 |
PART 6: POST TRANSPLANT MEDICATIONS
This section provides an overview of the different medications and their side effects. Our goal after your child’s transplant is to use the lowest medication dose that will prevent rejection and minimize side effects. Using drugs in combination allows us to use lower doses for each drug than if only one drug was used. Thus, we generally use a combination of drugs to suppress your child’s immune response. Basically, lower doses usually mean fewer side effects.
Our current protocol includes an induction medication (Thymoglobulin) along with steroids (prednisone or solumedrol) for the first several days after transplant; and Tacrolimus (Prograf, FK506) along with Mycophenolate Mofetil (Cell Cept) as primary maintenance anti-rejection medications for the rest of the patient’s life. Every patient is different therefore not all patients fit into the protocol perfectly. Some patients need a low dose of steroids forever, others need different combinations of medications. Your child’s medication plan will be discussed with you. Below provides an overview of all anti-rejection medications.
INDUCTION MEDICATIONS
Thymoglobulin
- Thymoglobulin is a medication used early after transplantation for “induction therapy”. Induction is a term used to describe the process of preparing your immune system for transplantation.
- Thymoglobulin is a medication that will be given by IV (into the vein) for several days after the transplant surgery. There is not an oral form of this medication. The patient will not go home on this medication.
- The side effects include: low blood pressure, anemia, low platelets, infection and adverse drug reaction or “allergic reaction”.
Steroids
Steroids are a class of medications that will be used in high doses early after transplant to prevent the onset of early rejection.
- Patients start out on relatively high doses of steroids immediately after transplant. The doses are rapidly decreased over the first days to weeks after transplant.
- Because steroids have so many side effects we hope to decrease to low doses or stop the drug completely within the first several days to weeks after transplant.
- The medication comes as an IV form (Solu-Medrol) or in oral form (prednisone).
- Side effects can include:
- Increase in fatty tissue on the cheeks (moon face) and mid-upper back
- Increase in hair growth
- Increased appetite
- Salt or fluid retention
- High blood pressure
- Loss of potassium in the urine
- Acne
- Ulcers or bleeding in the digestive system
- Fragile skin that is sun sensitive and bruises easily
- Muscle weakness
- Slowed growth (especially height)
- Osteoporosis or weakening of the bones
- Mood changes
- Poor concentration
- Blurred vision
- Cataracts
- Diabetes
MAINTENANCE IMMUNOSUPPRESSIVE DRUGS
Tacrolimus (Brand name: Prograf; sometimes referred to as "FK506")
- Tacrolimus is an immunosuppressant (anti-rejection medication) that is used as a primary maintenance anti-rejection medication.
- Tacrolimus is taken on a regular schedule everyday (either twice or three times per day, as directed). The dose is adjusted according to body weight and blood levels. If doses are missed, contact the heart transplant team for instructions.
- Tacrolimus cannot be taken with grapefruit juice. Common products that contain grapefruit juice include Fresca, Sunny Delight, Squirt and combination fruit drinks.
- The side effects can include: high blood pressure, kidney dysfunction, diabetes, anemia, shaking/tremors of the hands, headaches, mild diarrhea, and/or seizures
- Tacrolimus comes as .5 mg, 1 mg and 5 mg capsules. A liquid preparation can be specially made at compounding pharmacies in a 0.5mg/ml solution.
Mycophenolate Mofetil (Brand name: CellCept)
- Mycophenolate Mofetil (also shortened to MMF) is an immunosuppressant (anti-rejection medication) that is used as a primary maintenance anti-rejection medication. It is usually used in combination with Tacrolimus and/or prednisone.
- MMF is available in 250 mg or 500 mg capsules or a liquid preparation 200 milligrams per milliliter solution (200mg/ml).
- The drug is usually taken on a regular schedule everyday (either twice or three times per day, as directed). The dose is adjusted according to body weight and blood levels. If doses are missed, contact the heart transplant team for instructions.
- The side effects can include: nausea, vomiting, diarrhea, infection, and/or anemia.
Other maintenance immunosuppressive drugs that are used on a case by case basis:
Sirolimus (Brand names: Rapammune and Rapamycin)
- Sirolimus is a new immunosuppressant. The drug has been used to decrease kidney side effects of other anti-rejection medications or as an additive agent for cases of challenging rejection. It is not used as a primary anti-rejection medication early after transplant, patients are often converted to this medication for different reasons at various time points after transplant.
- Sirolimus comes as 1 mg tablet, 5 mg tablet or 1 mg per milliliter solution.
- The drug is given on a regular schedule (usually once to twice daily). Doses are adjusted based on body weight and drug levels. If doses are missed, contact the heart transplant team for instructions.
- The side effects can include: headaches, increased cholesterol levels, swelling, muscle aches, high blood pressure and tremors.
Cyclosporine (Brand name: Neoral)
- Cyclosporine is an immunosuppressant (anti-rejection medication) that is used as a primary maintenance anti-rejection medication.
- Cyclosporine is taken on a regular schedule everyday (either twice or three times per day, as directed). The dose is adjusted according to body weight and blood levels. If doses are missed, contact the heart transplant team for instructions. The drug cannot be given via a Gtube, it has to be given by mouth.
- Cyclosporine cannot be taken with grapefruit juice. Common products that contain grapefruit juice include Fresca, Sunny Delight, Squirt and combination fruit drinks.
- The side effects can include: high blood pressure, kidney dysfunction, diabetes, anemia, shaking/tremors of the hands, increased hair growth, headaches, mild diarrhea, and/or seizures.
- Cyclosporine comes as 25mg and 100 mg capsules. A liquid preparation is available in a 100mg/ml solution. Brand name “Neoral” cannot be substituted for other forms of this medication.
Azathioprine (Brand name: Imuran)
- Azathioprine is an immunosuppressant (anti-rejection medication) that is used as a primary maintenance anti-rejection medication.
- Azathioprine is available in 50 mg tablets or a liquid preparation can be made at most pharmacies.
- The drug is usually taken on a regular schedule everyday (once per day, as directed). The dose is adjusted according to body weight. If doses are missed, contact the heart transplant team for instructions.
- The side effects can include: nausea, vomiting, diarrhea, infection, bruising and/or anemia
ANTI-REJECTION IMMUNOSUPPRESSIVE DRUGS
Despite using the above maintenance immunosuppressive medications, episodes of acute rejection will occur in most patients. If rejection occurs, immunosuppression needs to be more intense to reverse the process. The following medications or procedures may be used:
Steroids: Prednisone or Methylprednisolone (Brand name: Solu-Medrol)
- Steroids can be given in the stronger intravenous form (Solu-Medrol) or in higher doses of the oral form (prednisone) in order to treat rejection. High doses are usually used for three days (“3-day pulse”) in an attempt to aggressively treat the rejection. Side effects of intravenous steroids and high oral doses are the same as described above.
Thymoglobulin
- Thymoglobulin is a medication used early after transplantation for “induction therapy” and during rejection episodes for treatment of rejection.
- Thymoglobulin is a medication that will be given by IV (into the vein) for several days after the diagnosis of rejection. There is not an oral form of this medication. The patient will not go home on this medication.
- The side effects include: low blood pressure, anemia, low platelets, infection and adverse drug reaction or “allergic reaction”.
- There is also an increased risk of viral infections when this medication is used for the treatment of rejection so we give an IV medication called ganciclovir (Brand name: Cytovene) that helps protect against certain viral infections.
Muromonab/CD3 (Brand name: Orthoclone OKT3)
- OKT3 is a drug that has been used mainly to treat severe acute rejection or episodes unresponsive to the other medications. The action of the drug is selective against a specific type of immune system cell (the T-lymphocyte) involved in rejection. The drug is given intravenously (IV) for 10-14 days.
- Side effects can be severe and include allergic reactions and high fever. Rarely, patients develop fluid in their lungs (pulmonary edema) from the drug. For this reason, fluid balance is carefully checked while a child is receiving OKT-3. Patients are monitored in our intensive care unit during the first few doses of this drug.
- There is also an increased risk of viral infections so we give an IV medication called ganciclovir (Brand name: Cytovene) that helps protect against certain viral infections.
Plasmapheresis
- While not a medication, plasmapheresis is a procedure used to treat severe acute rejection. Large volumes of blood are removed from the patient and “washed” of the cells/proteins that are causing rejection. The procedure is done in our intensive care unit under close monitoring.
Intravenous Immunoglobulin (IVIG)
- IVIG is an infusion of antibodies that is given periodically to help prevent and treat rare types of rejection. It is an infusion that is given on a regular schedule (every three to four weeks) through an intravenous line. Patients come to the hospital to the outpatient transfusion center for he infusion.
Rituximab (Rituxan)
- Rituxan is an infusion given periodically to treat aggressive rejection. It is given on a weekly basis for a duration of time (usually three to six weeks)
- Incidence of infection is very high with this medication and additional infection precautions are put in place.
OTHER COMMON MEDICATIONS
Diuretics (medications that eliminate extra salt and water)
- Furosemide (Brand name: Lasix), Chlorothiazide (Brand name: Diuril), or Spironolactone (Brand name: Aldactone) are three common medications that force the kidney to eliminate extra salt and water. Most patients require the medication for a few months after transplant.
- Using high doses of diuretics along with Tacrolimus may cause the body to lose magnesium and/or potassium. Some children need to take a magnesium and/or potassium supplement while taking diuretics.
Blood Pressure Lowering Medications
- Several of the immunosuppressant medications cause an increase in blood pressure. Blood pressure lowering medications are used for the first several months after transplant. The doses are gradually decreased as the immunosuppressant doses are decreased. The drugs come in pill and liquid formulations. They are taken several times a day and are well tolerated.
- These medications include: captopril (Brand name: Capoten), enalapril (Brand name: Vasotec), diltiazem (Brand name: Cardizem) and nifedipine (Brand name: Procardia).
Anti-platelet drugs (Aspirin)
- Anti-platelet drugs (e.g., aspirin) thin the blood by interfering with the normal function of platelets. Platelets have been found to stick to the walls of the coronary arteries causing narrowing or “hardening of the arteries”, also called atherosclerosis. Transplanted hearts may be more at risk so anti-platelet drugs are used to reduce the risk. A baby aspirin tablet once a day is the usual dose. Children that are on chronic aspirin therapy tend to bruise and bleed easily.
Medications to Prevent Infections
- Given that chronic immunosuppression raises the risk of certain uncommon infections, the following drugs are used regularly to lower the risk certain infections seen in children with transplants.
- Nystatin (Brand name: Mycostatin) is a liquid medication that decreases the colonies of fungus that can be found in the mouth. Nystatin prevents a common infection called “thrush.” It is taken for several months after the transplant. The drug is well tolerated and side effects are not seen. An alternative, Mycelex, is sometimes used in patients that do not tolerate the Nystatin.
- Trimethoprim/sulfamethoxazole (Brand name: Bactrim) is an antibiotic that is used to prevent a rare type of pneumonia caused by the bacteria called pneumocystis carinii. It is only seen in patients on immunosuppressant medications. It is taken twice a day for three consecutive days per week. The drug is generally taken for the first year after transplant. Side effects include sun sensitivity and nausea.
- Ganciclovir (Brand name: Cytovene) or Valganciclovir (Brand name: Valcyte) is used to prevent/treat certain viral infections (cytomegalovirus, epstein barr virus). It is taken for several months after transplant.
Antacids
- Stress and steroids place transplant patients at high risk for stomach ulcers. Ranitidine (Brand name: Zantac) is an antacid prescribed for the first 6-12 months after transplantation. Alternatives Omeprazole (Brand name: Prilosec) and Protonix are sometimes needed for patients who do not tolerate Ranitidine.
- Calcium carbonate (Brand name: Tums) is an antacid that provides extra calcium to prevent weakening of the bones caused by steroids. Most patients are instructed to take Tums or an alternative calcium supplement one to two times per day.
Cholesterol Lowering Agents
- An increase in cholesterol is common after heart transplantation. The elevated cholesterol levels are related to the immunosuppressant medicines and weight gain after transplant. The increase in cholesterol in the bloodstream contributes to the development of coronary artery disease.
- Pravastatin (Brand name: Pravachol) is a cholesterol-lowering agent that is used to help prevent cholesterol related coronary artery disease. This agent is not used in very young children. It is started several months after transplantation.
- This agent is used even if cholesterol levels are normal as a preventative agent. The medication is metabolized through the liver; therefore liver function tests will be monitored periodically after it is started.
- Side effects of the medication include nausea, vomiting, diarrhea, and muscle weakness.
|
|
