members and/or support persons to learn along with you if you need help managing your medications.

6 Medications Page 8-6 Tips to help organize your medications: Try to organize your regimen so that you aren t taking medicines more than four times a day (breakfast, lunch, dinner, and bedtime). Work with the pharmacist to devise a good schedule for you. Use your mediset box. Store it at room temperature away from light. You may want to carry a one-day reminder box with you during the day. You may want to get an inexpensive wristwatch with an alarm to help remind you when it s time to take medications. After Discharge When you leave the hospital, you ll be given a one-week supply of medications and prescriptions to fill at your regular pharmacy. Have the prescriptions filled as soon as possible after discharge to assure you do not run out of medication. Keep an up-to-date list of all of your medications (this is often called a profile) with you, along with the directions for taking them. Update the profile as needed and use it to restock

7 Page 8-7 Medications your mediset. There are blank profiles in your Medical Log. When you need renewals of your prescriptions (refills have run out), you should obtain them from your primary care doctor or gastroenterologist. When you come for clinic visits, bring your mediset, the medications you have filled at your pharmacy, and your records or profile. Always keep a written list of medications with you. If you have problems or questions about your medications after you are discharged, call your transplant nurse coordinator. Keep your appointments so your medications can be checked and adjusted if needed and refill your medications early so you do not run out. Guidelines for Taking Medications Here s a list of the basics about taking medications: Take only the medication prescribed for you by your doctor. Take your medications only as prescribed. Do not increase or decrease your dose or stop taking a medication without consulting your doctor or transplant coordinator.

8 Medications Page 8-8 If you accidentally miss or skip a dose of medication, do not double-up. Contact your transplant coordinator or doctor for further instructions. Do not take any new medications (including over-the-counter, herbal, natural, or vitamins) without telling your doctor or pharmacist. Know the side effects of your medications and report them to your doctor or transplant nurse coordinator if they occur. If you are unable to take the usual medications prescribed, an alternative medication is usually available. Notify the other health providers that you see (doctor, dentist, optometrist, etc.) of any new medications, including over-the-counter products, herbal or natural remedies, vitamin or mineral supplements that you re taking and be sure to tell them you are on immunosuppressive drugs (because you ve had a transplant). Notify your transplant coordinator before a visit to the dentist. They may need to prescribe an antibiotic to be taken before your visit.

9 Page 8-9 Medications Carry a list of your current medications and doses with you. Keep all medications out of reach of children and pets. Do not give your medications to anyone else. Do not let your medication supplies run out. Avoid these while taking immunosuppressive drugs: Grapefruit juice or any beverages containing citrus juices Non-steroidal anti-inflammatories, such as ibuprofen, (Advil, Nuprin ) and naproxen (Aleve ) Aspirin in large quantities Erythomycin Clarithromycin Azithromycin Ketoconazole Diltiazem Verapamil Dilantin Phenobarbital Rifampin

10 Medications Page 8-10 St. John s Wort (hypericum perforatum) Herbal and natural medications are not recommended. They may cause adverse drug interactions and toxicities, they are costly and they increase the complexity of managing your transplant regimen. Always check with your doctor before taking any herbal medications. Immunosuppressants Immunosuppressants or anti-rejection drugs are medications that suppress the body s immune system by decreasing the effects of lymphocytes (a type of white blood cell). This is necessary so that your body s immune system does not recognize the new organ as foreign and defend your body by attacking it with white blood cells. In general, immunosuppression may make the body more susceptible to infections with organisms that normally do not cause infections (opportunistic) and organisms from your environment (colds, flu). Immunosuppression also carries a small risk of developing tumors.

11 Page 8-11 Medications The transplant team uses three or four immunosuppressive drugs in combination. Each drug works by blocking a different pathway in the immune system. Working together they produce better immunosuppression, allow for the use of smaller doses of each drug, and reduce the number and severity of side effects caused by the drugs. The specific immunosuppressants and protocol for your type of transplant will be discussed by your transplant surgeon and at the pretransplant orientation class. It is important that you remember to take these medications daily as prescribed by your doctor to prevent rejection. If you forget whether you took your dose on a given day, call your doctor or transplant nurse coordinator for further instruction. It is not wise to double your doses. Even though you are on maintenance doses of your immunosuppressive medications, rejection may still occur. Acute rejection most often occurs within the first year after transplant and may be successfully reversed by using medication. Rejections are best determined by following your blood test results. Be sure to keep all appointments for blood tests.

12 Medications Page 8-12 Here is a list of immunosuppressant (anti-rejection) drugs that transplant patients may take or receive: Antithymocyte globulin (Thymoglobulin ) Purpose: ATG is a potent antirejection drug that is made up of antibodies that are made in animals and directed against human white blood cells. This results in destruction of the white blood cells. If you receive this drug, you will have a 12-hour infusion of ATG starting just prior to transplant and daily or every other day for at least three doses, infused over six hours each. Others might receive it to treat acute rejection episodes. Potential side effects: As lymphocytes are destroyed in your body they release chemicals that can cause allergic-type or flu-like symptoms. These symptoms are more common after the first few doses. Acetaminophen (Tylenol ) and an antihistamine (Benadryl ) are routinely given before your first three doses to prevent some of the allergic-type side effects.

13 Page 8-13 Medications Some side effects include: Flu-like symptoms Fever Chills Nausea Headache Shortness of breath Lowered or elevated blood pressure Excessive lowering of white blood cells Lowered platelets and red blood cells Increased susceptibility to infection Azathioprine (Imuran ) Purpose: Azathioprine is an immunosuppressant drug that helps decrease the number of white blood cells the body produces by its effects on the bone marrow. It is used in conjunction with cyclosporine or tacrolimus and steroids to prevent rejection episodes. Your maintenance dose will be taken once daily in the evening as oral tablets. Dosage forms: Azathioprine is available as a 50 mg peanut-shaped

14 Medications Page 8-14 tablet (yellow) (Imuran brand) or round tablet (yellow) (generics) that is scored. Usual maintenance dose: 25 mg to 175 mg taken daily as a single dose usually in the evening at bedtime. Potential side effects: Azathioprine affects cells that grow rapidly such as white blood cells, red blood cells, platelets and hair cells. The effects on blood cells usually can be reversed by lowering your dose. Some side effects include: Excessive lowering of white blood cells Anemia (lowered red blood cells) Bleeding (lowered platelets) Mild hair loss Nausea Jaundice (yellow skin caused by effects on the liver) Cost: $100 per month. Taken indefinitely. Generics available. Medicare may cover 80 percent of the cost for eligible transplant recipients at participating pharmacies.

15 Page 8-15 Medications Basiliximab (Simulect ) Purpose: Simulect is an antibody that blocks the action of an important hormone-like substance (cytokine) in the body called interleukin-2. (IL-2). IL-2 is important in the activation of T- lymphocytes, the white blood cells that are thought to attack the graft and destroy it. Some patients may receive an IV infusion of this drug at the time of transplant. A second dose is given before discharge from the hospital. Potential side effects: This agent has a very low incidence of side effects. There is a possibility of allergy symptoms (fever, chills). Cyclosporine (Neoral, Gengraf, Sandimmune ) Purpose: Cyclosporine is an immunosuppressant drug that decreases activation, growth, and function of lymphocytes (white blood cells). It is used in conjunction with mycophenolate and steroids to prevent rejection. If cyclosporine is part of your immunosuppressant drug regimen, you will start to receive cyclosporine about one to three days after your operation.

16 Medications Page 8-16 Dosage forms: There are several formulations of oral cyclosporine available including an oral solution. Capsules may be available in three sizes: 25 mg, 50 mg, and 100 mg. The strength of the liquid formulation is 100 mg\ml. Example: For 225 mg, take two 100 mg capsules plus one 25 mg capsule. For 175 mg, take one 100 mg capsule plus three 25 mg capsules. The capsules are sensitive to air and are contained within a special blister seal packaging. It is best to keep them in the blisters until you are ready to take your dose. They are stable for seven days outside the blister packaging. Usual maintenance dose: 100 to 500 mg taken every 12 hours, usually at 8 a.m. and 8 p.m. with or without food. Take at the same time every day. Your doctor will adjust your dose based on the result of a cyclosporine blood level. Potential side effects: The most serious side effect of cyclosporine is toxicity or injury to the kidney. This effect can be avoided or reversed by

17 Page 8-17 Medications close monitoring of your kidney s function and proper adjustment of your dose with the aid of the cyclosporine blood level. Side effects include: Decreased kidney function Increased blood pressure Increased blood potassium Decreased blood magnesium Shakiness or tremor Burning or tingling of hands or feet Increased or unwanted hair growth Increased gum growth Mood changes Acne Decreased liver function Convulsions Headache Increased cholesterol Increased susceptibility to infection Cost: $750 to $1,500 per month and will be taken indefinitely. Generics are available. Medicare may cover 80 percent of cost for eligible transplant recipients at participating pharmacies.

18 Medications Page 8-18 Mycophenolate mofetil (CellCept, MMF) Purpose: Mycophenolate mofetil is an immunosuppressant drug that decreases production of lymphocyte white blood cells in the body. It is used in conjunction with cyclosporine or tacrolimus and prednisone to prevent rejection episodes. If this drug is used as part of the transplant immunosuppressant regimen you may begin taking it by intravenous injection, then orally as three doses per day. Eventually you will take maintenance doses twice daily. Dosage forms: CellCept is available in two sizes: 250 mg capsule and a 500 mg tablet. It is also available as an oral suspension with a strength of 1 gm\5 ml (teaspoonful). There is no generic form available. Usual maintenance dose: 1000 mg (1gm) taken orally twice daily, preferably on an empty stomach. Avoid taking with liquid antacids (Maalox, Mylanta ) as they can reduce absorption of mycophenolate. Take your doses at the same time every day. Your doctor might adjust

19 Page 8-19 Medications your dose based on the result of a blood level. Potential side effects: More common: Leukopenia (excessive lowering of white blood cells) Nausea or vomiting Abdominal pain Diarrhea Increased susceptibility to infections Less common: Anemia (excessive lowering of red blood cells) Thrombocytopenia (excessive lowering of platelets) Cost: $500 to $1,000 per month and will be taken indefinitely. No generic is available. Medicare may cover 80 percent of cost for eligible transplant recipients at participating pharmacies. OKT3 (Muromonab) Purpose: OKT3 is a potent antirejection drug, which is made up of antibodies directed against specific white blood cells in the body (CD3 lymphocytes). This results in

20 Medications Page 8-20 destruction and inactivation of these cells. These particular white blood cells are thought to be highly involved in the rejection process. This immunosuppressant is usually reserved for the treatment of rejection. A once daily intravenous injection is given for 10 to 14 days. The first few doses will be given to you in the hospital to assess how you tolerate the medication. Further doses can be given to you as an outpatient. Potential side effects: As the CD3 lymphocytes are destroyed they are thought to release chemicals, which may cause allergic-like or flu-like symptoms. These side effects are more common after the first few doses. A pre-medication of steroids, acetaminophen (Tylenol ) and an antihistamine (Benadryl ) are routinely given before the first three doses to decrease these effects. Some side effects include: Flu-like symptoms Fever Chills Nausea

21 Page 8-21 Medications Headache Diarrhea Shortness of breath Lowered or elevated blood pressure Excessive lowering of white blood cells Arthralgias (joint aches) Susceptibility to infection Prednisone (Deltasone ), Methylprednisolone (Solumedrol ) Purpose: Prednisone (oral) and methylprednisolone (intravenous) are immunosuppressant drugs also known as steroids or corticosteroid hormones used to prevent or treat rejection of the transplanted organ. They are related to a natural hormone in your body called cortisol. They decrease the function and activity of white blood cells (lymphocytes). If this immunosuppressant is a part of your regimen, you will be given methylprednisolone by intravenous injection shortly before and for several days after the surgery. You will then be converted to oral tablets of prednisone, which will be given in

22 Medications Page 8-22 two daily doses. Your dose will be decreased (tapered) to a single daily maintenance dose. You will be given a taper schedule before you leave the hospital. Methylprednisolone in large doses (pulse therapy) may be used later in your post-transplant course to treat acute rejection of the organ(s). Dosage forms: Prednisone is available from many generic drug companies in six different sizes: 1 mg, 2.5 mg, 5 mg, 10 mg, 20 mg, and 50 mg tablets. The tablets are usually white and are scored which allows them to be easily broken in half. Usual maintenance dose: 5 to 10 mg per day as a single daily dose. Always take prednisone with food or a snack. Potential side effects: Some of the side effects of prednisone and methylprednisolone are associated with higher doses (dose related) and become less when the doses are reduced. Other side effects occur after many months or years of taking the drug at usual doses. Plenty of exercise and good nutrition is essential to keeping the body strong (especially bones and muscles) while taking prednisone.

23 Page 8-23 Medications Some patients may require treatment with insulin for increased blood sugar. If you are diabetic you might require higher doses of insulin initially after your surgery. Short-term (high doses) side effects: Stomach upset, heartburn, ulceration Emotional changes, mood swings, sleep disturbances Night sweats Weight gain; swelling Slowed wound healing Increased appetite; feeling hungry Increased blood sugar Face swelling ( moon face ) Acne Blurred vision Increased susceptibility to infection Long-term side effects: Muscle weakness Bone and joint weakness; pain Osteoporosis Weak, dry, thin skin; stretch marks Increased or unwanted hair growth Round shoulders ( buffalo hump )

24 Medications Page 8-24 Easy bruising Visual changes; cataracts Increased cholesterol Increased susceptibility to certain cancers Increased susceptibility to infection Cost: $5 to $10 per month and will be taken indefinitely. Generics are available. Medicare may cover 80 percent of cost for eligible transplant recipients at participating pharmacies. Sirolimus (Rapamune ) Purpose: Rapamune is an immunosuppressant drug that blocks the function of immune cells (Tlymphocyte white blood cells) and prevents them from destroying the transplanted organ. It is taken in conjunction with tacrolimus or cyclosporine and prednisone to prevent rejection. If used as part of your immunosuppressant regimen you may receive an oral dose before transplant and then continue taking a single oral dose daily.

25 Page 8-25 Medications Dosage forms: Rapamune is available in 1 mg tablets and is also available as an oral solution in a strength of 1 mg/ml. There is no generic formulation available. Usual dose: 1 to 10 mg taken once daily in the a.m., with or without food. Take your dose at the same time every day. Your doctor might adjust your doses based on the result of a blood level. Potential side effects: Increased blood cholesterol and triglyceride levels Decreased blood platelets and white blood cells Mouth ulcers or sores Acne Tingling of hands or feet Joint pain Increased susceptibility to infection Cost: $500 to $1,200 per month and will be taken indefinitely. No generic is available. Medicare may cover 80 percent of cost for eligible transplant recipients at participating pharmacies.

26 Medications Page 8-26 Tacrolimus (Prograf, FK-506) Purpose: Prograf is an immunosuppressant drug that decreases activation, growth, and function of lymphocytes (white blood cells). It is taken in conjunction with mycophenolate, prednisone or sirolimus to prevent rejection. If this drug is used in your regimen, it is usually started about one to three days after surgery. Tacrolimus may be used as an alternative to cyclosporine. Dosage forms: Tacrolimus is available in three sizes: 0.5 mg, 1 mg, and 5 mg capsules. You can use a combination of both sizes to make your dose. There is no generic form available. Usual maintenance dose: 1 to 10 mg taken every 12 hours, usually at 8 a.m. and 8 p.m. You may take it with meals. Your doctor might adjust your dose based on the result of a blood level. Potential side effects: The most serious side effects of tacroliumus include injury to the kidney and neurotoxicities such as tremor and headache. These side effects may be minimized by proper dosage

27 Page 8-27 Medications adjustment with the aid of a tacrolimus blood level. Some side effects include: Decreased kidney function Increased blood sugar Increased blood pressure Increased blood potassium Decreased blood magnesium Shakiness or tremor Headache Convulsions Nausea or vomiting Hair loss Increased cholesterol Increased susceptibility to infection Cost: $500 to $1,000 per month and will be taken indefinitely. No generic is available. Medicare may cover 80 percent of cost for eligible transplant recipients at participating pharmacies.

28 Medications Page 8-28 Antibiotics When your body s immune system has been suppressed, it is more susceptible to infections. Infections can be caused by organisms that come from your environment, another person or by organisms that live in or on you but normally do not cause infection. During the first three months after the transplant surgery, your body is especially susceptible to infections due to the large doses of immunosuppressant drugs that are used to prevent rejection. These infections can be more severe and more difficult to treat in a person that is immunosuppressed. It is important that you take several antibiotics during this period to prevent infection. Clotrimazole troche (Mycelex ), Nystatin suspension (Nilstat, Mycostatin ) Purpose: Transplant patients will use one of these antifungal (anti-yeast) drugs to prevent overgrowth of yeast flora in the mouth (thrush) for three months post-transplant. Usual Dose: The clotrimazole troche (10 mg) should be dissolved in the mouth or nystatin suspension (one

29 Page 8-29 Medications teaspoonful) swished and swallowed four times daily after meals and at bedtime. It is important to avoid eating or drinking for at least 30 minutes after each dose. Potential side effects: Unpleasant taste in mouth Dry mouth Chalky mouth Nausea Cost: $150 per month. Taken for three months after transplant. No generic is available for clotrimazole. Not covered by Medicare. Fluconazole (Diflucan ) Purpose: Fluconazole is an antifungal antibiotic used to treat or prevent infections with yeast. Liver transplant patients might take fluconazole for up to three months post-transplant to prevent infections in the mouth and the urine. Usual dose: It is taken as a once-daily oral dose (100 mg). It can be taken with food.

30 Medications Page 8-30 Potential side effects: Nausea Rash Diarrhea Abdominal pain Cost: $200 per month. Taken for three months after transplant. No generic is available. Not covered by Medicare. Valganciclovir (Valcyte ), Ganciclovir (Cytovene ), Acyclovir (Zovirax ), Valacyclovir (Valtrex ) Purpose: Valganciclovir, ganciclovir, acyclovir and valacyclovir are antiviral drugs that are effective in treating and preventing herpes infections and preventing cytomegalovirus (CMV) infections. Most patients will take them for three months post-transplant. Usual dose: The usual dose of valganciclovir is 450 mg once daily and the usual dose of ganciclovir is 1 gm three times a day to prevent CMV infections. The usual dose of valacyclovir for preventing herpes infections is 2 grams four times a day. The usual dose for acyclovir is 400 mg twice daily. They can be taken with food.

31 Page 8-31 Medications Potential side effects: Nausea Decreased kidney function Headache Decreased white blood cells Cost: $1,000 to $2,000 per month. Taken for three months after transplant. Acyclovir is available generically. No generics are available for ganciclovir, valganciclovir and valacyclovir. Not covered by Medicare. Trimethoprim/Sulfamethoxazole (Bactrim, Septra, Cotrimoxazole, Trim/Sulfa, TMP/SMX) Purpose: Septra or Bactrim is an antibacterial sulfa drug effective in treating or preventing bacterial bladder infections. It is also effective in preventing or treating lung infections caused by a fungal organism from the environment called pneumocystis. Usual dose: Most patients will take a single strength (SS) tablet daily, usually at bedtime, for six months. Take with a full glass of water. Generic forms are available.

32 Medications Page 8-32 Potential side effects: Rash Nausea Lowered white blood cell count Sensitivity to the sun Report any rashes to your doctor. Cost: $5 to $10 per month. Taken for six months to indefinitely after transplant. Generics are available. Not covered by Medicare. Dapsone Purpose: Dapsone is effective against pneumocystis lung infections. It may be used as an alternative to Trim/Sulfa in those allergic to sulfa drugs. Usual dose: Patients will take one tablet (100 mg) daily for six months. Potential side effects: Lowered red blood cells Pentamidine (Pentam ) Purpose: Pentamidine is an antibiotic used as an alternative Trim/Sulfa to prevent or treat infections with pneumocystis.

33 Page 8-33 Medications Usual dose: Patients will receive an inhaled treatment of 300 mg once per month for six months. Potential side effects: Unpleasant taste Cough, wheezing Antacids Antacids are used to coat the stomach, neutralize acid, or prevent acid secretion. They are needed initially to prevent stomach upset or injury caused by high doses of your immunosuppressant drugs or stress. Generally, these should be taken routinely for three months post-transplant unless you have a history of ulcer disease. You will be prescribed one of the following medications: Ranitidine (Zantac ) Purpose: Ranitidine is a drug that decreases the acid output of the stomach. This drug may be used alone or in combination with liquid antacids. Usual dose: The usual dose for ulcer prevention is 150 mg at bedtime. Generic forms are available.

34 Medications Page 8-34 Potential side effects: Rash Headache Mental changes Dizziness Cost: $10 per month. Taken for three months after transplant. Generics are available. It is available over the counter. Not covered by Medicare. Pantoprazole (Protonix ), Omeprazole (Prilosec ), Lansoprazole (Prevacid ) Purpose: Pantoprazole, omeprazole and lansoprazole are potent drugs that prevent the stomach from making acid and are used in the prevention and treatment of ulcers and heartburn. They are used as an alternative to ranitidine. Usual dose: The usual dosage of Protonix is 40 mg taken once daily, Prilosec is 20 mg taken once daily, or Prevacid 30 mg once daily. These agents should be taken on an empty stomach for best effect.

35 Page 8-35 Medications Potential side effects: Nausea Abdominal pain Constipation Headache Dizziness Cost: $100 per month. Taken for three months after transplant. No generics are available. Not covered by Medicare. Aluminum hydroxide (Amphogel, Alternagel ), aluminum and magnesium hydroxide (Maalox, Mylanta ) Purpose: Liquid antacids neutralize acid in the stomach. Patients may take liquid antacid doses between meals for additional heartburn relief. If you have kidney failure, it is suggested you use the aluminum containing antacids such as aluminum hydroxide. Potential side effects: Aluminum-containing antacids can cause: Constipation Phosphorous depletion in the body

36 Medications Page 8-36 Magnesium-containing antacids (such as Maalox or Mylanta ) can cause: Diarrhea Excess magnesium in the blood Laxatives Some common laxatives: Docusate (Colace, DOSS) Bisacodyl (Dulcolax ) Psyllium (Metamucil ) Cascara Milk of Magnesia Lactulose (Cephulac ) Senna (Senokot ) Purpose: Constipation and hard stools should be avoided after surgery. Straining to have a bowel movement can lead to problems with your wound. It is important to reduce your use of constipating medications (pain medications) as soon as possible after surgery, drink plenty of fluids, and increase your activity. Increasing the fiber in your diet at home can also help. Soft stools should be maintained for three months after surgery. Docusate (Colace )

37 Page 8-37 Medications is a mild stool softener that is most often used. Bisacodyl (Dulcolax ) is a stimulant laxative, which may also be prescribed for some patients. If diarrhea occurs while taking them, you should decrease your dosage or stop taking them. Cost: $5 to $10 per month. Taken for three months after transplant. Generics are available. It is available over-thecounter. Not covered by Medicare or many private insurances. High Blood Pressure Medications (Antihypertensives) Some common antihypertensives: Amlodipine (Norvasc ) Isradipine (Dynacirc ) Nifedipine (Procardia, Procardia-XL,Adalat ) Felodipine (Plendil ) Diltiazem (Cardizem ) Verapamil (Calan, Calan-SR, Isoptin ) Metoprolol (Lopressor, Toprol XL ) Labetalol (Normodyne, Trandate )

38 Medications Page 8-38 Atenolol (Tenormin ) Clonidine (Catapres ) Doxazosin (Cardura ) Losartan (Cozaar ) Enalapril (Vasotec ) Lisinopril (Zestril, Prinivil ) Purpose: High blood pressure after transplantation is common. Some patients might require blood pressure lowering drugs to treat pre-existing high blood pressure. High blood pressure can also be caused by some of the immunosuppressant drugs. It is important to control blood pressure to prevent damage to the new organs and other problems such as stroke and heart disease. Some blood pressure medications can also help the organ to recover by protecting it from the toxic effects of some anti-rejection medications (cyclosporine, tacrolimus). To allow us to adjust your doses, it is suggested you monitor and record your blood pressure and pulse while at home. It is common for the transplant team to use a combination of a calcium-channel blocker drug such as amlodipine (Norvasc ) and a beta-blocker drug such as metoprolol.

39 Page 8-39 Medications Special instructions: Do not abruptly stop therapy without the advice of your doctor. Monitor and record your blood pressure and pulse before taking your a.m. dose and your bedtime doses. Rise slowly from lying or sitting positions to minimize dizziness or lightheadedness. Potential side effects: Dizziness Rapid lowering of blood pressure Increased or decreased heart rate Flushing Headache Feeling tired Cost: $20 to $50 per month. Taken as required. Many have generics available. Not covered by Medicare. Clot Prevention Purpose: A small dose of aspirin can help prevent clotting of blood vessels leading to the new organ. It might also prevent heart attacks and strokes.

40 Medications Page 8-40 Usual dose: One tablet (81 mg or baby aspirin) may be prescribed daily. Not all patients will require this. Potential side effects: Bleeding of the soft tissues or gastro-intestinal tract Blood in the urine Ringing in the ears Cost: $5 per month. Taken indefinitely. Generic is available. It is available over the counter. Not covered by Medicare. Diuretics Some common diuretics: Furosemide (Lasix ) Torsemide (Demadex ) Bumetanide (Bumex ) Purpose: Diuretics or water pills can be used to help rid excess fluid (sodium and water), which can accumulate in the body in the form of edema or swelling. Cyclosporine and prednisone are common causes of sodium retention. Diuretics will also help rid the body of potassium, increase urine volume, and lower blood pressure.

41 Page 8-41 Medications Some patients might require potassium supplements if potassium loss is too great. Special instructions: Measure and record your blood pressure, pulse, and weight every morning. Wear sunscreen and protective clothing. Rise slowly from lying or sitting positions to minimize dizziness or lightheadedness. Potential side effects: Lowered blood potassium Dehydration Dizziness Increased urine volume Increased frequency of urination Headache Loss of appetite Leg cramps Increased heart rate

42 Medications Page 8-42 Cholesterol-Lowering Drugs Some common cholesterol-lowering drugs: Pravachol (Pravastatin ) Atorvastatin (Lipitor ) Purpose: Some patients may require addition or continuation of cholesterollowering therapy. Special instructions: Report any unexplained muscle weakness or pain to your doctor. Potential side effects: Dizziness Headache Rash Nausea Abdominal cramps Muscle aches Iron (Ferrous sulfate, ferrous gluconate) Purpose: Some transplant patients may need iron supplements if they are anemic. The iron helps the body build new red blood cells to help raise the hematocrit.

43 Page 8-43 Medications Usual dose: The usual dose is between one and three tablets a day. Vitamins Purpose: It is suggested that patients take a single multiple vitamin daily to supplement the diet. We usually suggest prenatal vitamins as these contain sufficient amounts of vitamins that transplant patients will need. These agents may be used to treat short-term deficiencies of important blood chemicals, minerals, or vitamins. Calcium Some common calcium supplements: Calcium carbonate (Tums and Oscal ) Calcium citrate (Citracal ) Purpose: Most transplant patients need supplements of calcium to help prevent bone disease and loss (osteoporosis). Usual dose: It is suggested to take between 600 to 1200 mg of supplemental calcium a day depending upon your intake of calcium through your diet. Dairy foods are a good source of calcium. Refer to the Nutrition section or consult with your transplant dietitian for additional information.

44 Medications Page 8-44 Vitamin D Some common vitamin D supplements: Cholecalciferol Calcitriol (Rocaltrol ) Purpose: Vitamin D is needed to help the body absorb the calcium from your diet or supplements. Usual dose: It is usually suggested to take about 400 units of cholecalciferol or 0.25 mcg of Rocaltrol daily in addition to the vitamin D that is in your multivitamin. Magnesium Oxide Some common magnesium supplements: MagOx Purpose: Magnesium is a mineral found in the body that can be measured with a blood test. Magnesium is especially important to muscles and nerves. It also helps some enzymes work. An enzyme is something that helps speed up a chemical reaction in your body. Many transplant patients develop low magnesium levels. This may be caused by some of the antirejection drugs (tacrolimus, cyclosporine). Oral supplements are

45 Page 8-45 Medications available in the form of tablets. There may be limited sources of magnesium in your diet. Refer to the Nutrition section or consult with the transplant dietitian for additional information. Phosphate Some common phosphate supplements: Sodium phosphate (K-Phos Neutral ) Phosphosoda Neutra-Phos Purpose: Phosphate or phosphorous is a mineral that is important for cell function and energy. It is also an important component of bone. Transplant patients occasionally develop low blood phosphate levels. This may be a temporary disturbance in how your body handles this mineral. Dairy products can be a dietary source of phosphate. Refer to the Nutrition section or consult with the transplant dietitian for additional information.

46 Medications Page 8-46 Notes

47 Page 8-47 Medications Notes

48 Medications Page 8-48 Questions? Notes Your questions are important. Call your transplant coordinator during business hours Box N.E. Pacific St., Seattle, WA University of Washington Medical Center 06/2003 UH1914