Medications. Patient Education Transplant Services. For a kidney/pancreas transplant

Transcription

1 Patient Education Medications For a kidney/pancreas 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 12-2 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 3 to 6 months after surgery. The immunosuppressive drugs make you more susceptible to infections. Antacids are taken during the first 2 to 3 months after transplant to prevent stomach upset or injury. Laxatives are taken for 2 to 3 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 12-3 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 pharmacist, or financial counselor where

4 Medications Page 12-4 you will receive your follow-up care. Know what your expected co-pays or deductibles will be. And 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 12-5 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. 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 1 to 6 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 12-6 Tips to help organize your medications: Try to organize your regimen so that you aren t taking medicines more than 4 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 1-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 1-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 your mediset. There are blank profiles in My Transplant Log section.

7 Page 12-7 Medications When you need renewals of your prescriptions (refills have run out), you should obtain them from your primary care doctor or nephrologist. 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. If you accidentally miss or skip a dose of medication, do not double-up.

8 Medications Page 12-8 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. 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). 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.

9 Page 12-9 Medications Avoid these while taking immunosuppressive drugs unless okayed by your doctor: Grapefruit juice 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 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.

10 Medications Page 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. The transplant team uses 3 or 4 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 physician and at the pre-transplant orientation class. It is important that you remember to take these medications daily as prescribed by

11 Page Medications 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. It is important for you to recognize the signs and symptoms of rejection so that appropriate treatment may be started promptly. Here is a list of immunosuppressant (anti-rejection) drugs that transplant patients may take or receive: Antithymocyte globulin (ATG, 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 then daily or every other day for at least 3 doses.

12 Medications Page 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. Steroids, acetaminophen (Tylenol ) and an antihistamine (Benadryl ) are routinely given before your doses to prevent some of the allergic-type side effects. Some side effects include: Flu-like symptoms. Fever. Chills. Nausea. Headache, muscle aches, and backache. Shortness of breath. Lowered or elevated blood pressure. Excessive lowering of white blood cells. Lowered platelets and red blood cells. Increased susceptibility to infection.

13 Page Medications 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. If this immunosuppressant is used in your regimen, you will receive a once daily intravenous infusion for several days after the transplant. Your maintenance dose will be taken once daily in the evening as oral tablets. Dosage Forms: Azathioprine is available as a 50mg peanut-shaped tablet (yellow) (Imuran brand) or round tablet (yellow) (generics) that is scored. Usual Maintenance Dose: 25mg to 175mg 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 can usually be reversed by lowering your dose.

14 Medications Page 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. 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.

15 Page Medications 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 1 to 3 days after your operation. Dosage Forms: There are several formulations of oral cyclosporine available including an oral solution. Capsules may be available in 3 sizes: 25mg, 50mg, and 100mg. The strength of the liquid formulation is 100mg\ml. You will use a combination of both sizes to make your dose. Use the smallest number of capsules possible to make the dose.

16 Medications Page Example: For 225mg, take 2 100mg capsules plus 1 25mg capsule. For 175mg, take 1 100mg capsule plus 3 25mg 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 7 days outside the blister packaging. Usual Maintenance Dose: 100 to 500mg 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 close monitoring of your kidney s function and proper adjustment of your dose with the aid of the cyclosporine blood level.

17 Page Medications Some 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 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 3 doses per day. Eventually you will take maintenance doses twice daily. Dosage Forms: CellCept is available in 2 sizes: 250mg capsule and a 500mg tablet. It is also available as an oral suspension with a strength of 1gm\5ml (teaspoonful). There is no generic form available. Usual Maintenance Dose: 1000mg (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 your dose based on the result of a blood level.

19 Page Medications 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. 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.

20 Medications Page 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 2 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 6 different sizes: 1mg, 2.5mg, 5mg, 10mg, 20mg, and 50mg tablets. The tablets are usually white and are scored which allows them to be easily broken in half. Usual Maintenance Dose: 5 to 10mg per day as a single daily dose. Always take prednisone with food or a snack.

21 Page Medications 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. Exercise and good nutrition are essential to keeping the body strong (especially bones and muscles) while taking prednisone. 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): 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.

22 Medications Page Blurred vision. Increased susceptibility to infection. Long-term: Muscle weakness. Bone and joint weakness, pain. Osteoporosis. Weak, dry, thin skin; stretch marks. Increased or unwanted hair growth. Round shoulders ( buffalo hump ). 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.

23 Page Medications 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. Dosage Forms: Rapamune is available in 1mg and 2mg tablets and is also available as an oral solution in a strength of 1mg/ml. There is no generic formulation available. Usual Dose: 1 to 10mg taken once daily in the morning, 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.

24 Medications Page Decreased blood platelets and white blood cells. Mouth ulcers or sores. Acne. Tingling of hands or feet. Joint pain. Increased susceptibility to infection. Shortness of breath (rare). 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. 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 1 to 3 days after surgery. Tacrolimus may be used as an alternative to cyclosporine.

25 Page Medications Dosage Forms: Tacrolimus is available in 3 sizes: 0.5mg, 1mg, and 5mg capsules. You can use a combination of both sizes to make your dose. There is no generic form available. Usual Maintenance Dose: 1 to 10mg 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 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.

26 Medications Page Nausea or vomiting. Convulsions. 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. 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 3 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.

27 Page Medications Clotrimazole troche (Mycelex ), Nystatin suspension (Nilstat, Mycostatin ) Purpose: Transplant patients will use one of these antifungal (antiyeast) drugs to prevent overgrowth of yeast flora in the mouth (thrush) for 3 months post-transplant. Usual Dose: The clotrimazole troche (10mg) should be dissolved in the mouth or nystatin suspension (one teaspoonful) swished and swallowed 4 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 3 months after transplant. No generic is available for Clotrimazole. Not covered by Medicare.

28 Medications Page Fluconazole (Diflucan ) Purpose: Fluconazole is an antifungal antibiotic used to treat or prevent infections with yeast. Pancreas or kidney/pancreas patients might take fluconazole for up to 3 months post-transplant to prevent infections in the mouth and the urine. Usual Dose: It is taken as a oncedaily oral dose (100mg). It can be taken with food. Potential Side Effects: Nausea. Rash. Diarrhea. Abdominal pain. Cost: $200 per month. Taken for 3 months after transplant (kidney or pancreas transplant). 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

29 Page Medications infections and preventing cytomegalovirus (CMV) infections. Most patients will take them for 3 months post-transplant. Usual dose: The usual dose of valganciclovir is 900 mg once daily and the usual dose of ganciclovir is 1 gm, 3 times a day to prevent CMV infections. The usual dose of valacyclovir is 2 grams, 4 times a day. The usual dose of acyclovir for preventing herpes is 400 mg twice daily. They can be taken with food. Potential side effects: Nausea. Decreased kidney function. Headache. Decreased white blood cells. Cost: $1,000 to $2,000 per month. Taken for 3 months after transplant. Acyclovir and ganciclovir are available generically. No generics are available for 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

30 Medications Page 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 6 months. Take with a full glass of water. Generic forms are available. 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 6 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 1 tablet (100mg) daily for 6 months.

31 Page Medications Potential Side Effect: Lowered red blood cells. Pentamidine (Pentam ) Purpose: Pentamidine is an antibiotic used as an alternative Trim/Sulfa to prevent or treat infections with pneumocystis. Usual Dose: Patients will receive an inhaled treatment of 300mg once per month for 6 months. Potential Side Effects: Unpleasant taste. Cough. 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 immuno-suppressant drugs or stress. Generally, these should be taken routinely for 3 months posttransplant unless you have a history of ulcer disease. You will be prescribed one of the following medications:

32 Medications Page 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 150mg at bedtime. Generic forms are available. Potential Side Effects: Rash. Headache. Mental changes. Dizziness. Cost: $10 per month. Taken for 3 months after transplant. Generics are available. It is available over-thecounter. 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.

33 Page Medications Usual Dose: The usual dosage of Protonix is 40mg taken once daily, Prilosec is 20mg taken once daily, or Prevacid 30mg once daily. These agents should be taken on an empty stomach 30 minutes before meals for best effect. Potential Side Effects: Nausea. Abdominal pain. Constipation. Headache. Dizziness. Cost: $100 per month. Taken for 3 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.

34 Medications Page Potential Side Effects: Aluminum-containing antacids can cause: Constipation. Phosphorous depletion in the body. 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 ) Citrucel 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

35 Page Medications 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 3 months after surgery. Docusate (Colace ) 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 3 months after transplant. Generics are available. It is available over-the-counter. Not covered by Medicare or many private insurances.

36 Medications Page 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 ) 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

37 Page Medications 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 organ(s) 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 calciumchannel blocker drug such as amlodipine (Norvasc ) and a beta-blocker drug such as metoprolol. 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.

38 Medications Page 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. Usual Dose: 1 tablet (81mg or baby aspirin) may be prescribed daily. Not all patients will require this. Potential Side Effects: Bleeding of the soft tissues or gastrointestinal tract. Blood in the urine. Ringing in the ears.

39 Page Medications Cost: $5 per month. Taken indefinitely. Generic is available. It is available overthe-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. 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.

40 Medications Page 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. Cholesterol-Lowering Drugs Some common cholesterol lowering drugs: Pravachol (Pravastatin ) Atorvastatin (Lipitor ) Purpose: Some patients may require addition or continuation of cholesterol lowering therapy. Special Instructions: Report any unexplained muscle weakness or pain to your doctor.

41 Page Medications 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. Usual dose: The usual dose is between 1 and 3 tablets a day. Vitamin 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 shortterm deficiencies of important blood chemicals, minerals, or vitamins.

42 Medications Page 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 1200mg 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 chapter on Nutrition or consult with your transplant dietitian for additional information. 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 0.25mcg of Rocaltrol daily in addition to the vitamin D that is in your multivitamin.

43 Page Medications 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 available in the form of tablets. There may be limited sources of magnesium in your diet. Refer to the chapter on Nutrition or consult with the transplant dietitian for additional information. Phosphate Some common phosphate supplements: Sodium phosphate (K-Phos Neutral ) Phosphosoda Neutra-Phos

44 Medications Page 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 especially those who have had kidney transplants. 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 chapter on Nutrition or consult with the transplant dietitian for additional information. Sodium Bicarbonate Purpose: Bicarbonate is a required supplement taken by patients receiving a pancreas or kidney/pancreas transplant who have bladder drainage of pancreas (refer to Surgery chapter). It helps prevent acidosis (increased acidity of the blood), which can result in nausea. Usual Dose: The usual dose is 4 650mg tablets 4 times a day. Cost: $40 per month. Taken indefinitely by pancreas transplant patients. Generic is available. It is available over-thecounter. Not covered by Medicare.

45 Page Medications Notes

46 Medications Page Notes

47 Page Medications Notes

48 Medications Page Questions? Your questions are important. Call your transplant coordinator during business hours Box N.E. Pacific St., Seattle, WA University of Washington Medical Center 03/2003 Rev. 01/2005