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Michigantransplant.org

YOUR NEW MEDICINES
General Overview
Your doctors have started you on many new medicines. These
medicines are needed to make sure your transplant is successful.
The medicines can be put into three different classes:
Anti-rejection – Help prevent your immune system from
Anti-infective – Help protect you against certain infections
Miscellaneous – Medicines that treat the side effects of the
anti-rejection medicines and other medical conditions You MUST learn or know all of your medicines. You must carry a current list of your
medications with you at ALL times.
Call your outpatient transplant coordinator two to three days
in advance
when you need a refill. Do not wait until your
prescription runs out

with a return office visit. When you have an appointment, make a note of the medicines that you need to be renewed. Your doctor can refill them during your visit.
Your transplant medicines may have strong interactions with over-the-counter medicines.
• You may take Tylenol® (Acetaminophen) for minor aches and pains without contacting your outpatient coordinator.
• Do not take over-the-counter medicine (including “cold remedies”) without contacting your outpatient • You should not take any medicine that contains ibuprofen or naproxen sodium (read the label carefully).
• Do not take any medicine prescribed by any other doctor (except your lung transplant doctor) without checking with your transplant coordinator first.
The following information will answer some of your questions about the medicines you will take. Not all of the medicines listed will apply to you. We have included them in case you need to learn about them in the future.
Anti-Rejection Medications
Tacrolimus (Prograf®) and Modified Cyclosporine (Neoral®, Gengraf®) are the primary medications to prevent rejection. You will be on one of these medicines after your transplant for life. Both of these medicines are adjusted by frequent blood levels. These blood levels are called troughs and represent the lowest amount of tacrolimus/modified cyclosporine circulating in your body before you take your next dose. The blood must be drawn in the morning, about 11 to 12 hours after your last dose. If you miss a dose of Tacrolimus (Prograf®) or Modified Cyclosporine (Neoral®, Gengraf®), and it is within four
hours of your normally scheduled time, go ahead and take
your dose. If it is past four hours, then contact your transplant coordinator or the physician
right away. Don’t decide what to do on your own. Do not double the next dose!
Medicine interactions: You must always be careful when taking new medicines. They
can make your tacrolimus/cyclosporine level either go higher or lower. High tacrolimus/
cyclosporine levels could hurt your kidneys, cause other side effects, or raise your risk of
getting an infection. Low tacrolimus/cyclosporine levels could increase your risk of rejection.
Besides medicines, certain foods can affect tacrolimus/cyclosporine levels, such as grapefruit.
Never eat grapefruit or drink grapefruit juice while taking tacrolimus/cyclosporine. Grapefruit
increases the amount of these medicines in your body.
Tacrolimus (ta-KROE-li-mus) — Brand Name: Prograf®
Possible Side Effects:
• Increased chance for infections
• Kidney problems
• Tremors
• Nausea/vomiting, diarrhea
• Headache
• High potassium levels and low magnesium levels (this can affect your heart) • Diabetes- blood sugar problems• Hair loss Dosing strengths: 0.5mg capsules
How Often:
Modified Cyclosporine (Sye-kloe-spor-een) — Brand Names: Neoral®, Gengraf®
Possible Side Effects:
• Increased chance for infections
• Increased hair growth or hair in unusual places • Gum hyperplasia (when the tissue around your teeth grows more than it should and can Dosing strengths: 25mg capsule
How Often:
Note: One brand name of cyclosporine may be absorbed differently in your body than another
brand name. Only take the brand prescribed by your doctor or transplant coordinator.
Azathioprine (Imuran), Mycophenolate Mofetil (Cellcept), Mycophenolate Acid
(Myfortic)

One of these medications will be your second anti-rejection medication. They are used together with the tacrolimus/modified cyclosporine. These medicines decrease white blood cells, and they are not monitored by blood levels.
Azathioprine (ay-za-THYE-oh-preen) — Brand Name: Imuran®
Possible Side Effects:
• Increased chance for infections
Dosing Strength: 50mg tablet
How Often:
Mycophenolate mofetil (mye-koe-FEN-oh-late) — Brand Name: Cellcept®
Possible Side Effects:
• Increased chance for infections
Dosing Strengths: 250mg capsules
**Do NOT break tablets or open the capsules.
How Often:
Mycophenolate Acid (mye-koe-FEN-oh-late) — Brand Name: Myfortic®
Possible Side Effects:
• Increased chance for infections
Dosing Strengths: 180mg tablet
**Do NOT break the tablets.
How Often:
Sirolimus (Rapamune®), Everolimus (Zortress®)
Sirolimus and Everolimus are other anti-rejection medications that may be used together with tacrolimus, cyclosporine, mycophenolate or azathioprine, or by itself. However, they are not used within three months of lung transplant because of an increased risk of an opening forming at the place where the lungs are connected to your airway (bronchus).
Sirolimus and Everolimus are adjusted by frequent blood levels like tacrolimus/modified cyclosporine. These blood levels are called troughs and represent the lowest amount of sirolimus/everolimus circulating in your body before you take your next dose. The blood must be drawn in the morning, approximately 23 to 24 hours after your last sirolimus dose, and 11 to 12 hours after your last everolimus dose. Do not take sirolimus or everolimus until your blood is drawn! Sirolimus (sir-OH-li-mus) — Brand Name: Rapamune®
Possible Side Effects:
• Increased chance for infections
• Low white blood cell count
• Low red blood cell count
• Low platelet count
• High cholesterol and triglyceride
• Delayed wound healing
Dose Strengths:
How Often:
Everolimus (e-ver-OH-li-mus)) — Brand Name: Zortress®
Possible Side Effects:
• Increased chance for infections
• Low white blood cell count
• Low red blood cell count
• High cholesterol and triglyceride
• Stomach upset and vomiting
• Diarrhea
Dose Strengths:
How Often:
Prednisone (Deltasone)
Prednisone is the last anti-rejection medication you will take. At first it will be given as an intravenous (IV) form, methylprednisolone, right after surgery. Once you are able to swallow pills, the prednisone will be changed to oral pills. The dose will be adjusted slowly over time until it reaches a certain level. Once the level is chosen, you should maintain this dose until you are told by your doctor or transplant coordinator to change it. The IV form is also used to treat rejection episodes.
No blood levels are necessary to monitor the Possible Side Effects:
• Increased chance for infections• Salt and fluid retention (swelling)• Muscle weakness and loss of muscle mass• Loss of calcium, leading to loss of bone density and a higher chance of bone fractures and • Stomach ulcers• Difficulty healing wounds, cuts and sores• Changing body features: full cheeks, redistribution of body fat away from arms and legs and • Increased appetite• Menstrual irregularities• Cataracts• Elevation of blood glucose (you may require insulin)• Dramatic changes in your emotions• Insomnia• Acne• Change in hair condition. Permanent hair dyes, tints, wave lotions, and bleach may cause your hair to become brittle and break.
Dosing Strengths: 1mg tablets
How Often:
Anti-Infection Medications
After your transplant, you are at higher risk of becoming infected by bacteria, fungus or viruses found in your surroundings. Your doctor will prescribe several medications to help protect you. Over time, your doctor may decide to stop some of the medications described in this section. Preventing Cytomegalovirus (CMV)
CMV is a common virus. You may have already been exposed to it. CMV is transmitted by body fluids such as blood, saliva, and breast milk. CMV may cause serious infections. The infections can lead to pneumonia, diarrhea, fever, weight loss, seizures, blindness, and encephalitis (infection of the brain). As a result, your doctor will prescribe Valganciclovir (Valcyte) pills or Ganciclovir (Cytovene) IV/pills to help protect you from CMV infection. In addition, you may also need to receive Cytomegalovirus Immune Globulin (Cytogam) to protect you against developing CMV.
Valganciclovir (val gan SYE kloh veer) — Brand Name: Valcyte™
Ganciclovir, (gan-sye-kloh-veer) — Brand Name: Cytovene®

Possible Side Effects:
• Nausea, vomiting, diarrhea, abdominal cramping
• Headache
• Anemia (low red blood cell count) • Low white blood cell count • Bruising, bleeding • Fever/chills Dosing Strengths: Valcyte: 450mg tablet
** Be careful to throw away any tablet that is broken or crushed.
How Often:
Valcyte: One to two times a day with food Cytomegalovirus Immune Globulin —
Brand Name: Cytogam®

Possible Side Effects:
Dose Strengths:
How Often:
As directed by transplant team. Your transplant coordinator will arrange IV infusions of this medication based on your individual case.
Preventing Herpes Simplex Virus (HSV)
You are protected against HSV (shingles) while on the above medications (Valcyte, Cytovene) for CMV prevention. If you have not been exposed to CMV or have finished your CMV prevention course, then you will be placed on Acyclovir.
Acyclovir (ay-sye-kloe-veer) — Brand Name: Zovirax®
Possible Side Effects:
• Nausea
• Vomiting
• Kidney dysfunction
• Visual changes
• Irritability, anxiety, confusion
• Low blood counts
Dosing Strengths: 200mg capsule
How Often:
Preventing Pneumocystis Jiroveci Pneumonia (PJP)
PJP can often lead to pneumonia. Because of this, your doctor will start you on a medicine called Bactrim. If you are allergic to sulfa-based medicines or to Bactrim, your doctor may prescribe either Dapsone, or Pentamidine.
Sulfamethoxazole/trimethoprim (sul-Fa-meth-o-xa-zole or tri-meth-O-prim) —
Brand Name: Bactrim™

Possible Side Effects:
• Itching
• Skin Rash
• Aching of joints and muscles
• Bleeding or bruising
• Sensitivity to sun
Dosing Strengths: 400mg/80mg (single strength tablet)
How Often:
One time a day on Mondays, Wednesdays, and Fridays with food Dapsone (DAP sone) — Brand Name: Avlosulfon®
Possible Side Effects:
• Rash
• Nausea/Vomiting
• Blood count abnormalities
Dosing Strength: 100mg tablet
How Often:
One time a day on Mondays, Wednesdays, and Fridays Pentamidine (pen TAM i deen) — Brand Name: NebuPent™
Possible Side Effects:
• Bronchospasm
• Cough
• Irritation of the airway
Dosing Strength: 300mg inhalation
How Often:
Preventing Candidiasis
Candida is a fungus found in the mouth. This may cause you to develop thrush right after your transplant. You will take Nystatin for prevention. Nystatin (ni’-stat-in) — Brand Names: Mycostatin®
Possible Side Effects:
• Bitter or foul taste
• Nausea or vomiting
• Diarrhea
Dosing Strength: 100,000 units/ml
How Often:
Four times a day after meals and before bedtime. Don’t eat or drink anything for 15 to 30 minutes after you take your medicine.
Preventing Aspergillus
Aspergillus is a fungus found in our environment, and it is not dangerous for those with a normal immune system. Aspergillus most often infects the lung in patients who receive a transplant. You will be placed on an oral medication and an inhaled medication for prevention right after transplant.
Oral Medications
Itraconazole (itra-con-a-zol) — Brand Name: Sporanox®
Possible Side Effects:
• Nausea, vomiting
• Loss of appetite
• Constipation
• Rash
• High liver enzymes
Dosing Strengths: 100mg capsule
How Often:
One to two times a day. The capsules should be taken with a meal and an acidic beverage (ex. orange juice). If you take medications that decrease stomach acid (ex. Omeprazole (Prilosec®), ranitidine (Zantac®)), take it as far from itraconazole as possible since they can decrease the absorption of itraconazole.
Voriconazole (vor i KOE na zole) — Brand Name: Vfend®
Possible Side Effects:
• Rash
• Sensitivity to sun
• Visual changes
• Hallucinations
• Elevated liver enzymes
Dosing strengths: 50mg tablet
How Often:
One to two times a day on an empty stomach (one hour before or one hour after a meal).
Inhaled Medication
Liposomal Amphotericin B (am foe TER i sin bee LYE po som) —
Brand Name: Ambisome®

Possible Side Effects:
• Cough
• Wheezing
• Nausea
How Often:
One time a day on Mondays, Wednesdays, and Fridays Other Medications
Sometimes there are side effects from one or more of the medicines you may take. So, you may be given another medicine to treat those side effects. If you are taking medicine for a medical condition you already have, this dose may be changed by your transplant doctor. Your transplant team will tell you when it is ok to continue taking the medicine.
This is a list of medicine that you may need to take:
Gastric Acid-Reducing Medications: These medications protect the stomach lining from
irritation or treat heartburn. Many of these medications can affect the absorption of some of
your oral medicines. Examples of these medications include ranitidine (Zantac®), omeprazole
(Prilosec®), esomeprazole (Nexium®), pantoprazole (Protonix®), and lansoprazole (Prevacid®).
Insulin: Tacrolimus and prednisone can cause your blood sugars to increase. Insulin and oral
medications, such as glyburide or repaglinide, may be used to lower the blood sugars. High
blood sugar may be a short-term or long-term problem. Long term management of diabetes
should be managed through your primary care doctor.
While on insulin, it is important to closely monitor blood sugars with a glucometer (measures blood sugars) at home. You will be taught how to use the glucometer and how to record your glucose levels. Calcium: Some of the medications you are taking cause calcium loss. This can weaken your
bones and put you at risk for developing osteoporosis. It is recommended for you to take a
calcium supplement, such as calcium carbonate (Tums) or calcium citrate with vitamin D
(Citracal with D), for prevention. Calcium is generally taken three times a day with meals.
Vitamin D helps your body to better absorb the calcium.
Osteoporosis Prevention: Along with calcium, other medications can help protect you from
getting osteoporosis. These drugs are taken once a week and must be taken first thing in
the morning with a full glass of water. After you take the pill you can’t lie down, take other
medicines, eat or drink anything besides water (especially calcium) for at least 30 minutes.
Some people have pain or trouble swallowing with this medicine. Examples of these medicines
are alendronate (Fosamax®) and risedronate (Actonel®).
Magnesium: Some of your medicines cause magnesium loss. This can put you at risk for
having irregular heart rhythms. Magnesium oxide will be prescribed to you right after your
transplant to increase your magnesium. Some people may have diarrhea and gastrointestinal
upset with this medicine.
High Blood Pressure Medicines: High blood pressure may be a result of the surgery and the
anti-rejection medications. The high blood pressure may be a short-term or long-term problem.
Cholesterol Lowering: These drugs are also called “statins” and are used to lower your
cholesterol. These drugs work best to prevent your body from making cholesterol when taken
at night because this is when your body makes cholesterol. Some people get muscle aches
or liver irritation with these drugs which your doctor will monitor. If you experience muscle
aches or pains please let your transplant nurse and doctor know. Examples of these medicines
include atorvastatin (Lipitor®) and simvastatin (Zocor®).
Approved Over-the-Counter (OTC) Medications
Below is a list of common symptoms and recommended over the counter treatment for symptom relief. Check with your transplant coordinator before taking any other medicines that are not listed below. Constipation: Colace, Senekot, Benefiber, Fiber-con, and Metamucil are medicines you may
take. Eating a diet high in fiber (bran, fresh fruits and vegetables) and drinking more water
will help with your constipation. Talk with your transplant coordinator if constipation remains
a problem.
Diarrhea: Imodium and Kaopectate are acceptable medicines you may take. Drink more water
and other fluids to prevent dehydration until your diarrhea goes away. Notify your transplant
coordinator if your diarrhea lasts for more than two days.
Headache, muscle aches, other aches and pains: Tylenol (Acetaminophen) is an acceptable
medicine to take. If your headache doesn’t go away or you have a fever with your headache, call
your transplant coordinator.
Over-the-Counter Medicines YOU SHOULD NOT TAKE!
These medicines will interact with your immune suppression medicine and may harm
your kidneys. DO NOT TAKE:
• Ibuprofen
• Motrin-IB

• Nuprin
We recommend that all transplant recipients avoid • Menadol
• Midol
• Genpril
• Ketoprofen
• Ordudis-KT
• Actron
• Naproxen
• Aleve

Allergy and cold medications: Do not take any cold medicines without the approval of your
transplant coordinator.
Herbal Supplements
We recommend that you DO NOT USE HERBAL SUPPLEMENTS. There are many
herbal supplements available to the public - often promoted as cures for many illnesses.
Herbal supplements are not regulated by the Federal Drug Administration (FDA) which means there are no standards for the ingredients used in each bottle of herbal supplements.
There can be a wide variation in the contents from one bottle to another – even with the
same brand. Some supplements are harmless, but others can be a serious health risk. This
is especially true of St. John’s Wort. ALL TRANSPLANT PATIENTS SHOULD NOT
TAKE ST. JOHN’S WORT.

Source: http://www.michigantransplant.org/pdf/lung/4-YourNewMedicines.pdf

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