Medications Heart Transplant Surgery

Medications

Shortly after your transplant, you will be taking care of yourself and living a nearly normal life. In order to prepare you to care for yourself, it is important for you to know about all aspects of your medications. The nursing staff will give you your medications for the first few days after surgery. During this time, however, the nurses will teach you the names, dosages, schedules, side effects, and reasons for taking each drug. Please be sure to ask them any questions that come to mind about each drug.

Note: This web site provides selected information available about cardiothoracic surgery which may become out of date over time. It is important that consumers see a healthcare professional for detailed information about medical conditions and treatment. This information is not intended to be a substitute for the advice of a healthcare professional, or a recommendation for any particular treatment plan. The USC Department of Cardiothoracic Surgery has made and will continue to make efforts to include accurate and up-to-date information on this web site.

• Rules for Medications
• Types of Medications
  • Avapro
  • Baby Aspirin or Ecotrin
  • Cellcept
  • Clonidine Hydrochloride (Catapres TTS1-TTS-3)
  • Cyclosporine A (Sandimmune) (Neoral)
  • Diuretics
  • Dynacirc (Isradipine)
  • FK 506 (Prograf) (Tacrolimus)
  • Furosemide (Lasix)
  • Imuran (Azathioprine)
  • Metolazone (Zaroxylin)
  • Norvasc (Amlodipine besylate)
  • OKT3
  • Prednisone (Deltasone)
  • Procardia (Nifedipine)
  • Vasotec (Enalapril Maleate)
• Medication Side Effects
• CVS Pro-Care Lifetime Program
• If You Have Problems Paying for Your Medicine

As you become familiar with your drugs, we will begin to increase your independence by letting you take them on your own. We have medication sheets with dates, times, and dosages to help you adjust to your new routine. The members of the transplant team will be happy to help you and to answer your questions whenever you wish. Please remember the following points:

• You will not be taking every single medication described in this section. You will only take those medications that are appropriate to your condition.
• A general range is listed for the dosage of each drug. Your doctor will determine the exact dose of each drug that is right for you.
• Your doctor will also tell you how often you should take each drug.
• You will not experience every side effect listed for each drug. It is important, however, that you are aware of the possible side effects for each drug so that you can seek medical attention if side effects do occur and so that you understand any changes that occur in your body from taking the drugs.
• If the side effects of a medication prescribed for you cause you concern, do not decide against using it without first checking with your doctor.

Rules for Medications

• Learn both the generic and brand names of each medication: often the generic names are written first and the brand names are in parentheses.
  
   
• Take all of your medications precisely as directed by your doctor. Try not to miss any doses and try to stick with your prescribed schedule.
  
   
• If you miss a dose, take it as soon as possible. If it is almost time for your next dose, do not take both the missed dose and the next dose, only take one dose.
  
   
• Do not take other medications unless they have been prescribed by, or discussed with one of the transplant doctors/nurses. This is especially true for over-the-counter drugs or herbal supplements bought without your doctor's prescription.
  
   
• Store all of your medications away from heat and direct light. Do not keep medicines in the bathroom cabinet since heat and moisture can cause deterioration.
  
   
• Keep your medications in their original containers since the label on the container always shows the expiration date, the prescribing doctor, the original prescription date, and the direction for taking the medication.
  
   
• Keep all medications out of reach of children.
  
   
• If you want more information about your medication, ask your doctor or one of the nurse coordinators.

Avapro (Irbesartan)

Dosage
Usually 150 mg once daily, dosage can go up to 300 mg daily.

Action
Helps to control blood pressure by blocking the process that causes narrowing of the blood vessels, which causes blood pressure to rise.

Side effects
Impaired kidney function, low blood pressure, dizziness, edema, headache, abdominal pain, anxiety/nervousness, nausea and vomiting.

Baby Aspirin or Ecotrin

Dosage
80 mg or one tablet per day.

Action
Works to slow down the thickening and narrowing process of the blood vessels of the heart.

Side effects
Bleeding gums, bruising easily, intestinal bleeding, stomach pain, ringing in the ears.

Cautions
Never take aspirin for a fever or headache--only use Tylenol.

Cellcept (Mycophenolate Mofetil)

Dosage
Usually between 250 mg to 1000 mg twice a day.

Action
An immunosuppressive drug which works by killing T-lymphocytes (immune cells) in the blood. T-lymphocytes detect and attack your transplanted organ.

Side Effects
Causes lowering of the entire white blood cell (immune cell) count, which puts you at risk for developing infections; diarrhea.

Clonidine Hydrochloride
(Catapres TTS1-TTS-3)

Dosage
The patch is applied weekly. Dosages range from 0.1 mg to 0.3 mg a day through the skin.

Action
Helps to control high blood pressure by blocking that part of the brain which causes the narrowing of blood vessels. As a result, the blood vessels relax and dilate. When blood vessels dilate, your blood pressure is lowered.

Side Effects
Most common are: dry mouth, drowsiness, sedation, constipation, dizziness, headache, and fatigue. Most of these side effects will decrease over time. Other possible effects include: nausea, vomiting, and decrease in sexual function.

Cautions
Because this drug causes drowsiness, be careful about driving or operating any sort of appliance or machinery. Avoid using alcohol, cough, cold or allergy medications, pain or sedative medications, and tranquilizers with Catapres, it may increase effect.

Cyclosporine A (Sandimmune) (Neoral)

Dosage
About 6 mg per kilogram of body weight a day, initially, then changing dosage according to your blood levels. For best absorption by the stomach, take cyclosporine before meals. Capsules come in 100 mg and 25 mg.

Action
An immunosuppressive drug which is believed to work by blocking the action of the immune cells in your blood known as the T-lymphocytes. These immune cells normally take part in the rejection process.

Side Effects
Chills, fever, rash, increased hair growth (hirsutism), impaired kidney function, high blood pressure, soft tissue tumors, burning pain in feet and hands, and hand tremors. Because cyclosporine is supplied in an olive oil base, you may have temporary episodes of diarrhea, but this is usually mild.

Cautions
Most patients need some medications for high blood pressure caused by cyclosporine. This will be adjusted by the doctors on an individual basis.

Note
Increase hair growth is a temporary side effect of cyclosporine. Although bald patients appreciate the new hair growth, women are not so appreciative. Excessive facial hair can be removed easily by the use of depilatories such as Surgi-Cream or other facial hair removers. Some cosmetic manufacturers, such as Merle Norman or Revlon, produce special facial hair removers. Products designed to remove body hair from legs and underarms, such as Neet or Nair, should not be used on your face. Before using any depilatory, do a patch test on your hand to check for an allergic reaction. Once the patch test is completed, wait 24 hours to evaluate the skin on your hand. If there is no reaction (like redness, itching, or swelling) you can assume you are not allergic and use the product. You may also undergo waxing to remove excessive hair.

Getting the right medication dose of Cyclosporine/FK506 (Prograf) level for you
While you are in the hospital, your medication levels will be drawn daily for some time after transplant. You must wait to take your morning dose of medication until after the blood level has been drawn. The reason for this careful planning is that we want to know the lowest level of medication in your blood during a 24-HOUR PERIOD. This lowest level, or "trough" blood level, occurs just before you take your next dose of medication. Based on the trough levels of medication in your blood, we will either raise, lower or keep the same medication dosage.

We may also vary the number of times you will be taking your Cyclosporine or Prograf during a 24-hour period. Once your blood has been drawn, you may take your morning dose of Cyclosporine/Prograf.

Diuretics

Diuretics, also called water pills by many patients, help the body get rid of extra fluid that tends to build up. The tendency of the body to hold extra fluid is often a side effect of Prednisone. There are a few types of diuretics that work in slightly different ways. All of the diuretics, however, act to get rid of the extra fluid in your body by decreasing the amount of urine made by the kidneys. As a result, if you are taking a diuretic, you will urinate more often and in larger amounts than usual.

• Furosemide (Lasix)
• Metolazone (Zaroxylin)
• Baby Aspirin or Ecotrin

General rules

• The action of the drug may last 2-12 hours after you take it. Plan your activities so that a bathroom is nearby during the drug’s peak hours of action.
• If you are scheduled to take an evening dose of your diuretic, take it early in the evening to prevent the inconvenience of getting up often to urinate during sleeping hours.
• Weigh yourself once every morning before breakfast and after emptying your bladder. Keep a record of your weight. In general, changes in body weight reflect the holding of fluid as well as fluid loss. Thus, weighing yourself is one way to see how well the diuretic is working.

Possible side effects

• Many diuretics can cause a decrease of potassium in your blood. This happens because the diuretics cause the kidneys to filter the potassium out of the blood and into your urine. Having a low potassium level can cause muscle cramping, muscle weakness, and an irregular pulse rate.
• If the diuretic causes the kidneys to make too much urine, you may become dehydrated, have low blood pressure and dizziness, or have fainting and dry mouth as a result of losing too much fluid.
• With high doses of a diuretic, you may have ringing in your ears or deafness may even occur.

Dynacirc (Isradipine)

Dosage
Usually initiated at 2.5 mg twice a day but can go up to 5 mg twice a day.

Action
Helps to control blood pressure by decreasing the amount of blood pressure.

Side Effects
Dizziness, edema, nausea, weakness, headache, flushing, low blood pressure, fainting, cramps on leg/feet.

FK 506 (Prograf) (Tacrolimus)

Dosage
About 1 to 10 mg every 12 hours. Dosage is based on the level drawn in the hospital. The blood test to check for the Prograf level must be drawn 11 to 11.5 hours after the last dose. It is very important that the level be drawn precisely or it will be inaccurate result.

Action
An immunosuppressive drug which blocks the action of the immune cells in your blood known as the T-lymphocytes. These immune cells normally take part in the rejection process.

Side Effects
Chills, fever headaches, tremors, diarrhea, nausea, high blood pressure, abdominal pain, impaired kidney function, low blood count.

Caution
Some medications may affect drug concentrations. Your dose will be adjusted on an individual basis.

Getting the right medication dose of Cyclosporine/FK506 (Prograf) level for you
While you are in the hospital, your medication levels will be drawn daily for some time after transplant. You must wait to take your morning dose of medication until after the blood level has been drawn. The reason for this careful planning is that we want to know the lowest level of medication in your blood during a 24-HOUR PERIOD. This lowest level, or "trough" blood level, occurs just before you take your next dose of medication. Based on the trough levels of medication in your blood, we will either raise, lower or keep the same medication dosage.

We may also vary the number of times you will be taking your Cyclosporine or Prograf during a 24-hour period. Once your blood has been drawn, you may take your morning dose of Cyclosporine/Prograf.

Furosemide (Lasix)

Dosage
Dosage ranges from 20 mg to 80 mg one or two times a day.

Action
The action of the drug may last 2-12 hours after you take it. Plan your activities so that a bathroom is nearby during the drug’s peak hours of action.

Side Effects

• Many diuretics can cause a decrease of potassium in your blood. This happens because the diuretics cause the kidneys to filter the potassium out of the blood and into your urine. Having a low potassium level can cause muscle cramping, muscle weakness, and an irregular pulse rate.
• If the diuretic causes the kidneys to make too much urine, you may become dehydrated, have low blood pressure and dizziness, or have fainting and dry mouth as a result of losing too much fluid.
• With high doses of a diuretic, you may have ringing in your ears or deafness may even occur.

Imuran (Azathioprine)

Dosage
Usually between 25 mg to 150 mg per day. This dose is based on your white blood cell (immune cells) count and required frequent blood tests.

Action
An immunosuppressive drug that works by killing T-lymphocytes (immune cells) in the blood. T-lymphocytes detect and attack your transplanted organ.

Side Effects
Causes lowering of the entire white blood cell (immune cell) – this puts you at risk for developing infections; hand tremors.

Metolazone (Zaroxylin)

Dosage
Doses range from 2.5 mg to 10 mg once a day.

Action
In addition to the diuretic functions described above, Zaroxylin also lowers blood pressure directly. The way the drug does this is unknown.

Side Effects

• Many diuretics can cause a decrease of potassium in your blood. This happens because the diuretics cause the kidneys to filter the potassium out of the blood and into your urine. Having a low potassium level can cause muscle cramping, muscle weakness, and an irregular pulse rate.
• If the diuretic causes the kidneys to make too much urine, you may become dehydrated, have low blood pressure and dizziness, or have fainting and dry mouth as a result of losing too much fluid.
• With high doses of a diuretic, you may have ringing in your ears or deafness may even occur.

Norvasc (Amlodipine besylate)

Dosage
Ranges from 5 mg to 10 mg daily.

Action
Helps to control blood pressure by decreasing the amount of calcium allowed to enter muscle cells of the blood vessels. Without calcium, the blood vessels relax and dilate, lowering the blood pressure.

Side Effects
Dizziness, edema, nausea, weakness, headache, flushing, low blood pressure, fainting, cramps on leg/feet.

OKT3

OKT3 is a "mouse monoclonal" antibody that works to prevent or to treat rejection. OKT3 may be used right after your transplant, if your kidneys are not functioning optimally, so that you do not need to take cyclosporine, thus allowing your kidneys to rest period before beginning cyclosporine. OKT3 may be also used to treat moderate to severe rejection episodes unresponsive to "conventional" therapy.

A side effect of cyclosporine can be high blood pressure. Antihypertensive medications are used to lower your blood pressure. Often, antihypertensive are used in combination with other medications to reach a blood pressure that is right for you.

Prednisone (Deltasone)

Dosage
Initially, 15 mg two times a day. This will be reduced to 10 mg per day at about five months after transplant. Larger patients may be on higher maintenance doses and smaller children will usually be on smaller doses.

Action
An immunosuppressive drug known as a "steroid" which works by decreasing inflammation or swelling which is a normal, protective, immune response of the body.

Side Effects
May mask infections; may cause bones to become weak due to loss of calcium (osteoporosis); may cause muscle weakness or wasting; may cause the cells of the body to hold more salt and water and to lose potassium; causes thin, fragile skin, and may lead to bruises and stretch marks; may cause nausea or vomiting; increases the cholesterol and Triglycerides (fats) in the blood; increases the blood sugar; increases huger; may cause blurred vision or headaches; will cause some degree of "moon face" or rounding of the cheeks and some bloating of your belly; may cause insomnia and mood swings from depression to euphoria; may cause hand tremors; may cause acne.

Note
To decrease amount of calcium lost from your bones, you will be asked to take calcium and vitamin D or TUMS. It should be noted that, although there are many scary sounding side effects or Prednisone, you will notice most of them only when you are on high doses of the drugs like during periods of rejection. You will not necessarily have all of the side effects listed. If you do have any of the side effects or if you are worried about them, be sure to discuss it with the nurses and doctors. Heart-lung and single lung transplant patients will not start taking Prednisone until 2 weeks after surgery.

Cautions

• Never stop or reduce your Prednisone dose without the advice of your doctor.
• Take Prednisone with meals and antacids to avoid getting stomach ulcers.
• Eat leafy vegetables, bananas, whole grains, and citrus fruits to combat potassium loss.
• Eat a low cholesterol diet and control the amount you eat to avoid thickening of your blood vessels and weight gain.
• Exercise to help control your weight and to hold calcium in your bones.
• If your blood sugar gets too high, you may need to take insulin.
• Take good care of your skin.
• Protect your skin from the sun. Prednisone may increase the sensitivity of your skin to the sun, making you more prone to sunburns and sun poisoning. To guard against overexposure to the sun, you should always use a sunscreen with a high SPF.

Procardia (Nifedipine)

Dosage
From 10 mg to 30 mg 3-4 times a day. Procardia should NOT be taken on an empty stomach.

Action
Decreases the amount of calcium allowed to enter muscle cells of the blood vessels. Without calcium, the blood vessels relax and dilate, lowering blood pressure.

Side Effects
Dizziness, edema, nausea, weakness, headache, flushing, low blood pressure and fainting.

Vasotec (Enalapril Maleate)

Dosage
Dosage ranges from 5 mg to 40 mg once a day or divided into two doses a day.

Action
Used to treat high blood pressure. It acts by blocking the kidney from producing an enzyme which causes an increase in blood pressure.

Side Effects
Most common are: headache, dizziness, tiredness, diarrhea, rash, low blood pressure, cough and nausea. Less common effects: fainting, inability to sleep, nervousness, decreased sexual function.

Medication Side Effects

Medicines help. You will need to take transplant medicines for as long as you have the heart transplant. If you stop taking them, you could lose your transplant.

But transplant medicines are strong. Each has some side effects. These side effects are different in each person. The doctors will try to give you medicine that has the fewest side effects for you. Here are some problems you should be aware of:

1. The biggest problem with any of the transplant medicines is that they make it hard for your body to fight off infections.
2. Also, transplant medicines can make you more likely to get some types of cancer, mostly cancer of the lymph glands and skin cancers.

Your doctors will try very hard to make sure your body gets enough transplant medicine to keep your new heart or lung healthy. At the same time, they will try to keep you from having infections and getting cancer.

CVS Pro-Care Lifetime Program

CVS Pro-Care is a comprehensive medication program for organ transplant recipients. This is an excellent program for several reasons:

• Every month, you will receive your entire month's supply of medications in one package.
• There is no delivery charge.
• Any changes or additions to your medications will be mailed to you with 24 hours of notifying CVS Pro-Care.
• You will never need to worry about medication bills since CVS Pro-Care works directly with your insurance company.
• CVS Pro-Care accepts whatever your insurance company pays as payment in full for your medication.

To begin receiving CVS Pro-Care Lifetime Service, simply call them and tell them you are a transplant recipient. Have your insurance information on hand. The only other step is to have the doctor or the nurse coordinator call CVS Pro-Care.

CVS Pro-Care Lifetime Program
600 Penn Center Blvd, Suite 400
Pittsburgh, Pennsylvania 15235

Telephone:
In Pennsylvania: (800) 231-7828
Out-of-state: (800) 238-7828
Fax: (800) 426-9613
International, call collect.

If You Have Problems Paying for Your Medicine

If you have problems paying for your medicine, tell the doctor. The cost of transplant medicine is very high. Most health plans will cover the costs of medicine for a certain amount of time.

If you worry that you cannot pay for your medicine, tell your transplant team right away. They may be able to make some changes in your medicine. Also talk to the social worker at the transplant center.

Vitamins , Minerals and Anitobiotics

• Bactrim
  Acts to prevent pneumocystis carinii pneumonia is one of the opportunistic infections frequently seen in patients taking immunosuppressive drugs. 
• Ferrous Gluconate
  An iron compound which works with folic acid. Your red blood cell is usually low after transplant surgery due to blood loss during the surgery. 
• Folic Acid
  Works with iron to increase your red blood cell count. Also prevents folic acid deficiency for those on Imuran. 
• Nystatin (Mycostatin)
  Works to decrease the growth of opportunistic fungus infections in the mouth and digestive tract while you are on high doses of immunosuppressive drugs. 
• Prenatal vitamin
  General replacement of essential vitamins. 

Bactrim

Dosage
One double strength (DS) tablet once a day.

Action
It acts to prevent pneumocystis carinii pneumonia is one of the opportunistic infections frequently seen in patients taking immunosuppressive drugs.

Side effects
It interacts with cyclosporine and may actually lower your cyclosporine blood level. This might make it necessary to raise your cyclosporine dosage. Bactrim may also cause nausea and vomiting, but this is rare.

Ferrous Gluconate

Dosage
300 mg by mouth three times a day.

Action
An iron compound which works with folic acid. Your red blood cell is usually low after transplant surgery due to blood loss during the surgery. Together, iron and folic acid give your body the nutrients it needs to produce more red blood cells. Iron is given only until your blood count returns to normal after surgery.

Side effect
Constipation.

Folic Acid

Dosage
1 mg by mouth once a day.

Action
Works with iron to increase your red blood cell count. Also prevents folic acid deficiency for those on Imuran.

Side effects
None.

Nystatin (Mycostatin)

Dosage
5cc four times a day -- swish and swallow.

Action
Works to decrease the growth of opportunistic fungus infections in the mouth and digestive tract while you are on high doses of immunosuppressive drugs.

Note
You may stop taking this drug once you are down to a maintenance level of Prednisone. Check with your doctor about when you can stop taking this drug.

Prenatal Vitamin

Dosage
1 tablet per day.

Action
General replacement of essential vitamins.

Side effects
Generally safe as long as you do not "overdose" or take "mega doses" (doses that are much greater than the recommended daily allowance over a long period of time).

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Source: USC Cardiothoracic Surgery

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