Medications

This is a very important section of the website. You will refer back to it many times.

Information in this page includes anti-rejection drugs, their side effects, self medication program, and general tips about medication.

Medications play a very important role in post-transplant therapy. There are a certain number of drugs that you will have to take for the rest of your live. Depending on your specific needs, more medications may be added to help control various side effects and complications.

Medications are an expense that should be budgeted for. While in hospital, all your medications are paid for. However, after discharge you will have to pay. Out of province patients will have to pay full cost for cyclosporine. This is the most expensive drug, and will cost about $200 per 50 ml bottle.

Since your drugs will be specific to your needs, you may not be taking everything listed here. You must know the name, purpose, dose, and side effects of all your drugs before you leave the hospital.

1. Anti-rejection Drugs

The drugs that prevent rejection are the most important ones you will be taking. You may hear these anti-rejection drugs called “immunosuppressants” or “drugs to suppress the immune system”. You will have to take these drugs for the rest of your life. Each one works in a slightly different way. You will take a combination of two or three of these drugs, because the combination will work better than any one drug alone.

The anti-rejection drugs currently used at TGH include: M.A.L.G., cyclosporine, prednisone and imuranl.

a) M.A.L.G. (Minnesota Antilymphoblast Globulin)

Purpose: M.A.L.G. is a very strong immunosuppressive medication used to help prevent your body from rejecting your transplanted organ.
Proper Use: M.A.L.G. is given intravenously for the first 5 – 7 days after your transplant. It can also be used for severe episodes of rejection.

Side Effects: Some people are allergic to M.A.L.G. Before transplant, you will be given a skin test to see if you are allergic to the serum. Side effects are relatively rare. The most common is fever.

Dose: The dose of M.A.L.G. is specific for each individual. It is adjusted by the doctor according to your blood tests (specifically your white blood cell and platelet count).


b) Cyclosporine A (also called Sandimmune)

Purpose: Cyclosporine A is an immunosuppressive drug used to prevent your body from rejecting the transplanted liver. Cyclosporine is the cornerstone of post-transplant therapy.

Proper Use: Cyclosporine can be given intravenously or orally. You will usually start on cyclosporine about five days after your transplant. There will be a few days where you will receive both cyclosporine and M.A.L.G., but soon the M.A.L.G. is stopped.
The success with post-transplant treatment with this drug depends on you to take the dose properly per doctors orders.

Side Effects: Cyclosporine is a very good drug to prevent rejection, but it does have some unwanted side effects. The main side effects are high blood pressure (which can be controlled by medications), and kidney damage (a dose adjustment down will have to be made). Although very rare, there is an increased risk of developing cancers. Lumps or changes of colour in the skin should be reported to your doctor.
The action of all immunosuppressive drugs, by the way they work, make you more susceptible for infection. Be aware of the signs and symptoms of infection.

Dose: Each person’s dose is chosen specifically for the individual based on many factors (height, weight, side effects, absorption capacity, drug levels, kidney function). The doctor’s aim is to reach a certain level of cyclosporine in the blood. This is measured by blood tests. If there is too little cyclosporine in the blood, there is a chance of rejection. On the other hand, if there is too much drug, then there will be more side effects. The doses will be adjusted for you.
The blood tests to measure the cyclosporine are taken at the time when there is the least amount of cyclosporine in the body. This happens 11 – 12 hours after your last dose, or in other words, just before your next dose is due (most people take cyclosporine every 12 hours). On the morning of your blood test at the lab, you should hold off taking the dose until after the blood is drawn. Be sure to take the Cyclosporine with you to the lab as you must take your dose as soon as possible.

Form: Cyclosporine is available as a 100mg/ml liquid and as 100 mg + 25 mg capsules. There are special instructions you must follow when taking cyclosporine.

If taking the liquid form, you will have to use a glass or ceramic mug to mix it in (not plastic, paper, or Styrofoam, as the drug will stick to the sides). You will dilute the cyclosporine in some type of vehicle, either milk or juice. There is a special sying supplied with the cyclosporine for measuring the dose. The order of mixing should be as follows:

1) Put ½ cup of milk or juice in a glass or ceramic cup.
2) Using the syringe, draw up the correct dose of cyclosporine (check that there are no air bubbles).
3) Add the CSA to the milk or juice, stir and drink.
4) Add a little more milk or juice to rinse the glass and drink.

If you ever forget to take cyclosporine or vomit after taking your dose, call the transplant coordinator for advice. Cyclosporine should be stored at room temperature. Once the container is opened the first time, it is stable for two month. You should date the bottle when it is first opened. You can only get a supply of cyclosporine from transplant hospitals.

c) Prednisone

Purpose: Prednisone is a steroid which prevents rejection of your liver by suppressing the immune system.

Proper Use: Steroids will be given intravenously after your surgery. The dose is tapered down and changed to a tablet form as soon as you are able to take medications by mouth.


Side Effects: Prednisone is a very useful drug, but it does have side effects that you should be aware of. This is a list of some side effects that you should report to your doctor:

1) The drug may reactivate or cause stomach ulcers. To prevent this you should take the drug with food or milk. You may also put on anti-ulcer medication while on prednisone.
2) The body is more inclined to retain fluid, and salt intake may have to be restricted.
3) Most patients gain weight when on prednisone.
4) Mood changes or nightmares sometimes occur. These symptoms tend to improve as the dose is reduced.
5) This drug may increase blood sugar. Diabetes has been known to develop; existing diabetes may be harder to control.
6) Let your doctor know if you have had tuberculosis in the past; this drug may reactivate T.B.
7) You will be more susceptible to infections because of the immunosuppresant effects of this drug. Report any kind of infections to your doctor right away.
8) Prednisone may cause different bone disease. The most common sites for bone or joint pain are the hips, knees and ribs. Notify the doctor if these symptoms occur.

Your doctor will choose the best dose for you. You should never stop taking the drug suddenly, even if you experience side effects. If your dose is to be lowered, the drug will be tapered off slowly.

d) Azathioprine (also called Imuran)

Purpose: Azathioprine is yet another immunosuppressant or anti-rejection drug. Occasionally in liver transplant patients, it is added to the cyclosporine and prednisone regimen.

Proper Use: Imuran is given once a day and should be taken with food or milk as it can cause an upset stomach.

Side Effects: This drug, like other immunosuppressant drugs, increases your risk of getting an infection. You will also have the tendency to bruise more easily. Any excessive bruising or bleeding should be reported.

Dose: The dose is based on your individual needs and varies from patient to patient. The dose will occasionally change based on the result of blood tests (specifically white blood cells).

Drug Interactions: Do not start taking the drug ALLOPURINOL (use for gout) while on Azathioprine, without consulting the doctor first.


2. Other Drugs

The immunosuppressant drugs are the cornerstone of therapy after transplant. In addition to those drugs, you will need to take other drugs to prevent or to treat side effects. You may be on some or all of them depending on your needs.

a) Prevention and Treatment of Infection

The following drugs that are prescribed by your doctor to prevent some of the very common side effects that occur:

i. Ranitidine (Zantac) or Sucralfate (Sulcrate)

The stress of surgery and the high doses of prednisone may cause ulcers. Zantac or sulcrate are drugs used to prevent stomach ulcers from occurring. They are also used for treating patients who have had ulcers in the past. It is not unusual for patients to stay on these drugs for along time.

ii. Cotrimoxazole (Septra/Apo-Sulfatrim/Bactrim)

This drug is a combination of antibiotics (one of them is a “sulfa”), used for the prevention and treatment of different infections. It is given to prevent certain type of pneumonia (pneumocystis carinii pneumonia) which transplanted patients are more susceptible to because of being immunosuppressed.

It is available in regular strength and double strength (DS) tablets. The doctor will decide on the dose that is best for you. This drug should be taken with LOTS of water to make sure it flushes through the kidneys. You may also become more sensitive to sunlight while on this drug. This means you should avoid excess exposure to sunlight and/or wear a good sunscreen and protective clothing.

The immunosuppressive drugs prevent your body’s own defense mechanism from fighting foreign invaders. You are, therefore, more susceptible to infections that can be caused by bacteria, fungi and viruses. If you do get an infection, it is important that you be treated with drugs as your body can’t fight the infection alone. Depending on what type of bug causes an infection, the treatment will be different.

i. Antibacterials

If a bacteria is causing an infection, you may have to come to the hospital to receive intravenous (I.V.) antibiotics. Depending on what bacteria is causing the infection, the doctor will choose the right antibiotic. If you are allergic to any antibiotics such as penicillin or sulfa, be sure to tell the doctor, nurse, and pharmacist ahead of time.

ii. Antifungal

The first place you will notice a fungal infection is inside the mouth as a white patch. Nystatin (Mycostatin/Niltsat) is an antifungal mouthwash, usually used four times a day. It is used to prevent or treat these fungal “thrush” infections.

iii. Antiviral

Acyclovir (Zovirax) is an antiviral drug used to treat infections caused by the herpes simplex virus. The first sign of a herpes infection is a cold sore on or around the lips. You should report these sores as soon as possible to your doctor. Acyclovir is available in ointment or as five-sided blue tablets.

b) Mineral/Electrolyte Supplements

Electrolytes are minerals found in the blood and cells. A balance is necessary for body function and maintenance. When electrolyte levels are low, supplements will be prescribed.

i. Magnesium Glucoheptonate (Rougier)

This drug is used to supplement low magnesium levels in the blood. It comes in a liquid form and will be prescribed until your magnesium levels return to normal.

ii. Potassium Chloride (slow K or K-lyte or Kay Ciel)

There are many different drugs that can be used to treat low potassium levels. Potassium can be irritating to the stomach, therefore it should be taken with food.


c) Treatment for High Blood Pressure (BP)

Antihypertensives are drugs used to treat high BP. High BP is a relatively common side effect of the drug cyclosporine. To control high BP, you may be started on one or more of these medications. Some of the common names are: nifedipine (adalat); metoprolol (lopressor); furosemide (lasix); spironolactone (aldactone); plus many more. If you are started on any of these medications, you can get specific details from your pharmacist.

3. The Self Medication Program

While in the hospital, the nurses are responsible for bringing the medications to each patient. As a transplant patient there are many things to learn and we want to make the transition from hospital to home as easy as possible. For this reason, a “Self Medication Program” has been developed where you will be responsible for taking your own medications as an in-patient. This program is intended to help you learn to take your medications correctly and to learn the name, purpose, dose and side effects of each.

You will start on this program a few weeks after your transplant. The pharmacists will be in to see you several times to give you verbal/written information on all of your medications. By the time you are discharged, you should be confident in your medication regimen.

4. General Tips About Medication

Administer all medications exactly as prescribed. Do not omit any doses. Should you accidentally miss a dose, take it as soon as you can. If it is almost time for the next dose, do not take the missed dose. Never double up on a dose. Keep all medications in their original labeled container. Store your medications safely. Do not take over-the-counter medications unless approved by the physician. Keep an up to date record of your current drugs and bring to clinic. Always keep enough medication on hand. Do not allow your prescription to run out before you get it refilled. DO NOT EXPOSE YOUR MEDICATION TO HEAT OR SUN.