Transplant Flashcards
(21 cards)
Thymoglobulin
Induction and rejection therapy
- lymphocyte depletion
- SE: Leukocytopenia, thromybocytopenia, Fever and chills (can pre-medicate with diphenhydramine)
Alemtuzumab
off label use for SOT induction
- Causes profound depletion of T cells
- Infusion-related reactions: Chills, rigors, fever
Monitor WBC, Platelets, ALC, and vitals
Induction therapy monitoring (same for all drugs)
Monitor WBC, Platelets, ALC, and vitals
Basiliximab
what does it do and who is it reserved for
- NON-lymphodepleting (wont knock out T and B cells)
Reserved for patients
- Hx of malignancy
- high infection risk, immunocompromised
- HIV, untreated HCV
- Advanced age (>65)
Maintenance options
Calcineurin inhibitors (best option)
Antimetabolites
mTOR inhibitors
Corticosteroids
T-cell Co- stimulation blockers
Cyclosporin (Calcineurin inhibitor=CNI)
Typically try to avoid IV formul,ation due to nephrotoxicity
Metabolized through p-glycoprotein and CYP3A4- EXAM
Tacrolimus (FK) (CNI)
Preferred over cyclosporin
Has a immediate release and extended
- better adherence with extended as its once daily dosing and not BID like the immediate
Different conversions from IR vs ER
50x more potent than cyclosporine
Cyclosporine AEs
- hypertension
- Hypercholesterolemia
- Hypertriglyceridemia
- Gingival hyperplasia
- Hirsutism
Tacrolimus AEs
- neurotoxicity (HA, insomnia, dizziness)
- Hyperglycemia, post transplant diabetes
- Alopecia
CNI drug interactions
CYP inducers LOWER cyclosporin or tacrolimus concentration (ex: rifampin, phenobarbital)
CYP inhibitors will INCREASE cyclo/tacro concentrations (Erythromycin, Clarithromycin, Azoles)
Cypro/Tacro dose adjustment?
Is it needed for liver or renal dysfunction
Liver - dose alteration is needed
Renal - no dose adjustment needed
Azathioprine AEs
GI - N/V/D
Bone marrow suppression
Interacts with allopurinol and febuxostat when taken together it will increase toxicity of azathioprine
Mycophenolic Acid
Most commonly used adjunct agent with CNIs
FDA prego category D - must have REMs sign up and patient must be on 2 forms of birthcontrol
Sirolimus and everolimus
Metabolism, what they are approved for, and AEs
Metabolism: CYP3A4 and P-glycoprotein
Sirolimus is approved for Kidney transplant rejection
Everolimus approved for Kidney and liver rejection
Edema, Hyperlipidemia, Hypertriglyceridemia, impaired wound healing, mouth ulcers, proteinuria
NEVER USE immediately after transplant due to the impairment in wound healing
Methylprednisolone, Prednisone, Dexamethasone
original cornerstone
- some transplant centers utilize early steroid withdrawal or steroid free regimens
T-cell co-stimulation blocker - Belatacept
Contraindicated for use in liver transplant
Routinely Q4 weeks at an infusion clinic = guaranteed adherence
Can use with CNI or can replace (like if patient was to have nephrotoxicity with CNI)
contrainidicated in EBV seronegative patients
Triple drug regimen MOST COMMONLY USED
Tacrolimus
Mycophenolate
+/- prednisone
what to consider when choosing therapy?
Organ dependent
Avoid CNIs in renal problems
- could use sirolimus + Mycophenolate or Azathioprine + corticosteroids
Acute Cellular rejection treatment (T cell mediated)
Mild to moderate: Methylprednisolone x 3-5 days
Moderate to severe: rabbit antithymocyte x 6-7 days
- if refractory alemtuzumab
Antibody mediated rejection treatment (B cell mediated)
Steroid + Rituximab + IVIG (IV immunoglobulin?)
Infection Tx for
CMV, fungal, PJP
CMV - valgancyclovir
Fungal - posaconazole
PJp - Bactrim or atovaquone if sulfa allergy)
