Drugs
Liver Transplant Drugs
Immunosuppressive Drugs
Your body recognises that the liver graft is foreign and your immune system will launch an attack against this 'invader' . Immunosuppressive drugs prevent the rejection of the liver transplant by weakening the response of your immune system. At the same time, however, immunosuppressive drugs can make you a little more susceptible to infections. Fortunately the amount of immunosuppressive medication necessary to preserve a functioning transplanted organ decreases after the first months following surgery, and so does the extra risk of infections. Nevertheless, some immunosuppression is always necessary even many years after transplant surgery, and you must never skip doses or reduce the amount of your medication without your doctor's permission. Not all transplant patients receive all the drugs. So do not be alarmed if one or the other drug does not form part of your immunosuppressive regimen.What follows is general information only which is intended to supplement, not substitute for the expertise and judgment of your physician. You must consult your physician for further details.Most side effects of the drugs listed below can be overcome by temporarily reducing or discontinuing the drug. However, this should never be done without explicit instructions of the physician.
Consult your doctor or transplant team immediately if you think you are pregnant.
Neoral
CYCLOSPORIN (Sandimmune / Neoral )
Cyclosporin works by preventing the activation of the T-lymphocytes ( a type of white blood cell) so that they are unable to attack your new liver. Neoral is usually given orally in combination with azathioprine and / or corticosteroids. The concentration of cyclosporin circulating in your body can be measured with a blood test, and the result used to decide when and how to adjust your dose if necessary.
Taking Neoral
- Take your medication with milk or apple juice at the same times every day, 12 hours apart.
- On the day of your check up visit, give the first sample before (C0) and second 2 hours after (C2) the Neoral dose.
- Do not store cyclosporin in the refrigerator. Keep your medicine in a cool, dry place away from light.
- Neoral can interact with some frequently used medicines. Always check with your doctors or transplant team before taking any new medications.
Side Effects
These include abnormalities of kidney function, high blood pressure, thickening of the gums, high blood sugar, increased hair growth where hair is not normally present, shakiness of the hands called tremor.
Most of these side effects can be avoided or reduced if the dosage is decreased. Remember that you are not likely to experience all, or even most of them and as your dose is reduced with time, you will probably experience fewer side effects.
TACROLIMUS
Like cyclosporin, tacrolimus also blocks the activation of the T-lymphocytes thereby preventing them from attacking your new liver. Tacrolimus is usually taken in combination with azathioprine and / or corticosteroids. The concentration of tacrolimus circulating in your body can be measured with a blood test and the results used to decide when and how to adjust your dose if necessary
Taking Tacrolimus (capsules)
- Take your medication with milk or apple juice at the same times every day, 12 hours apart.
- On the day of your check up visit, give the blood sample before taking the Tacrolimus dose.
- The capsules should be taken at least one hour before or 2-3 hour before or 2-3 hours after a meal.
Side Effects
Tacrolimus may cause abnormalities of kidney function, high blood pressure, sleep disturbances, high blood sugar levels, numbness and tingling in hands and feet, shakiness of hands (tremor). Tacrolimus can interact with some frequently used medicines. Always check with your doctors or transplant team before taking any new medications.
Most of these side effects can be avoided or reduced if the dosage is decreased. Remember that you are not likely to experience all, or even most of them and as your dose is reduced with time, you will probably experience fewer side effects.
Rapamune (SIROLIMUS)
Sirolimus is a TOR inhibitor which results in inhibition of both B and T lymphocytes which are special white blood cells that are responsible for rejection. Its action is different from Neoral and Tacrolimus and hence it is free of several of their side effects such as kidney toxicity, diabetes and high blood pressure.
The concentration of Sirolimus circulating in your body can be measured with a blood test and the results used to decide when and how to adjust your dose if necessary
How to Take this Medication
Take this tablet (usually) once daily at the same time every day, either consistently with or without food. If you are prescribed cyclosporine along with sirolimus, take this medication four hours after your cyclosporine dose.
Side Effects
The most commonly observed side effects are nausea, diarrhea, mouth ulcers and acne. There may be increased levels of blood cholesterol and triglycerides but this improves with time. Decreased platelet or white cell count in the blood have also been noted. Most of these side effects can be avoided or reduced if the dosage is decreased.
Missed Dose
If you miss a dose, take it as soon as you remember. If it is near the time of the next dose, skip the missed dose and resume your usual dosing schedule. Do not double the dose to catch up.
CORTICOSTEROIDS (Wysolone - Prednisolone)
Prednisolone is a corticosteroid that can be used for life long immunosuppression to prevent organ rejection, or in higher doses, for the treatment of rejection. Corticosteroids are manufactured naturally in the body in a 24-hour rhythm. You should take your corticosteroid medication first thing in the morning so that you can copy your body’s natural rhythm.
Taking Corticosteroids
Take your tablets with meals. If you take tablets once a day, take them in the morning with breakfast.
Side Effects
The short-term side effects of corticosteroids include:
- Increased susceptibility to infection, impaired wound healing
- Suppression of the normal fever response and other signs of infection
- Elevation of blood sugar, particularly in patients who already have diabetes
Over the long-term, the side effects of corticosteroids are related to the dose taken. Only in high doses they may cause increase in appetite and weight, a shift in the distribution of body fat (development of Cushingoid features – puffy cheeks, rounded back), thinning of the skin and bones, muscle weakness, increased blood pressure, gastritis, ulcers and heartburn, Diabetes, cataracts, some increase in acne.
Although this list is awesome, it must be emphasised that with the relatively low doses of corticosteroids used nowadays, these side effects are quite uncommon.
AZATHIOPRINE
Azathioprine works by interfering with the ability of cells of divide. It is always given in combination with other immunosuppressants.
Taking Azathioprine
You can take your tablets at any time of the day, but try to get into the routine of taking your medication at the same time every day.
Side Effects
For most people, Azathioprine is safe at the low doses required to prevent organ rejection. Bone marrow cells divide frequently and are very sensitive to the effects of azathioprine. Patients taking azathioprine may have increased susceptibility to infection or reduced haemoglobin, white cell or platelet counts. Effects of azathioprine on the bone marrow are reversible if the drug is stopped temporarily.
Cellcept (MYCOPHENOLATE MOFETIL)
Cellcept inhibits the proliferation of lymphocytes which are vital for rejection.
Taking Cellcept
Take this medication as directed usually twice daily on an empty stomach one hour before or two hours after meals. Swallow this medication whole. Do not crush, chew or open it.
Side Effects
This medication may cause dizziness, drowsiness, headache, nausea, vomiting, diarrhea, gas, tremors, mood changes, or vision changes. It may also cause white cell or platelet counts in the blood to drop. The physician can usually overcome these problems by temporarily reducing or discontinuing the drug.
Missed Dose
If you miss a dose, take it as soon as you remember. If it is near the time of the next dose, skip the missed dose and resume your usual dosing schedule. Do not double the dose to catch up.
MYFORTIC
Recently, Myfortic has been developed as a new enteric-coated formulation of the above drug (Mycophenolate Sodium) in order to protect the upper gastrointestinal tract from damage and hence, lessen the stomach upset caused by Cellcept.
Zenapax (DACLIZUMAB - INJECTION)
This medication is a humanized monoclonal antibody that binds the IL2 receptor on activated lymphocytes. This prevents the important action of IL2 in causing proliferation of cells (lymphocytes) that lead to rejection, hence blocking the rejection phenomenon. Given with other conventional drugs, it has been shown to augment their role in preventing organ transplant rejection.
How to Take this Medication
This medication is given by injection into a vein (IV) after proper dilution in a saline solution. 2-5 doses are given, each over a 15 minute period, every 14 days starting upto 24 hours before the transplant.
Side Effects
Nausea, vomiting, or stomach upset may occur. Allergic reaction (rash, itching, breathing trouble), headache, dizziness, chest pain, arm or leg swelling, cough, fever, poor wound healing, and muscle pain have also been reported.
Storage
Vials should be refrigerated between 2-8 degrees C away from light. Do not shake or freeze.
Simulect (BASILIXIMAB - INJECTION)
This medication is a murine-human chimericl antibody that binds the IL2 receptor on activated lymphocytes. This prevents the important action of IL2 in causing proliferation of cells (lymphocytes) that lead to rejection, hence blocking the rejection phenomenon. Given with other conventional drugs, it has been shown to augment their role in preventing organ transplant rejection.
How to Take this Medication
This medication is given by injection into a vein (IV) after proper dilution in a saline solution. It is usually given in two doses: the first dose is given within 2 hours prior to transplant surgery and the second dose is given 4 days after surgery.
Side Effects
Nausea, vomiting, or stomach upset may occur. Allergic reaction (rash, itching, breathing trouble), headache, dizziness, fever, poor wound healing, vision problems, mood changes and irregular pulse have also been reported.
Storage
Vials should be refrigerated between 2-8 degrees C away from light. Do not shake or freeze.
FAQ’s
1. What medications are prescribed after a liver transplant?
After a liver transplant, immunosuppressive drugs are essential to prevent the body’s immune system from rejecting the new liver. The most commonly used immunosuppressants include tacrolimus, cyclosporine, and prednisone. Other medications, such as mycophenolate mofetil (MMF) may also be added to further reduce the immune response.
In addition to immunosuppressants, patients are often prescribed antibiotics, antivirals, and antifungal medications to lower the risk of infections, which is heightened in patients with a suppressed immune system. This includes medications for cytomegalovirus (CMV) prophylaxis and Pneumocystis jirovecii pneumonia (PJP) prevention. Proton pump inhibitors (PPIs) or H2 blockers may be prescribed to prevent gastrointestinal ulcers, and some patients may receive statins or antihypertensives depending on other health conditions.
2. Why are immunosuppressants necessary after a liver transplant?
Immunosuppressants are critical after a liver transplant because they prevent the immune system from recognizing the transplanted liver as foreign and attacking it, a process called rejection. Without immunosuppression, the immune system would initiate a response against the transplanted liver, leading to acute or chronic rejection, which can damage the liver tissue, impair its function, and potentially lead to liver failure. By suppressing this response, immunosuppressants allow the liver to function normally in the body. However, these drugs must be carefully managed to balance preventing rejection with minimizing side effects and infection risk.
3. How long will I need to take immunosuppressant drugs?
Immunosuppressive therapy is generally required for life after a liver transplant, although the dosage and type of drugs may be adjusted over time. Initially, higher doses are necessary to prevent acute rejection, which is most common in the first few months post-transplant. Over time, as the risk of rejection decreases, doses are usually lowered, and the regimen may be simplified to one or two medications. However, chronic rejection remains a lifelong risk, so stopping these medications is not advised. Your transplant team will tailor the treatment plan based on regular monitoring of liver function, overall health, and potential side effects.
4. Are there side effects of liver transplant medications?
Yes, immunosuppressive drugs can cause a range of side effects. Common side effects include:
- Hypertension (high blood pressure)
- Kidney dysfunction (especially with tacrolimus and cyclosporine)
- Diabetes (new-onset diabetes after transplant, or NODAT)
- Infections due to weakened immunity
- High cholesterol and triglycerides, increasing cardiovascular risk
- Bone thinning (osteoporosis), especially with long-term steroid use
- Weight gain
- Gastrointestinal disturbances like diarrhoea or nausea
- Tremors and hair growth changes
Regular monitoring by the transplant team is crucial to manage these side effects and adjust the medications as needed.
5. What should I do if I miss a dose of my medication?
If you miss a dose of your immunosuppressant, take it as soon as you remember, unless it is almost time for your next dose. In that case, skip the missed dose and continue with your regular schedule. Do not double the dose to make up for the missed one, as this increases the risk of toxicity. Missing doses can reduce the effectiveness of the medications and increase the risk of organ rejection. Always inform your transplant team if you miss a dose, so they can closely monitor your liver function and adjust the treatment plan if necessary.
6. How are drug interactions managed after a liver transplant?
Managing drug interactions is a critical part of post-transplant care. Immunosuppressants can interact with a wide range of other medications, including antibiotics, antifungals, anticonvulsants, and even over-the-counter drugs like nonsteroidal anti-inflammatory drugs (NSAIDs). Certain medications can either increase the toxicity or reduce the effectiveness of immunosuppressants. For example, azole antifungals can increase tacrolimus levels, leading to toxicity, while rifampin can lower immunosuppressant levels, increasing the risk of rejection. Always consult your transplant team before starting any new medication or supplement to avoid harmful interactions.
7. Can I stop taking my liver transplant medications if I feel better?
No, it is crucial to continue taking your immunosuppressant medications even if you feel well. These drugs are necessary to prevent organ rejection, which can occur even in the absence of symptoms. Stopping your medications without medical advice can lead to liver damage, failure, and the need for another transplant. Always discuss any concerns or side effects with your transplant team before making any changes to your medication regimen.
8. Can liver transplant drugs affect my overall health?
Yes, immunosuppressive drugs can affect overall health, particularly when used long-term. Common health issues include:
- Increased susceptibility to infections
- Diabetes
- Kidney disease
- High blood pressure
- Osteoporosis and bone fractures
- Elevated cholesterol, leading to a higher risk of heart disease
A healthy lifestyle, including regular exercise, a balanced diet, and routine follow-up appointments, can help mitigate some of these risks. Your transplant team will work closely with you to monitor for potential complications and adjust your treatment plan as necessary.
9. Are there dietary or lifestyle restrictions while taking liver transplant drugs?
Yes, there are some dietary and lifestyle restrictions after a liver transplant to optimize health and reduce complications. Patients should avoid grapefruit and grapefruit juice, as these can interfere with the metabolism of immunosuppressants like tacrolimus and cyclosporine, leading to dangerous drug levels. A diet low in salt, sugar, and unhealthy fats is recommended to help control blood pressure, cholesterol, and weight gain—side effects of both the medication and the transplant process.
Regular exercise is important to strengthen bones, maintain a healthy weight, and improve cardiovascular health. Patients should also practice good hygiene, avoid contact with sick individuals, and be cautious about potential infection sources due to their weakened immune systems.
