Medications to Prevent Rejection After Liver Transplantation

Resource Category: Medical Complications and Future Medical Needs, Immunosuppression, Supported by American Legion Child Welfare Foundation Grant

Resource Type: Info Sheet

Age of Child: <5, 6-12, 13+

Years Since Transplant: <2, 3-5, 5+

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Guide to Medications

For each medication the guide will review: How it Works, How to Take it, Storage, Side Effects, Lab Tests, and any Food and Medication Interactions

Introduction

Medications are very important after liver transplant to prevent your child’s body from attacking the new liver and trying to reject it. The medications used to prevent rejection are known as “immunosuppression”, “immunosuppressive”, or “anti-rejection” drugs.
Your child will be on several medicines depending on what is best for their body. These medicines and doses may change overtime.
Right after transplant, your child’s body is most unfamiliar with the new liver and will be more likely to reject, so bigger doses of these medicines will be needed. Over time, the chance of rejection typically goes down, and the amount of medicine needed will also become less.
- It is very important to remember that, even as the doses get smaller, your child will need to take the medicines regularly, according to the transplant team’s instructions, to always protect the liver from rejection.
Some side effects may happen because of these medicines, especially at bigger doses. These side effects do not happen to everyone, but it is always good to know and look out for them so you can tell your transplant team if you notice anything. Together we can take the best care of your child’s new liver.
To know the amount of some of the medicines in your child’s body, we can measure the amount with a blood test.
Most medicines only last a few hours in the body so if a dose is taken late or not taken at all, the liver will not be properly protected until the next dose is taken.
- It is very important that your child takes the medicines at the same time and in the same way to make sure you are always protecting your liver from rejection
It is always important that you have a way to remember what medicines and doses your child is taking. Different ways such as medication lists, phone apps, and internet sites can help you to not forget your child’s medicines and to take them at the right times.
We will talk to you about many medicines used to stop rejection from happening. It is important to follow your transplant team’s advice as each patient’s plan is made just for them and will be different from other patients. Please contact your transplant team if you are concerned about your child’s anti-rejection plan.

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TACROLIMUS

Tacrolimus is an immunosuppression medicine that prevents rejection. Tacrolimus has many nicknames such as Tac, Tacro, Prograf®, FK, and FK506.

How it Works

Tacrolimus prevents the body from making the white blood cells that attack your new liver.

How to Take it

Tacrolimus should be taken on time, at the same time each day, usually 12 hours apart. A few special formulations may be taken once daily.

It should be taken the same way every time, usually by mouth, but in some patients through a feeding tube or under their tongue.

Taking Tacrolimus in the same way includes the form (liquid, capsule, powder) and how it is taken (with or without food).

Tacrolimus is classified as a hazardous medication. It is always recommended for those other than the patient to wear gloves when handling Tacrolimus.

For patients that use the liquid:

Shake the medicine very well usually for more than one minute before giving it. If giving the liquid medicine by mouth, plastic toys, bottles, pacifiers and anything else plastic that may be put in the mouth should be avoided for 30 minutes after giving the medicine because tacrolimus sticks to plastic and your child may not get the full effect of the medicine. If giving liquid medicine through a feeding tube, your transplant team will tell you how to help prevent the medicine sticking to the inside of the tube. It is important to not use plastic containers, spoons, or medication syringes other than what your pharmacy gives you to give the medication.

For patients that use the granules:

Empty the contents of each packet into a glass or ceramic (non-plastic) cup and mix with 15 to 30 mL (1 to 2 tablespoons) of room temperature drinking water. Use whole packet(s) to prepare, adding additional 0.2 mg packets if necessary. The granules will not dissolve completely. If drawing it up, use a syringe provided by the pharmacy and avoid plastic utensils.

For patients taking it under the tongue:

Hold the powder or capsule under the tongue for at least 15 minutes until fully dissolved. Try not to let your child put plastic in their mouth for at least 30 minutes after.

Missed Dose

If you miss a medication dose and it is less than 4 hours after medication administration time, take the medication as soon as you notice. If it has been more than 4 hours after medication administration time, ask your transplant team for instructions.

Storage

All formulations should be stored at room temperature away from moisture, light and heat.

Side Effects

Tacrolimus has a few side effects that could happen that are listed below. Your transplant team will look out for these side effects. One of the ways your team can find these side effects is on the blood test results, so it is important to come in for labs and clinic visits when arranged and on time.

Side effects that may occur:

Changes in blood chemistry
Increased cancer risk
Kidney damage
High blood sugar and diabetes
High blood pressure
Tremors · Headaches
Fluid retention
Seizures

All transplant patients have a greater chance than others of getting skin cancer, so it is very important to wear sunscreen (SPF 30+) when going out in the sun for longer than 10 minutes and to get yearly skin checks from your doctor.

Lab Tests

We measure the amount of tacrolimus in your body with a blood test. We measure a level to make sure there is enough medication to prevent rejection, but not too much to cause side effects or increase chance of infection.

The blood is drawn 30 minutes before your usual tacrolimus dose, so it is important you get to the lab earlier, maybe 45 min to 1 hour before your dose. For an example, if your dose is at 9 am you should arrive at 8 am for your level to be drawn at 8:30 am.

Always bring your medicines with you when getting your labs to make sure you can take them when they are due after the level is drawn.

Food and Medication Interaction

Food and Drink

Tacrolimus is affected by grapefruit, grapefruit juices and a similar fruit that looks and smells like a grapefruit known as pomelo. These can cause your tacrolimus levels to be too high and damage your body. It is very important to avoid grapefruit and pomelo and all related products. Grapefruit items include drinks such as sodas (Squirt®, Mountain Dew®, Fresca®) and juices such as Sunny Delight® and Simply Orange® (grapefruit juices). It is always good to read packages and labels and avoid these products. It is very important to review other possible food interactions (including pomegranate) with your healthcare team.

Other Medicines

Tacrolimus can be affected by many medicines including vitamins, supplements, prescription medicines, natural remedies and essential oils. It is important to always talk to your transplant team before starting a new medicine even ones given to you by a local doctor or naturopath.

There is a group of medicines used for pain called NSAIDS (non-steroidal anti-inflammatory drugs). They include ibuprofen also known as Motrin®/Advil®, naproxen, also known as Aleve®, and ketorolac, also known as Toradol®. It is important to avoid these medicines as they increase the chance of kidney damage with tacrolimus. The best choice is to always take acetaminophen also known as Tylenol® for pain and contact your transplant team for other options.

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CYCLOSPORINE

Cyclosporine is an immunosuppression medicine that prevents rejection. It has nicknames based on brand such as Gengraf®, Neoral®, or Sandimmune®. It is important to stick to the same brand unless indicated by your transplant team.

How it Works

Cyclosporine prevents the body from making the white blood cells that attack your new liver.

How to Take it

Cyclosporine should be taken on time, at the same time each day, usually 12 hours apart. The brand of cyclosporine is important and should be consistent – let your team know if you are given something new or different.

It should be taken the same way every time, usually by mouth, but in some patients through a feeding tube or under their tongue.

Taking cyclosporine in the same way includes the form (liquid, capsule, powder) and how it is taken (with or without food).

Cyclosporine is classified as a hazardous medication. It is always recommended for those other than the patient to wear gloves when handling Cyclosporine.

For patients that use the liquid:

It is important to not use plastic containers, spoons, or medication syringes other than what your pharmacy gives you to take the medication. If giving the liquid medicine by mouth, plastic toys, bottles, pacifiers and anything else plastic that may be put in the mouth should be avoided for 30 minutes after giving the medicine because cyclosporine sticks to plastic and your child will not get the full effect of the medicine. If giving liquid medicine through a feeding tube, your transplant team will tell you how to help prevent the medicine sticking to the inside of the tube. If mixing with juice or water, room temperature makes it taste better.

For patients taking it under the tongue:

Hold the powder or capsule under the tongue for at least 15 minutes until fully dissolved. Try not to let your child put plastic in their mouth for at least 30 minutes after.

Missed Dose

Storage

All formulations should be stored at room temperature away from moisture, light and heat.

For patients taking the liquid:

Store liquid cyclosporine in its original container only and use within 2 months after opening.

For patients taking the capsules:

It is important to keep them in the special wrapping even if placing in a medicine box because the capsules dissolve with exposure to air, moisture, and light.

Side Effects

Cyclosporine has a few side effects that could happen that are listed below. Your transplant team will look out for these side effects. One of the ways your team can find these side effects in the blood test results, so it is important to come in for labs and clinic visits when arranged and on time.

Side effects that may occur:

Changes in blood chemistry
Increased cancer risk
Kidney damage
High cholesterol
High blood pressure
Gum swelling · Hair growth
Headaches
Tremor
Seizures

Lab Tests

We measure the amount of cyclosporine in your body with a blood test. We measure a level to make sure there is enough medication to prevent rejection, but not too much to cause side effects or increase chance of infection.

The blood is drawn 30 minutes before your usual cyclosporine dose, so it is important you get to the lab earlier, maybe 45 min to 1 hour prior to your dose. For an example, if your dose is at 9 am you should arrive at 8 am for your level to be drawn at 8:30 am.

Always bring your medicines with you when getting your labs to make sure you can take them when they are due after the level is drawn.

Food and Medication Interactions

Food and Drink

Cyclosporine is affected by grapefruit, grapefruit juices and similar fruit that looks and smells like a grapefruit known as pomelo. These can cause your cyclosporine levels to be too high and damage your body. It is very important to avoid grapefruit and pomelo and all related products. Grapefruit items include drinks such as sodas (Squirt®, Mountain Dew®, Fresca®) and juices such as Sunny Delight® and Simply Orange® (grapefruit juices). It is always good to read packages and labels and avoid these products. It is very important to review other possible food interactions (including pomegranate) with your healthcare team.

Other Medicines

Cyclosporine can be affected by many medicines including vitamins, supplements, prescription medicines, natural remedies and essential oils. It is important to always talk to your transplant team before starting a new medicine, even ones given to you by a local doctor or naturopath.

There is a group of medicines used for pain called NSAIDS (non-steroidal anti-inflammatory drugs). They include ibuprofen also known as Motrin®/Advil®, naproxen, also known as Aleve®, and ketorolac, also known as Toradol®. It is important to avoid these medicines as they increase the chance of kidney damage with cyclosporine. The best choice is to always take acetaminophen also known as Tylenol® for pain and contact your transplant team for other options.

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MYCOPHENOLATE

Mycophenolate is an immunosuppression medicine that prevents rejection. It is often called by the nickname MMF or by the brand name Cellcept®. There is also a different form of the same medication that may be gentler on the gastrointestinal system known as Myfortic®. If you are on this your team may call it MMF or Myfortic®.

WARNING: Use of this medicine during pregnancy may cause birth problems or death of the unborn baby. Your team will talk with you and your child about this and importance of avoiding getting pregnant while taking this medicine. If your child could become pregnant, it is recommended to have your child use 2 types of birth control to prevent pregnancy while taking this drug. If your child gets pregnant or plans to get pregnant while taking this drug, call your healthcare team right away so that they can talk about next steps.

How it Works

Mycophenolate prevents the body from making cells that tell your body to attack your new liver.

How to Take it

Mycophenolate should be taken on time, at the same time each day, usually 12 hours apart.

It should be taken the same way every time including with or without food. It is preferred to take it without food, but If you have side effects including stomach aches or cramping, it may help to take it with food.

Mycophenolate is classified as a hazardous medication. It is always recommended for those other than the patient to wear gloves when handling mycophenolate.

For patients taking the liquid:

Shake the medication before giving. It may be given via tube but should not be mixed with other liquids before giving.

For patients taking the tablets or capsules:

You may be given smaller capsule or tablet sizes than your total dose. This is to allow us to increase and decrease the medications to the best amount for your body.

Please do not chew, cut, or crush tablets or capsules.

Missed Dose

Storage

All formulations should be stored at room temperature away from moisture, light and heat.

For patients taking the liquid:

The liquid can be stored in the fridge or at room temperature and it is only good for 2 months after the pharmacy makes it.

For patients taking the tablets or capsules:

Protect tablets and capsules from light – a pillbox or medicine bottle will work.

Side Effects

Mycophenolate has a few side effects that could happen that are listed below. Your transplant team will look out for these side effects. One of the ways your team can find these side effects in the blood test results, so it is important to come in for labs and clinic visits when arranged and on time.

Side effects that may occur:

Nausea
Diarrhea/ Constipation
Fluid Retention
Ulcers
High blood sugar · Decreased blood counts
Increased infection risk
Upset Stomach
High blood pressure

Lab Tests

We measure the amount of mycophenolate in your body with a blood test. We measure a level to make sure there is enough medication to prevent rejection, but not too much to cause side effects or increase chance of infection.

Always bring your medicines with you when getting your labs to make sure you can take them when they are due after the level is drawn.

Food and Medication Interactions

Mycophenolate can be affected by some medicines including those that change your stomach acid amount such as antacids, including over the counter options like Maalox® or omeprazole, for example. Your doctor may recommend you stay on medications that do reduce stomach acid. It is important to always talk to your transplant team before starting a new medicine, even ones given to you by a local doctor or naturopath.

Mycophenolate can be given with or without food, please check with your team for recommendations on which may be preferred for you.

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SIROLIMUS

Sirolimus is an immunosuppression medicine that prevents rejection. Some people may call sirolimus by its brand name Rapamune®.

How it Works

Sirolimus prevents the body from making the white blood cells that attacks your new liver. Sirolimus also prevents the body from making antibodies that also damage your new liver.

How to Take it

Sirolimus should be taken every day at the same time, usually once daily or every 12 hours. Sirolimus may be taken with or without food, but it should be taken the same way every time to keep the medication amounts in your body consistent.

Sirolimus is classified as a hazardous medication. It is always recommended for those other than the patient to wear gloves when handling sirolimus.

For patients that use oral solution either by mouth or through tube:

Oral: Use an amber oral syringe to take the right amount of medicine from the bottle. Mix this medicine with at least 2 ounces or ¼ cup of water or orange juice in a glass or plastic cup. No other liquids should be used to mix. Mix the liquid and medicine well and drink the sirolimus mixture right away. Then refill the same cup with another 4 ounces or ½ cup of water or orange juice; mix well and drink this remaining solution right away. If 2 ounces or ¼ cup of water/orange juice is too much, please contact your transplant team for directions.

Feeding tube: Use an amber oral syringe to take the right amount of medicine from the bottle. Mix this medicine with at least 2 ounces or ¼ cup of water in a glass or plastic cup. No other liquids should be used for dilution. The sirolimus mixture should be given right away through the feeding tube.

Missed Dose

Storage

For patients taking tablets:

Store at room temperature away from moisture and light. Do not store in a bathroom. Do not take this medicine out of the blister pack until you are ready to take it. Take this medicine right away after opening the blister pack. Do not store this medicine out of the blister pack for future use including in pillboxes or medication containers.

For patients taking the liquid:

Store in a refrigerator, but do not freeze. After bottle is opened, throw away any part not used after 1 month. Solution may look hazy when refrigerated; bring to room temperature and shake gently until the haze goes away. If solution is drawn up in a syringe, the solution may be stored at room temperature or in a refrigerator for up to 24 hours.

This drug can also be stored at room temperature; if stored at room temperature, throw away any part not used after 15 days.

Side Effects

Sirolimus has a few side effects that could happen that are listed below. Your transplant team will look out for these side effects. One of the ways your team can find these side effects in the blood and urine test results, so it is important to come in for labs and clinic visits when arranged and on time.

Side effects that may occur:

May affect wounds healing
High blood pressure
High cholesterol and triglyceride levels
Proteinuria
High blood sugar
Low platelet counts
Anemia · Headaches
Edema
Skin rash
Constipation or diarrhea
Increased risk of skin cancer
Increased risk of infection

All transplant patients have a greater chance than other people of getting skin cancer from sunburn, so it is also very important to wear sunscreen (SPF 30+) when going out in the sun for longer than 10 minutes and to get yearly skin checks from your doctor.

Lab Tests

We measure the amount of sirolimus in your body with a blood test. We measure a level to make sure there is enough medication to prevent rejection, but not too much to cause side effects or increase chance of infection.

The blood is drawn 30 minutes before your usual sirolimus dose, so it is important you get to the lab earlier, maybe 45 min to 1 hour prior to your dose. For an example, if your dose is at 9 am you should arrive at 8 am for your level to be drawn at 8:30 am.

Always take your medicines with you when getting your labs to make sure you can take them when they are due after the level is drawn.

Food and Medication Interactions

Food and Drink

Sirolimus is affected by grapefruit, grapefruit juices and a similar fruit that looks and smells like a grapefruit known as pomelo. These can cause your sirolimus levels to be too high and damage your body. It is very important to avoid grapefruit and pomelo and all related products. Grapefruit items include drinks such as sodas (Squirt®, Mountain Dew®, Fresca®) and juices such as Sunny Delight® and Simply Orange® (grapefruit juices). It is always good to read packages and labels and avoid these products.

Other Medicines

Sirolimus can be affected by many medicines including vitamins, supplements, prescription medicines, natural remedies and essential oils. It is important to always talk to your transplant team before starting a new medicine, even ones given to you by a local doctor or naturopath.

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AZATHIOPRINE

Azathioprine is an immunosuppression medicine that prevents rejection. It is also sometimes called by its brand name Imuran®.

WARNING: Use of this medicine for a long period of time may increase your child’s chance of cancer.
Lymphoma and other cancers including hepatosplenic T-cell lymphoma have happened in patients on long-term azathioprine. Most of the time, these cases happened in male teenagers or young adults. Most of these patients were using this drug to treat certain types of bowel problems which it was not approved for. Tell your child's doctor if your child has ever had any type of cancer. Your healthcare team will continually work with you to monitor and prevent this risk.

How it Works

Azathioprine works by slowing or preventing the production of new cells in your body’s immune system. It prevents these cells from attacking your new liver.

How to Take it

Azathioprine should be taken on time, at the same time each day, usually once a day. Sometimes it may be given twice a day to help decrease stomach upset. It can be given with or without food but giving it with food can decrease any nausea or stomach cramping.

Azathioprine is classified as a hazardous medication. It is always recommended for those other than the patient to wear gloves when handling azathioprine.

Missed Dose

Storage

All forms of this medication (tablet or liquid) should be stored at room temperature away from moisture, light and heat. Azathioprine comes in a tablet form which can be protected from light in a pillbox or medicine bottle.

Side Effects

Azathioprine has a few side effects that could happen that are listed below. Your transplant team will look out for these side effects. One of the ways your team can find these side effects in the blood test results, so it is important to come in for labs and clinic visits when arranged and on time.

Side effects that may occur:

Nausea
Stomach discomfort
Diarrhea
Decreased blood counts · Increased infection risk
Generalized weakness or tiredness
Increased liver function tests
Increased cancer risk including skin cancer

Lab Tests

Your healthcare team will need to draw blood for special tests before you can start azathioprine to make sure your body is able to safely take the medication. Your team will also continue to monitor your labs including blood counts to make sure you are on the right dose and medication for you.

Food and Medication Interactions

Azathioprine has less interactions than other immunosuppressant medication. However, it is always good to check with your healthcare team when starting something new to make sure new medications, supplements or vitamins do not interact with your azathioprine.

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PREDNISONE/PREDNISOLONE

Prednisone and prednisolone are known as steroids and are used for anti-inflammatory effects in many health problems like allergy, asthma, or skin rashes. This is not a list of all health problems that this medicine may be used for. After transplant, this medicine is used to treat and prevent rejection.

How it Works

Prednisone and prednisolone suppress the immune system by reducing activity and volume of lymphatic system. They are usually used with other immunosuppression medicine to prevent the body from attacking your new liver.

How to Take it

Prednisone/prednisolone should be taken every day at the same time. Take after meals or with food or milk to decrease stomach upset.

Missed Dose

Storage

All formulations should be stored at room temperature away from moisture, light and heat. Prednisone comes in a tablet form which can be protected from light in a pillbox or medicine bottle. Prednisolone comes in a bottle as a liquid which should be stored in its original container.

Side Effects

Prednisone/prednisolone has a few side effects that could happen that are listed below. Your transplant team will look out for these side effects. One of the ways your team can find these side effects in the blood test results, so it is important to come in for labs and clinic visits when arranged and on time.

Side effects that may occur:

High blood pressure
Body fluid retention
Increased appetite
Weight gain
Upset stomach
High blood sugar
Changes in blood chemistry · Trouble sleeping
Mood changes
Sweating a lot
Dizziness or headache
Trouble breathing
Glaucoma, cataract
Low bone density

Lab Tests

Your healthcare team will draw blood to check blood chemistry to make sure you are on the right dose and medication for you.

Food and Medication Interactions

Prednisone/prednisolone has less interactions than other immunosuppressant medication. However, it is always good to check with your healthcare team when starting something new to make sure new medications, supplements or vitamins do not interact with your medicine.

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BASILIXIMAB

Basiliximab is an immunosuppression medicine that prevents rejection usually given right after transplant in the hospital. It is also sometimes called by its brand name Simulect®.

How it Works

Basiliximab prevents activation of the cells that tell your body to attack your new liver.

How to Take it

This medicine is given by your nurse or healthcare team directly into your vein as an infusion right after transplant. It will usually be given over 20 or 30 minutes but can be given longer if it makes you nauseous.

Storage

Basiliximab should be given as soon as possible after being made by the hospital pharmacy. All formulations should be stored at room temperature away from moisture and heat and given within 24 hours of being made.

If you are receiving this medication at home, talk with your child's doctor, nurse, or pharmacist about how to store it.

Side Effects

Basiliximab has a few side effects that could happen that are listed below. Your transplant team will look out for these side effects. One of the ways your team can find these side effects in the blood test results so they will be monitoring your labs while you are in the hospital.

Side effects that may occur:

Headache
Stomach discomfort
Diarrhea/ Constipation
Difficulty sleeping · Acne
Decreased blood counts
Increased risk of infection
Changes in blood chemistry

Lab Tests

Your healthcare team will monitor your labs after transplant to make sure the medicine works and that you are not having any side effects.

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RABBIT ANTI-THYMOCYTE GLOBULIN

Rabbit Anti-thymocyte Globulin is an immunosuppression medicine that prevents your body from rejecting a transplanted liver. It is also used to treat severe rejection. Some people may call this medicine ATG, Thymoglobulin, or Thymo.

How it Works

ATG attacks one type of immune cells to suppress your immune system so that your body will not attack your new liver.

How to Take it

This medicine is given by your nurse or healthcare team directly into your vein. You will most likely receive this medicine in the hospital or a clinic right after transplant or when you have rejection. You may be given other medications with this medicine to help prevent reactions or side effects. It is usually given over 4-6 hours.

Side Effects

ATG has a few side effects that could happen that are listed below. Your transplant team will look out for these side effects. One of the ways your team can find these side effects is in blood test results, so it is important to come in for labs and clinic visits when arranged.

Side effects that may occur:

Allergic reaction. If you have an allergy to rabbits, please let your team know.
High blood pressure
Changes in blood chemistry
Changes in blood cell counts
Increased risk of infection · Headaches
Muscle pain
Fever

Lab Tests

Your nurse will check blood pressure, temperature, pulse, breathing rate and oxygen levels before, during, and after receiving this medicine.

Your healthcare team will also draw blood to check blood chemistry and blood cell counts.

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This information should not replace medical advice from your doctors or medical team. We encourage our readers to follow their transplant team's medical advice and reach out to their doctors and medical team for further recommendations.