Medications

Cyclosporine

Cyclosporine prevents the body’s immune system from attacking the transplanted organ. It is taken in the morning and at night with 12 hours between each dose. Cyclosporine comes in a liquid medicine with an oil base and a gelatin capsule. The liquid preparation should be given in another liquid (chocolate milk or juice) and in a glass container to mask the strong taste. Make sure the entire dose is taken.

• Do not use plastic or styrofoam for mixing the medicine because it will absorb the Cyclosporine.
• Do not mix the dose in advance because it will form clumps. A syringe is provided with the medicine; after each dose, dry the outside of the syringe with a paper towel.
• Do not rinse the syringe with water.

Give this medicine to your child at the same time each day because it affects the blood levels. For example, about six hours after your child takes the medication, the blood level rises to its peak. Twelve hours after the medication is ingested, the blood levels are at its lowest level. Therefore, blood levels drawn after the 12-hour period provide the most accurate information for determining the effect of the medication and for adjusting the dosage, if necessary.

Cyclosporine levels are drawn daily while children are hospitalized to monitor drug levels. After discharge the medical team will need to continue monitoring the level. On the day of clinic visits, do not give the morning dose of cyclosporine, instead bring it with you to the hospital. After blood work is obtained, give the dose.  If a dose is missed, give the next scheduled dose at the regular time. Do not administer a double dose.

Side effects may include high blood pressure, abnormal kidney function, tremors, swollen gums and increased hair growth on the face and arms. The dose will be adjusted to decrease the side effects as much as possible. Vomiting and diarrhea may interfere with cyclosporine absorption and cause the cyclosporine levels to drop quickly. Call the doctor if these symptoms persist longer than 24 hours. Avoid the following medications if your child is taking cyclosporine: ibuprofen (Advil^(R) or Motrin^(R)), erythromycin and clarithromycin (Biaxin^(R)) and ciprofloxin (Cipro^(R)).

Important Facts:

• No double doses
• Avoid ibuprofen (Advil^(R) or Motrin^(R)), erythromycin, clarithromycin (Biaxin) and ciprofloxin (Cipro^(R))
• Give medication at same time each day
• No dose administered before blood drawn at clinic visit

Neoral^(R) (Cyclosporine)

Neoral^(R) is a new preparation of cyclosporine that is more easily absorbed than the older formulation. The result is that blood levels of Neoral^(R) should remain more stable and more of the drug should get into the body.

Neoral^(R) is distributed as an oral liquid or a soft gelatin capsule of 25 mg or 100 mg. The oral liquid should be mixed with room temperature orange or apple juice. Do not bite or chew the capsules. Neoral is taken twice a day, 12 hours apart. On the morning of clinic visits, do not give the morning dose; hold until blood work has been obtained. (See explanation of blood levels under Cyclosporine).

The usual side effects may include a slight hand shaking or tremors, swollen gums, increased body hair growth and an upset stomach.

Important Facts:

• No double doses
• Avoid ibuprofen (Advil^(R) or Motrin^(R)), erythromycin, clarithromycin (Biaxin) and ciprofloxin (Cipro^(R))
• Give medication at same time each day
• No dose administered before blood drawn at clinic visit

Tacrolimus (Prograf^(R) FK-506)

Prograf is an immunosuppressant medication used to prevent rejection. It is 10 times more potent than cyclosporine, thus requiring a smaller dose to achieve the same effect. Prograf is taken twice daily, 12 hours apart. It should be taken on an empty stomach, whenever possible. It is available in 1 mg and 5 mg capsules. Because there is currently no pediatric preparation available, you will be taught to separate the capsules and prepare the appropriate dose.

As mentioned with cyclosporine, the medication levels are drawn daily while children are hospitalized to monitor drug levels. (See explanation of blood levels under cyclosporine). On the day of clinic visits, do not give the morning dose of Prograf, instead bring it with you to the hospital. After blood work is obtained, give the dose.  If a dose is missed, give the next scheduled dose at the regular time. Do not administer a double dose.

The most common side effects include neurologic symptoms such as difficulty sleeping or shaking hands. Prograf can also cause high blood pressure, but it seems to be less of a problem for patients than cyclosporine. It may also cause diarrhea. Avoid the following medications when your child is taking Prograf^(R)henytoin (Dilantin^(R)erythromycin and clarithromycin (Biaxin^(R)nd ciprofloxin (Cipro^(R)

Important Facts:

• No double doses
• Avoid phenytoin (Dilantin^(R)erythromycin and clarithromycin (Biaxin^(R) and ciprofloxin (Cipro^(R)).
• Give on an empty stomach
• No dose administered before blood drawn at clinic visit

Mycophenolate Mofetil (CellCept^(R))

CellCept^(R)  is a new immunosuppressant used in combination with either cyclosporine, Neoral or Prograf to treat rejection. CellCept^(R) specifically effects the T and B cell lymphocytes that are responsible for turning on rejection. It is available in an oral capsule and is administered two or three times a day. CellCept^(R)  may be taken with or without food.

The major side effects include diarrhea, increased susceptibility to infection, vomiting and a decrease in the white blood cell count.

Prednisone (Deltasone^(R), Liquid Pred^(R))

Prednisone is a steroid that works with cyclosporine or Prograf^(R) to prevent rejection. It comes as an oral liquid or a small pill, which can be crushed, swallowed or dissolved, in a small amount of liquid before giving it to your child. Prednisone can cause an upset stomach if given on an empty stomach. When given in high doses, Prednisone can temporarily interfere with normal growth. Over the months following transplant the medical team will decrease the steroid dose until your child only takes the medication every other day. At this point, children begin to have rapid growth. Large doses of steroids will also increase their appetite. For most children who have not eaten very well before transplantation, this may be a blessing. However, prednisone causes some children to retain water. To avoid this problem, limit the amount of salt in their diet (avoid salty chips, crackers, canned soups and salt on the table). Preteens and teenagers may notice increased acne. This is due to increased activity of the surface glands in the skin or may cause increased sweating at night. Your child may also experience mood swings. Prednisone may slow the rate of healing and decrease the body’s ability to fight infection.

Important Facts:

• Do not give on an empty stomach
• Limit salty foods

Azathioprine (Imuran^(R))

Imuran^(R) prevents the body’s immune system from attacking the transplanted organ. It is usually only administered during the hospital stay. Imuran^(R) works with cyclosporine, Prograf^(R) and prednisone to prevent rejection. Imuran^(R) is supplied as a small eight-sided, yellow scored tablet and is given once a day, usually in the evening. The major side effect is a decrease in the white blood cell count. Other side effects include loss of appetite, nausea and vomiting, unusual bleeding or bruising and bloody dark stools. If side affects occur, the drug is discontinued. Imuran^(R) may also decrease the body’s ability to fight infection.

OKT3^(R) (Murmonab)

OKT3^(R) is a monoclonal antibody used to treat episodes of acute rejection that are not responsive to an increased dose of steroids. It is usually given once a day for 10-14 days. OKT3^(R) is given as an injection through a vein. Prior to each dose of OKT3^(R), your child will be given a dose of Tylenol^(R) and Benadryl^(R) to minimize the side effects. Most children experience “flu like symptoms,” (i.e., fever, headache, nausea, chills and muscle aches) after the first three doses. A few children may get fluid in the lungs. A chest x-ray will be obtained prior to the first dose to make sure the chest is clear. Most patients are hospitalized for the entire course of therapy.

Zenapax^(R) (Daclizumab)

Zenapax^(R) inhibits the immune system's response to transplanted organs by blocking the interleukin 2 (IL-2) receptor. This receptor blockade limits the lymphocytes reaction to antigen's from the transplanted lungs and prevents episodes of rejection. This medication is given intravenously in the immediate post-operative period and then every week for the next five weeks.

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Nifedipine (Procardia^(R))

Nifedipine is used to control high blood pressure. Nifedipine is usually taken one or three times a day. Nifedipine comes in a soft gelatin capsule, long-acting, extended release tablet or a liquid preparation. Possible side effects include headaches, aching joints, flushing, swollen gums and dizziness. Do not crush, break or chew the extended release tablets. Good dental care — brushing and flossing — is important to minimize sore gums.

Important Facts:

• Do not crush, break or chew extended release tablet
• Good dental care, including extra visits to the dentist

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Several antacids are available to buffer the increased stomach acid caused by the prednisone. When the dose of prednisone is decreased, the antacids can often be discontinued.

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Trimethoprim and Sulfamethoxazole (Co-Trimoxazol, Bactrim^(R) or Septra^(R))

Bactrim^(R) is an antibacterial combination of two antibiotics. It is prescribed to transplant patients to prevent serious pneumonia caused by pneumocystis carnii that immunosuppressed patients are at risk of contracting. It is prescribed as a suspension or a tablet and is usually administered three times a week - Monday, Wednesday and Friday. Side effects include vomiting, anorexia, allergic rash, anemia and sun sensitivity. Encourage your child to drink plenty of fluids.

Important Facts:

• Drink plenty of fluids with dose
• Avoid sun exposure

Acyclovir (Zovirax^(R))

Acyclovir is an antiviral drug used to help prevent and/or treat viral infections such as herpes simplex, varicella zoster (chicken pox), EBV or CMV. Acyclovir comes in a 200 mg capsule and a suspension. Although side effects are rare, they do include fever, headache, dizziness and hair loss. Some patients report problems with nausea, vomiting and diarrhea. Take the medication with food or milk.

Ganciclovir

Ganciclovir is an antiviral drug used in the treatment of CMV infections. If your child receives a lung from a CMV positive donor then he or she will be given ganciclovir. Your child will need 12 weeks of intravenous therapy with ganciclovir which will be given twice daily for the first month and then once a day, 5 days per week for the remaining two months. If your child develops an acute CMV infection he or she will also receive ganciclovir.

Nystatin

Nystatin is an antifungal medication used to prevent thrush, an oral fungal infection. Thrush appears as a white coating on the tongue or cheeks or as a diaper rash. Nystatin is prepared as an oral liquid and must always be shaken before it’s given. If other medications are given at the same time, give nystatin last. Your child should wait 30 minutes after the dose of nystatin to eat or drink, since its effectiveness depends on how well the mouth is coated with the medication.

Amphotericin is a potent anti-fungal medication. It can be administered both intravenously and by nebulizer (inhaler). Most children will receive inhaled amphotericin for several days following their transplant. Intravenous amphotericin can cause kidney dysfunction, but this is not a problem when this drug is given by nebulizer.

Immunoglobulins

Immunoglobulins are antibodies purified from the blood of volunteers. The antibodies are removed when the blood is processed for blood transfusions. The immunoglobulins can be enriched to contain antibodies against a specific infection.

Immunoglobulins are administered intramuscularly (into the muscle) or intravenously (into the veins). Common side effects with intravenous administration of immunoglobulins include flushing, chills, fever, nausea and vomiting. Prior to the intravenous first dose of an immunoglobulin your child will be given Tylenol and Benadryl to prevent any problems. Occasionally, a serious reaction, called anaphylaxis, can occur within an hour of infusion of the drug. Infusing the medication more slowly or temporarily stopping the infusion can relieve these symptoms. Immunoglobulins administered intramuscularly have few side effects.

Cytomegalovirus Immunoglobulin (Cytogam^(R))

Cytogam^(R) is given to treat or prevent CMV infections in transplant patients who are CMV negative and receive a CMV positive donor organ. If your child is receiving Cytogam^(R) to prevent CMV, it will be administered intravenously every two weeks for five doses and then once a month for two doses. It is administered as an intravenous infusion. The usual side effects include flushing, chills, fever, nausea and vomiting. Prior to the first dose your child will be given Tylenol^(R) and Benadryl^(R) to prevent any problems. Cytogam^(R) is also used to treat acute CMV infections.

Intravenous Immunoglobulin (IVIG)

IVIG is used to prevent or treat CMV infection in transplant patients who are CMV negative and receive a CMV positive donor organ. For prevention your child will receive a dose within 72 hours of the transplant, on Post Operative Day 5 (POD5) and POD7. Then the dose will be administered weekly by IV for eight weeks. If IVIG is used for treatment, Ganciclovir is given along with it. Arrangements will be made for a home care company to provide doses of IVIG at home after discharge.

Respiratory Synthial Virus (RSV) Immunoglobulin (RespiGam^(R) - intravenous, or Synagis^(R) - intramuscular)

These immunoglobulins prevent RSV, which can cause serious respiratory infections in young children. Children under 2 years old will need to receive either RespiGam or Synergis monthly during the winter months.

Varicella Immunoglobulin (VZIG)

VZIG is given to children who have not had chicken pox if they are exposed to chicken pox after their transplant. This medication is administered once within 48 hours of exposure.

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Insulin is used to treat the high blood sugar levels that occur with diabetes. Immunosuppressive medications sometimes cause high blood sugar levels that need insulin therapy. Children with cystic fibrosis often require insulin because of their pancreatic dysfunction. Insulin is administered under the skin with a small needle one to two times daily.

Other medications may be prescribed, but are specific to each child’s condition at the time of discharge.