After a liver transplant, all recipients will be on a number of drugs. Some of these are short-term, and some will be for life. The range of drugs is dependent on individual situations and reactions. The following information is general, and not to be taken as the authorative picture of your own drug regime.

TACROLIMUS (SANDOS)

Tacrolimus is prescribed to prevent rejection. You will be on this drug for life. You will need regular blood tests to be carried out to measure the level of drug in your blood and to monitor and detect any side effects which may occur. The amount you take will alter depending on your blood results.

•   Tacrolimus is taken twice a day, 12 hours apart
•   It comes in 1mg  (white coloured opaque body and light brown coloured cap) and 5mg  white coloured opaque body and Swedish orange coloured cap capsules. VERY IMPORTANT NOT TO MIX THESE UPwhite coloured 
•   It should be taken 1 hour before meals or 2 hours after meals
•   Tablets should be kept at room temperature

DO NOT TAKE YOUR MORNING TACROLIMUS
UNTIL AFTER YOUR BLOOD HAS BEEN TAKEN

Side Effects
You may experience some side effects such as headaches, high blood pressure, tremor, insomnia (poor sleep pattern), abnormal kidney function, hair loss, diarrhoea, diabetes and sometimes seizures or fits. Usually these side effects are related to higher doses and usually minimise after the first month.

IMPORTANT NOTICE

From 1 May 2014, PHARMAC is changing the funded brand of tacrolimus, The funded brand of tacrolimus will change from Prograf to Tacrolimus Sandoz.  For more information please contact The Liver Transplant Co-ordinators

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CYCLOSPORIN (NEORAL)
Manufactured by NOVARTIS

If you have not been prescribed Tacrolimus you will be prescribed Neoral. It is similar to Tacrolimus as it prevents rejection and you will be on it of life. You will need regular blood tests to be carried out to measure the level of drug in your blood and to monitor and detect any side effects which may occur. The amount you take will alter depending on your blood results.

•   Neoral is taken twice a day, 12 hours apart
•   It comes as 25mg, and 100mg capsules, or a liquid form
•   The liquid can be taken with milk drinks or orange juice
•   The liquid can be mixed in a glass or hard plastic container using a metal spoon
•   Store away from direct sunlight and extreme temperatures

DO NOT TAKE YOUR MORNING DOSE OF NEORAL
UNTIL AFTER YOUR BLOOD HAS BEEN TAKEN

Side Effects
Include tremor, headaches, high blood pressure, increased hair growth, gum enlargement, insomnia and abnormal kidney function. These side effects are usually related to higher drug doses. Other side effects include light sensitivity. Sunbathing should be avoided and sunblock should be used.

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SIROLIMUS
Manufactured by WYETH

Occasionally patients may be changed to sirolimus or it may be added to cyclosporin or tacrolimus therapy. Sirolimus is currently being used on a semi trial basis in Liver patients as it is not yet registered in New Zealand for liver transplant patients. (It is for renal transplant patients). It differs from cyclosporin and tacrolimus in that it does not cause the same amount of kidney problems so it is very useful in patients who have kidney problems or patients who are having troublesome side effect with the other drugs.

•   Sirolimus is taken once a day in the morning.
•   It comes in a liquid suspension either 5mg/ml or 1mg/ml or tablet form
•   Liqued form should be stored in the fridge

DO NOT TAKE SIROLIMUS
UNTIL AFTER YOUR BLOOD HAS BEEN TAKEN

Side effects
Include a reduction in your white blood cell count, increase in blood lipids and cholesterol. Regular blood tests are necessary to monitor blood levels of the drug and any side effects.

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Important Drug Interactions

Please inform the Liver Transplant Team if you are prescribed any of the following drugs:-

 The drugs listed below REDUCE blood levels of Cyclosporin and Tacrolimus and Sirolimus

• Rifampicin
• Carbamazepine
• Phenobarbitone
• Phenytoin
• Prednisolone
• Sodium Valporate
• St. John’s Wort

The drugs listed below INCREASE blood levels of Cyclosporin and Tacrolimus and Sirolimus

• Amiodarone
• Oral contraceptives
• Itraconazole
• Erythromycin
• Metoprolol
• Fluconazole
• Co-trimoxazole
• Grapefruit juice

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PREDNISONE
Manufactured by APOTEX and many other companies

Prednisone is a steroid hormone which is produced naturally in your body. It has anti-inflammatory properties which protects your transplanted liver from being destroyed. Initially you will be on higher doses but this will gradually be reduced to a lower maintenance dose and in some cases will be completely withdrawn usually within the first year. If you have any episodes of rejection prednisone may be given intravenously for three days in high doses.

•   Prednisone is taken once a day, usually in the morning
•   It comes in 1mg, 2.5mg, 5mg, 10mg and 20mg tablets
•   Do not take on an empty stomach, always take with food

Prednisone should NEVER be stopped suddenly

Side Effects
Side effects include fluid retention, raised blood pressure, an increase in appetite causing weight gain, stomach ulcers, skin changes (such as papery skin, acne, bruising, delayed healing), increased body hair, mood swings and diabetes. Most of these side effects can be combated with the use of other drugs such as diuretics (fluid tablets) for fluid retention, antihypertensive drugs for raised blood pressure, antacids to prevent ulcers or stomach irritation and in some cases insulin to manage diabetes. The dietitian will monitor your diet to minimise excessive weight gain and diabetes.

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MYCOPHENOLATE MOFETIL (CELLCEPT)
Manufactured by ROCHE

Mycophenolate is another drug that is sometimes used to prevent or treat rejection which has not responded to high-dose steroids.

•   Mycophenolate is usually taken twice daily.
•   It comes in 250mg capsules.
•   It is given as well as your Tacrolimus (or Neoral).
•   Do not open capsules; swallow whole.

Side-effects
Include nausea, vomiting, diarrhoea, constipation and anorexia. Other side-effects are anaemia (low red blood cell count) and low white blood cell count.

Regular full blood counts will be carried out to monitor for such problems.

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OKT3 (MUROMONAB-CD3)
Manufactured by JANSSEN - CILAG

OKT3 may be given to you to treat rejection which does not respond to the high-dose steroid treatment. It is given in severe cases and, therefore, rarely used. It is given intravenously once a day for 10 to 14 days. It has quite severe side-effects, which mainly occur during the first 4 doses.

To reduce the side-effects you will be given paracetamol and an anti-histamine 30 minutes before treatment.

Side-effects
Include wheezing, difficulty in breathing, chest pain, fever, chills, nausea, vomiting, diarrhoea, tremor, headache, rapid heart rate, muscle stiffness, and high or low blood pressure.

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ATGAM
Manufactured by PHARMACIA

ATGAM may be given to you to treat rejection which does not respond to the high-dose steroid treatment. This is given instead of OKT3 and, similarly, is only given in severe cases.

It is given intravenously once a day for 10 days. The infusion is given over approximately 5 hours. To reduce any side-effects you will be given an anti-histamine, paracetamol and intravenous steroids 30 minutes before treatment.

Side Effects
Include difficulty in breathing, fever, chills, nausea, vomiting, rash, diarrhoea, low platelet or white blood cell count, abnormal kidney function and muscle aches.

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OMEPRAZOLE (LOSEC)
Manufactured by ASTRA-ZENECA

Omeprazole combats the side effects of the prednisone by preventing stomach irritation and ulcers.

•  Omeprazole is taken once a day
•  It come in 20mg capsules

Other drugs to prevent stomach irritation may be used instead of omeprazole e.g. Pantoprazole (Somac) which act in exactly the same way as omeprazole.

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CO-TRIMOXAZOLE (BACTRIM/TRISUL/APO-SULFATRIM)
Manufactured by many different companies

Co-trimoxazole is given to prevent a particular type of pneumonia called Pneumocystis carinii pneumonis (PCP). Co-trimoxazole is given in tablet form at a dose of one tablet twice daily, twice weekly on Mondays and Thursdays starting one week after transplant and continued for six months.

Side Effects
Can cause reduction in white cell counts and may cause rashes.

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NYSTATIN (MYCOSTATIN)
Manufactured by BRISTOL-MYERS SQUIBB

Nystatin is given to prevent fungal infections in your mouth such as thrush.

  It is taken four times a day

  It is a yellow suspension which tastes quite sweet

Remember to swish and swallow

Side Effects
Can very occasionally cause nausea and diarrhoea.

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GANCYCLOVIR (CYMEVENE)
Manufactured by ROCHE

Gancyclovir is the drug given to treat or prevent CMV infection (cytomegalovirus).

•   It can be given intravenously or in capsules
•   Capsules must be swallowed whole and not broken open
•   Capsules should be taken with food

Take plenty of fluids with this medication

Side Effects
Include reduced white blood cell count which may make you more susceptible to infections, abnormal kidney function, headaches, fever, rash and sometimes confusion. In some cases it can reduce your platelet count which may make you more prone to bleeding. You should inform your Transplant Team if you notice any unusual bleeding or bruising, black tarry stools or blood in your urine.

As Gancyclovir can cause birth defects, all patients, male and female, should use adequate contraception whilst they are taking this drug and for three months thereafter.

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LAMIVUDINE (ZEFFIX)
Manufactued by GLAXO SMITH KLINE

This is an antiviral drug given only to those people who have cirrhosis due to the hepatitis B virus. It is commenced before transplantation and is continued life-long after transplantation. It is given to eradicate, or stop, the activity of the hepatitis B virus and to prevent infection of hepatitis B in the new liver.

•   It comes in 100mg tablets and solution
•   It is taken once a day

You must NEVER run out of supplies

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HEPATITIS B IMMUNOGLOBULIN

HBIG is commenced post-transplant in those patients who have had cirrhosis due to the hepatitis B virus. It is given as an intramuscular injection once a month to prevent infection of the hepatitis B virus in the new liver. These injections will be necessary life-long.

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ANTI - HYPERTENSIVES

There are many anti-hypertensive drugs, which can be used to lower your blood pressure. You may already be on one of these prior to transplantation, or you may be commenced on these due to side-effects of your immunosuppressive drugs.

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WARNING: OTHER DRUGS AND NATURAL / HERBAL REMEDIES

You should not take any drugs which are not prescribed by your doctor. Some herbal or over the counter medicines can be dangerous to your transplanted liver, or can have adverse reactions to the immunosuppression drugs which you are already taking. Any agent that is an immune stimulant e.g. echinacea, may counteract the effect of your immunosuppression and cause you to get rejection of your new liver.

It is very important that you discuss any alternative therapies with your doctor before taking them as they increase the likelihood of side effects of immunosuppression.

You should avoid taking aspirin and non-steroidal anti-inflammatory drugs (NSAIDs) such as Voltaren, Brufen or Naprosyn as they increase the likelihood of side effects of immunosuppression. If you do require any painkillers you may take paracetamol, but no more than two (2) tablets six-hourly. As with any pain, if it persists or worsens you will need to see your doctor.

Before you take ANY other drugs or medicines,
please ask your Transplant Team first.

Reminder: Never stop taking your medication or change the dosage without your doctor’s approval.

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