I thought I’d be able to stop many of the medications I took before the transplant. Why am I still taking so many medications?

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You may be able to stop many of the medications you were taking before your transplant. Because of the multitude of risks and side effects caused by the immunosuppressive drugs, however, you need to take additional medications to minimize their risks and control the side effects. The immunosuppressive drugs decrease the function of your immune system. As a result, common viruses and bacteria, which are typically kept at bay by the intact immune system, may now cause serious infections. These potential infections include cytomegalovirus (CMV) and Pneumocystis carinii pneumonia (PCP).

CMV is a common virus that is similar to infectious mononucleosis. It may cause no symptoms or perhaps a febrile illness. When the immune system is intact, you can get CMV only once. However, in the immunosuppressed patient the virus can reemerge and cause inflammation in the new liver, kidney problems, pneumonia, and blood problems. Pneumocystis carinii infection usually causes pneumonia if it occurs in transplant recipients. Because these infections can be devastating or even fatal after transplantation, medications are prescribed to significantly reduce the risk of occurrence. As time goes by after transplantation, many of these preventive medications can be stopped as the degree of immunosuppression required to prevent rejection decreases.

Anti-Infection Medications (Antibacterials)

Antibacterials (also called antibiotics) are prescribed to prevent and treat bacterial infections. Because antirejection medications can weaken your immune system, you are more at risk for the development of an infection, especially in your urinary tract or lungs. Antibiotics may be prescribed to decrease your chances of developing an infection and are definitely prescribed if an infection develops. Several antibiotics are commonly prescribed, including trimethoprim-sulfamethoxazole, levofloxacin, and ciprofloxacin.

Trimethoprim-sulfamethoxazole (TMP-SMZ, Bactrim, Cotrim, Septra) is prescribed to prevent PCP.

Notes About Trimethoprim-Sulfamethoxazole

• TMP-SMZ is available as a pill or a liquid.

• Take TMP-SMZ with 8 ounces of water.

• Do not take TMP-SMZ if you are allergic to sulfa.

• TMP-SMZ may be used to treat a urinary tract infection or pneumonia.

• Tell your transplant team if you become pregnant while taking TMP-SMZ.

Possible Side Effects

Low white blood cell count, nausea, vomiting, rash, itching, loss of appetite, abnormal kidney function tests.

Levofloxacin (Levaquin) and ciprofloxacin (Cipro) are antibiotics with many uses. They are effective therapy for some types of pneumonia (but not PCP), urinary tract infections, and bacterial cholangitis (infection of the bile ducts). Levofloxacin and ciprofloxacin are typically not used as preventive medicine but rather as a treatment.

Notes About Levofloxacin and Ciprofloxacin

• Drink a lot of fluids when taking levofloxacin or ciprofloxacin.

• Tell your transplant team if you have hives, a skin rash, or ringing in your ears.

• If you also are taking an antacid, do not take it within 2 hours of ciprofloxacin or levofloxacin.

Possible Side Effects

Upset stomach, diarrhea, nausea, vomiting, low blood sugar.

Antifungal Medications

Antifungal medications are prescribed to prevent and treat infections that are caused by fungus or yeast.

These include infections in the mouth (also called thrush), vagina (yeast infections), skin (jock itch, athlete’s foot), blood, or lungs. There are several commonly prescribed antifungal medicines, including Mycostatin, clotrimazole, ketoconazole, and fluconazole.

Mycostatin (nystatin) is an antifungal medication primarily used to prevent thrush from developing in the mouth. It also comes in a powder to treat fungal skin infections like athlete’s foot.

Notes About Mycostatin

• Mycostatin is a mouthwash that prevents or treats infections in your mouth.

• Mycostatin should be taken after meals and at bedtime.

• Make sure you do not have anything in your mouth before taking Mycostatin.

• Mycostatin is swished around in your mouth for a few minutes and then is swallowed.

• You should not eat or drink anything for 15 to 20 minutes after taking this medicine.

• Take good care of your mouth by brushing and flossing your teeth regularly.

Possible Side Effects

Nausea.

Clotrimazole (Mycelex) is an alternative to Mycostatin to prevent thrush.

Notes About Clotrimazole

• Clotrimazole is a lozenge that prevents or treats mouth infections.

• Clotrimazole should be taken after meals and at bedtime.

• You should let the lozenge dissolve in your mouth over a period of 15 minutes.

• Do not chew the lozenges or swallow them whole.

Possible Side Effects

Nausea, vomiting.

Ketoconazole (Nizoral) is another antifungal medication.

Notes About Ketoconazole

• Ketoconazole is a pill that should always be taken with food.

• Do not drink alcoholic beverages when taking ketoconazole.

• Antacids and acid blockers, such as Pepcid, Tagamet, or Zantac, should not be taken for at least 2 hours after taking ketoconazole. • Call your doctor if you have a rash, itching, dark urine, pale stools, yellow skin, or sores in your mouth.

• Ketoconazole can affect the levels of cyclosporine, sirolimus, or tacrolimus found in your blood.

• Do not stop taking ketoconazole or change the dose or the time at which you take it unless your transplant team instructs you to do so, because such a change could have a serious effect on your cyclosporine or tacrolimus blood levels.

Possible Side Effects

Diarrhea, nausea, vomiting, impotence, menstrual irregularity, dizziness.

Fluconazole (Diflucan) is an antifungal with many uses. It can be used to treat known fungal infections and is often prescribed to prevent fungal infections.

Notes About Fluconazole

• Fluconazole can affect the amount of cyclosporine or tacrolimus found in your blood.

• Do not stop taking fluconazole or change the dose or the time at which you take it unless your transplant team instructs you to do so, because such a change could have a serious effect on your cyclosporine, sirolimus, or tacrolimus blood levels.

Possible Side Effects

Nausea, vomiting, diarrhea.

Antiviral Medications

Antiviral medications are prescribed to reduce the chance of specific viral infections, such as CMV and herpes, occurring after your transplant. You are at risk of developing these infections if you or your donor has had them at any time before transplantation. Antiviral medicines include valganciclovir, ganciclovir, and acyclovir. 

Valganciclovir (Valcyte) and ganciclovir (Cytovene) are antiviral agents effective against the herpes viruses. These viruses include herpes simplex, CMV, and varicella (chickenpox).

Notes About Valganciclovir and Ganciclovir

• Do not stop taking valganciclovir or ganciclovir or change the dose or the time at which you take it unless your transplant team instructs you to do so.

• Valganciclovir and ganciclovir can be given in pill form or intravenously (in the vein).

• Call your transplant team if you have a skin rash, sore throat, fever, chills, or pain.

Possible Side Effects

Fever, rash, headache, abnormal kidney function tests, increased risk of infection, fatigue, diarrhea, nausea, vomiting.

Acyclovir (Zovirax) is occasionally used to prevent or treat herpes infections or varicella.

 Notes About Acyclovir

• Do not become pregnant or father a child while you are taking acyclovir.

• Do not stop taking acyclovir or change the dose or the time at which you take it unless your transplant team instructs you to do so.

• If you are taking acyclovir for herpes simplex infection of the mouth or genitals, avoid kissing and sex if you have open sores.

Possible Side Effects

Nausea, vomiting, diarrhea, abnormal kidney function tests, rash, headache.

Medicines That Protect Your Digestive System

Two types of medicines that protect your digestive system are acid blockers and antacids. These agents are often necessary after transplantation to prevent stress ulcers in the stomach and gastroesophageal reflux disease (GERD) or heartburn symptoms.

Histamine-2 (H2) acid blockers decrease the amount of acid produced by your stomach. They are used to prevent and treat ulcers. The most commonly used H2 acid blockers are cimetidine (Tagamet), ranitidine (Zantac), famotidine (Pepcid), and nizatidine (Axid). These drugs are now available over the counter, but your transplant physician may want you to take prescriptionstrength doses.

 Notes About Histamine-2 Acid Blockers

• Do not take an acid blocker at the same time you take fluconazole, ketoconazole, or another antacid.

• Take your acid blocker before meals.

• Your doctor will prescribe an acid blocker based on your needs.

Possible Side Effects

Diarrhea, constipation, nausea, gas, headache, dizziness.

Proton pump inhibitors block the formation of gastric acid in the stomach by inhibiting the activity at the surface where secretions are produced. The most commonly used proton pump inhibitors are omeprazole (Prilosec), lansoprazole (Prevacid), esomeprazole (Nexium), pantoprazole (Protonix), and rabeprazole (Aciphex). They are very well tolerated and extremely effective in treating ulcers and heartburn.

Notes About Proton Pump Inhibitors

• Swallow capsules whole. Do not open or crush them.

Possible Side Effects

Headache, diarrhea, abdominal pain.

High Blood Pressure Medications

(Antihypertensives)

People who take high blood pressure medications before surgery are likely to continue to need those medications to lower their blood pressure after surgery. In addition, some people who had normal blood pressure before surgery may have high blood pressure after a transplant. Both cyclosporine and tacrolimus cause hypertension in about 70% of people who take them. The most commonly prescribed medicines for high blood pressure include diltiazem (Cardizem, Cartia, Dilacor, Tiazac), enalapril (Vasotec), lisinopril (Zestril), nifedipine (Procardia, Adalat), atenolol (Tenormin), and metoprolol (Lopressor).

Notes About Antihypertensive Medications

• You may be advised to follow a low-sodium diet if you have or develop high blood pressure.

• Some high blood pressure medications can affect your cyclosporine or tacrolimus blood levels. Check with your transplant team before starting or stopping any high blood pressure medication.

Possible Side Effects

Dizziness and lightheadedness for the first few days, fatigue, nausea, loss of appetite, headache, rash, dry cough, swelling in the feet, slow pulse, high potassium levels, kidney dysfunction.

Low Blood Pressure Medications

If your blood pressure is too low, your doctor may prescribe medicine to raise it. The medicine most commonly prescribed for low blood pressure is fludrocortisone (Florinef).

Notes About Fludrocortisone

• Fludrocortisone raises blood pressure by helping you to retain salt in your body and to discard potassium in your urine.

• Mild ankle swelling is common.

• Fludrocortisone usually is taken in the morning.

• Take fludrocortisone under close medical supervision.

Possible Side Effects

Swelling in the hands or feet, rapid weight gain, water retention, headache.

Diuretics

Patients who take prednisone may retain excess fluid in their bodies. Removing excess fluid also is helpful for lowering blood pressure. Diuretic medications (fluid pills) may be used briefly after transplantation to help you get rid of excess fluids caused by intravenous hydration during the surgery and while you were unable to eat. The most commonly used diuretics are furosemide (Lasix), hydrochlorothiazide (HCTZ), torsemide (Demadex), and bumetanide (Bumex). Spironolactone (Aldactone) may have been one of your diuretics before transplantation—this medication should be used very cautiously after transplantation.

Notes About Diuretics

• Take the diuretic early in the day so you will not have to get up several times a night to go to the bathroom.

• Taking a diuretic could cause your body to lose potassium. Potassium supplements may be prescribed for a short time to replenish the supply in your blood.

• Do not increase or decrease the dosage of your diuretic without consulting your transplant team. 

Possible Side Effects

Low blood pressure, dizziness, lightheadedness, dehydration, more frequent urination, low potassium.

Cholesterol-Lowering Medications

Lowering your cholesterol may help prevent heart disease. People who have high cholesterol levels may be given medicine to lower it. The most commonly used cholesterol-lowering medicines are atorvastatin (Lipitor), simvastatin (Zocor), rosuvastatin (Crestor), pravastatin (Pravachol), and lovastatin (Mevacor). The primary immunosuppressive agents, cyclosporine and sirolimus, are the culprits causing high cholesterol and triglyceride levels in many patients who take them.

Notes About Cholesterol-Lowering Medications

• Cholesterol-lowering medicines usually are taken at night.

• The results of taking a cholesterol-lowering medication may not be seen for weeks or months.

• You will have blood tests while taking a cholesterollowering medicine to confirm that your liver is functioning normally and to monitor your cholesterol levels.

• Do not take a cholesterol-lowering medication if you are pregnant or considering pregnancy.

• Call the doctor who prescribed the cholesterollowering medication immediately if you experience muscle cramps or weakness, especially in your legs.

Possible Side Effects

Upset stomach, heartburn, change in the way foods taste, diarrhea, skin rash, headache, constipation, blurred vision, muscle damage.

Drug Interactions

Some medicines can interfere with the way cyclosporine, sirolimus, and tacrolimus are processed in your body and can lead to very high or very low blood levels of these drugs. This effect can result in toxicity or rejection of the transplanted liver. Be sure to discuss possible drug interactions with any physician who prescribes a new medicine for you. If you are unsure about a new medication, contact your transplant team.

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