What Every Non-hepatologist Should Know About Caring For Transplanted Patients. Gia Tyson, MD, MPH Ochsner Health System March 31, 2017
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1 What Every Non-hepatologist Should Know About Caring For Transplanted Patients Gia Tyson, MD, MPH Ochsner Health System March 31, 2017
2 Agenda Liver transplant statistics Post-transplant patient information Medications Guideline recommendations Frequently Asked Questions
3 Liver Transplantation- Statistics about 150,000 liver transplants about 7,000 liver transplants 1 Graft failure after deceased donor liver transplantation OPTN/SRTR 2015 Annual Data Report: Liver Report
4 Liver transplantation- Causes of death Peri-operative issues Bleeding Infection Cardiovascular events Pulmonary embolus >1 year post-transplant Infections Cardiovascular disease Renal insufficiency Malignancy Recurrent liver disease Rejection is an uncommon cause of death
5 Liver transplantation - Complications AASLD Long-term Management Adult Liver Transplant. Hepatology. 2012
6 Patient Information
7 Safe Living- Step 1 Hand washing
8 Safe Living- Step 2 Infection Awareness Education about immunosuppression and increased risk of infections Avoid contact with people recently ill Avoid large crowds within 6 months of transplant or recent treatment for rejection Early evaluation for a fever ( F) or cold longer than 3 days Quickly wash scraps and cuts; apply antibiotic ointment Staying up to date on needed immunizations Wait until 6 months post-transplant to receive vaccines Only dead viruses, no live viruses Wait 7-10 days to have contact with someone who received a live virus
9 Safe Living- Step 3 Best Daily Action Do not eat after other people Only pasteurized and fully cooked foods Peel cooked foods Limit time outdoors or in the sun Insect repellent especially for mosquitoes Sunscreen Pets needs shots up to date, avoid cleaning up after them Wear work gloves when gardening or yard work Wear metal mesh gloves when fishing
10 Health Maintenance
11 Prevention Dental cleaning twice a year Avoid tobacco Cancer screening Skin cancers: Use SPF 30, cover skin, yearly dermatologic exam Routine cancer screening for males and females
12 Immunosuppressive Medications Primary immunosuppression can NEVER be stopped
13 Immunosuppressive Medications Secondary immunosuppression can be stopped and is usually tapered Need to discuss with transplant team
14 Immunosuppressive Medications* Tacrolimus (Prograf) Renal insufficiency Tremor, neuropathy, headaches, seizures or other neurologic symptoms Elevated blood sugars Elevated blood pressure Elevated potassium Low magnesium Vision changes or hair loss *Infection is a risk associated with all immunosuppressive medications
15 Immunosuppressive Medications Cyclosporine(Neoral) Similar side effects to tacrolimus Increased hair growth on face and upper trunk Gingival hyperplasia Flushing Elevated cholesterol Sirolimus (Rapamune) Elevated cholesterol and triglycerides Poor wound healing Needs to be stopped 2 weeks before and after surgery Nausea, vomiting, diarrhea Mouth ulcers Leukopenia Joint pains Rash or acne
16 Immunosuppressive Medications Mycophenolate mofetil (CellCept) Leukopenia Diarrhea, stomach cramps, nausea Birth defects Mycophenolate sodium (Myfortic) Fewer GI side effects Prednisone Thrush Elevated blood sugars Sodium and fluid retention Gastrointestinal bleeding Acne Moon facies Stretch marks Anxiety, mood swings, sleep disturbance Nocturnal diaphoresis
17 Preventative Medications P. jirovecii (previously PCP) prophylaxis for 6 months after transplant Bactrim Leukopenia Elevated potassium Cholestasis Dapsone Hemolytic anemia Pentamidine Shortness of breath Cough Chest tightness Atovaquone CMV prophylaxis for 3 or 6 months after transplant Valcyte Leukopenia Birth defects Acyclovir Fungal prophylaxis while on steroids Nystatin Fluconazole Aspirin-indefinite to improve hepatic artery blood flow These medications are restarted after inpatient treatment of acute rejection
18 Medication interactions Tacrolimus, Cyclosporine, Sirolimus Decreased levels Increased levels Cholestyramine Azithromycin, St. John s wart erythromycin, Efavirenz clarithromycin Phenytoin, carbamazepine, Fluconazole, phenobarbital itraconazole, Rifampin ketoconazole, voriconazole Diltiazem, verapamil Grapefruit and pomegranate Amiodarone Protease inhibitors
19 Medication Interactions Mycophenolate Decrease absorption with antacids (Magnesium and Calcium) and cholestyramine Caution when using statins and cyclosporine Increased risk of rhabdomyolysis Pravastatin 20mg/day Rosuvastatin 5mg/day Fluvastatin 20mg/day
20 Safe Antibiotics Amoxicillin Augmentin Cephalosporins Ciprofloxacin Clindamycin Doxycycline Levaquin Azithromycin (Z) pack
21 Hepatitis C Medications
22
23
24 Recommendations Grade 1 Level A Smoking cessation-strong association of lung, head and neck cancers Treatment of hypertension to goal 130/80 Annual dermatologic exam If osteopenic need to evaluate for causes, i.e. vitamin D levels, calcium intake, thyroid Attention to risk of cardiovascular disease and cancers Level B Goal hemoglobin A1C <7.0% Annual influenza vaccine Level C Ongoing dietary counseling to avoid obesity
25 Recommendations Grade 2 Level B Bone mineral density (BMD) yearly for 5 years after transplant if patient is osteopenic and every 2-3 years is previous normal BMD Annual lipid panel; LDL goal 100 History of primary sclerosing cholangitis with ulcerative colitis need annual colonoscopy with biopsies
26 Frequently Asked Questions 1. Do I need antibiotics before dental procedures -No, antibiotics should be given according to the American Heart Association guidelines 2. Do I need to wear a mask in crowds? -No, it will not protect from colds 3. When can sexual activity be resumed? -Around 4 weeks after transplant 4. Can patients have Tylenol? -Tylenol (max 2 grams) is safer than nonsteroidal anti-inflammatory drugs
27 Thank You
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