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Toolbox: Managing Your Medications

Learn about managing your medications

Why is it important to take my transplant medications?

The immune system is the body's defense mechanism against foreign invaders. Foreign matter can include such things as bacteria, viruses or foreign tissue cells. The bone marrow produces different types of white blood cells that control and carry out most of the immune responses.

Your transplanted organ is viewed as an invading protein, just like a virus or bacteria and can come under attack by your immune system. This process is known as rejection and is a normal response of your body. While a rejection does not mean failure of the transplant, it can interfere with the normal function of your new organ. It is very important to try to prevent rejection through the use of medications that suppress your immune system.

Immunosuppressive drugs are used to reduce the activity of your immune system in order to protect your new organ from rejection. These medications fool the body's normal immune response and help to prolong the amount of time the transplanted organ stays healthy and functioning. It is very important that you take these medications exactly as directed by your transplant team.

Most patients will be prescribed a combination of two or three of the following medications:

  • Cyclosporine (Neoral®)
  • Tacrolimus (Prograf® or Advagraf®)
  • Prednisone
  • Azathioprine (Imuran®)
  • Mycophenolate mofetil (Cellcept®)
  • Mycophenolate sodium (Myfortic®)
  • Sirolimus (Rapamune®)

While you are taking these medications your immune system will be suppressed so your body will be less able to fight off infection. You will also be prescribed additional medications to help protect you against developing certain types of bacterial, viral and fungal infections.

It is important to realize that side effects from medications are to be expected, especially right after your transplant. This is the time when your body is adjusting to the new organ as well as many new medications. Since each person responds differently to their medications, it normally takes some time for your transplant team to determine the best doses of these medications for you.

During the initial period after transplant surgery, it is normal for you to:

  • be tired
  • be confused or disoriented
  • have difficulty concentrating
  • have difficulty sleeping

Your transplant team knows to expect these side effects, and they are trained to manage them. It is most important to know that these symptoms are temporary and should be improving by the time you are ready to leave the hospital. Simple changes in medication or routine are usually all that are needed to deal with these side effects. Sometimes, other medications are added to counteract these side effects. It is important to remember never to stop or change the way you are taking any of your medications without consulting your transplant team. Your transplant team is ready to listen and to help if you or your family have concerns about your symptoms. If you have any new symptoms such as confusion or disorientation once you return home you should report them to your transplant team.

To learn more about your transplant medications please go to the Transplant Medication Information Teaching Tool.

Why do I need my blood work monitored?

Blood tests help your transplant team to determine the dose of anti-rejection medication that is best for you. Anti-rejection drugs can be absorbed differently by each patient which makes it very difficult to predict what dose you will need. With blood tests, your transplant team will monitor the amount of medication in your body and adjust the dose up or down accordingly.

If your blood level of anti-rejection medication is too high, you may be at increased risk of side effects and your transplant team will lower your dose. If your blood level is too low, you may be at increased risk of rejection and your transplant team will increase your dose. The goal is to find the best dose for you in order to maximize the benefits of these medications while minimizing the side effects. Medications which usually require blood level monitoring include cyclosporine (Neoral®), tacrolimus (Prograf®or Advagraf®) and sirolimus (Rapamune®).

Regular blood tests are also important to help your transplant team determine if there are any problems with your new organ. As well as checking levels of medication, blood tests can also help your transplant team to look for signs of rejection, infection, dehydration and preventable side effects.

The timing of bloodwork is critical. Blood tests must be done at a specific time of the day in relation to when you take your medication. Bloodwork done at the wrong time will not be helpful and in some cases could even be dangerous if it results in improper dose adjustments or failure to adjust a dose. Always follow the instructions provided to you by your transplant team regarding the timing of your bloodwork.

Your transplant team will leave you a message on Easy Call to let you know if you need to change your dose of medication based on your blood level results.

Are there any medications I need to avoid after a transplant?

Yes. There are many prescription drugs and over-the-counter medications that should be avoided after a transplant. Certain drugs may interact with your transplant medications that may increase your risk of side effects or make your transplant medications less effective. Do not take any new medications, vitamins, supplements, herbal remedies or products from the health food store without first speaking with your transplant team.

Are there any important drug interactions with my transplant medications?

Yes, there are a number of drugs that may interact with your transplant medications. These interactions may increase your risk of side effects or make your transplant medications less effective. Some common interactions include:

Ibuprofen (Advil®, Motrin®), ASA (aspirin)
These medications may increase your risk of kidney problems, especially if you are taking the anti-rejection medications cyclosporine or tacrolimus. These products may also cause stomach irritation or increase your risk of bleeding and should be avoided. Once daily low-dose "baby" aspirin is safe to take if it is on the advice of your doctor.

Magnesium-containing products (e.g. Maalox®, Milk of Magnesia®) or iron supplements
These products may decrease the absorption of certain anti-rejection medications such as mycophenolate mofetil (Cellcept®) or mycophenolate sodium (Myfortic®) if taken at the same time. If you are taking any products containing magnesium or iron, be sure to space them at least two hours before or after your transplant medications.

Echinacea is an ingredient in many herbal remedies sold over-the-counter at many drug stores and health food stores and is used to prevent colds and flu. Echinacea works by stimulating the immune system. This can counteract the effects of your anti-rejection medications, which are used to suppress the immune system in order to prevent organ rejection. All products containing Echinacea should be avoided.

What medications are safe to take for pain?

If you need to take medication for pain or headache, acetaminophen (Tylenol®) is usually safe to take. Do not take ASA (aspirin) or ibuprofen (Advil®, Motrin®) as these products can cause stomach irritation and increase your risk of bleeding. They may also increase your risk of kidney problems. Check labels carefully as some pain relief products contain a mix of aspirin with other drugs (e.g. Alka Seltzer®, Bufferin®, Robaxisal®, Excedrin®).

When in doubt, ask your pharmacist if the product contains aspirin. One exception to this is once daily, low-dose "baby" aspirin – this product is safe to use on the advice of your doctor.

What can I do to remember to take my medications?

Transplant patients often have complicated medication regimens with many doses of different medications each day. Some patients may find it difficult to keep track of their medications and when they need to be taken. Below are some suggestions that may assist you in managing your medication regimen.

  • Get into a routine of taking your medications at the same time each day.
  • Set up a time once a week to sort out your medicines for the coming week. Using a special pill box with multiple compartments (also called a dosette, see photo below) can help to keep your medications organized. Ask a family member or caregiver to help you if you are having difficulty.
  • There are many different sizes and styles of dosettes. Larger dosettes that have compartments for the 7 days of the week and 4 different dosing times each day (morning, noon, supper and bedtime) may be most useful.
  • Some dosettes have removable compartments. These are convenient if you need to take just one day's worth of medication with you (i.e. going to work, or going on a day trip).
  • Instead of a dosette, some patients use small baggies labelled with days of the week and times of the day to sort their medications.
  • Setting an alarm clock or wristwatch alarm to beep at times when your doses are due is a useful trigger to remember your medications.

Picture of pills 

A dosette can help you keep your medications organized

Besides anti-rejection medications, what other medications will I need after my transplant?

There are a number of other supportive medications that may be needed after a transplant. These medications are usually prescribed to prevent or manage possible side effects of the anti-rejection medications.

Anti-rejection medications work by suppressing your immune system. This decreases your body's ability to fight infection. Antibiotics are often used to prevent or treat different types of bacterial infections. After a transplant most patients will be prescribed an antibiotic called cotrimoxazole which is used to prevent a particular type of pneumonia called PCP. You are much more susceptible to PCP when your immune system is suppressed. To learn more about cotrimoxazole, please go to the Transplant Medication Information Teaching Tool and click on the cotrimoxazole course on the left side of the page.

Anti-Fungal medications
After transplant, an anti-fungal medication will be prescribed to prevent a fungal infection from developing in the mouth or throat. This type of infection is usually referred to as oral thrush and may appear as white spots or patches on your tongue or on the inside of your mouth or throat. The most commonly prescribed anti-fungal medication to prevent oral thrush is called nystatin. Nystatin is a liquid which is swished in your mouth and swallowed four times per day. It is important to use this medication exactly as directed in order for it to be effective. To learn more about nystatin, please go to the Transplant Medication Information Teaching Tool and click on the nystatin course on the left side of the page.

Anti-viral medications
Anti-viral medications are used after transplant to both prevent and treat viral infections should they occur. You are more susceptible to viral infections after a transplant when your immune system is suppressed. Common viral illnesses after transplant include infection with the herpes virus or cytomegalovirus (also called CMV). Valganciclovir is an anti-viral medication which may be prescribed for a few months after your transplant to protect you from viral infection. To learn more about valganciclovir, please go to the Transplant Medication Information Teaching Tool and click on the valganciclovir course on the left side of the page.

Acid-Reducing medications
Acid-reducing medications are often prescribed after transplant to prevent and treat problems caused by excessive stomach acid such as heartburn, acid reflux and stomach ulcers. Acid-reducing medications can also prevent stomach irritation or heartburn which may be caused by certain anti-rejection medications such as prednisone.

Diuretics are also known as water pills and they are often prescribed after a transplant to help reduce leg swelling and fluid retention. Diuretics work by increasing the amount of urine made by the kidneys which helps to rid the body of excess fluids. These medications can also be used to manage high blood pressure.

Cholesterol-lowering medications ("Statins")
Some anti-rejection medications may increase your cholesterol levels after a transplant. Some patients already have high cholesterol before transplant and these levels become higher after transplant. High cholesterol levels can increase your risk of heart attacks and strokes. Your doctor may prescribe a cholesterol-lowering medication to help manage this condition. The most commonly prescribed cholesterol-lowering medications are called statins, although other medications may be used.

Tips on Safe Medication Practices

  • Store your medications out of the sun and extreme heat
  • Always store your medications in a cool, dry place
  • Keep all medications out of the reach of children and pets
  • Always check with your transplant team before taking any new medicine, even those that can be purchased over-the-counter
  • Do not take any medication if it has become soft, sticky, hard or cracked or has a notably different colour or odour. Speak with your pharmacist about replacing it with a new supply
  • Always swallow capsules whole and never take them crushed, chewed or opened unless instructed to do so by your transplant team
  • Always avoid grapefruit and grapefruit juice as these may interact with your medications
  • In case you are ever in an accident, it is important to keep a list of your medications with you at all times
  • Wear a Medic-Alert bracelet that indicates the type of transplant that you have received (e.g. "kidney transplant") and that you are "immunosuppressed"
  • Always dispose of your medications properly by bringing them back to your local pharmacy