Transplant Overview + Drugs

Question 1

mycophenolate

Answer 1

First-line Antiproliferative agent

MOA: inhibits T-lymphocytes proliferation by altering purine synthesis
Class: antiproliferative agent
Brands: CellCept & Myfortic not interchangeable
SE: causes diarrhea (less with myfortic bc enteric coated
Notes: CellCept IV - D5W only; decrease PO contraceptives

Question 2

tacrolimus

Answer 2

First-line CNI

MOA: inhibits T-lymphocyte activation
Class: calcineurin inhibitor
Brands: Prograf (w/ or w/o food); Astagraf XL (oes)
SE: increase BP/BG, neuro/nephrotoxic, QT prolongation, hyperlipidemia
Notes: IV must be administered in non-PVC bag; CYP3A4 and P-gp substrate

Question 3

Which agent is associated with a genetic deficiency of thiopurine methyltransferase (TPMT) and increase risk for myelosuppression?

Answer 3

azathioprine (Azasan, Imuran)

Question 4

antithymocyte globulins

Answer 4

MOA: binds to T-lymphocytes (killer cells) and interferes with their function
Agents: Atgam - Equine | Thymoglobulin - Rabbit
SE: infusion-related rxns
Notes: premedicate (diphenhydramine, APAP, steroids) to lessen rxn

Question 5

induction immunosuppressants

Answer 5

1) basiliximab, IL-2 receptors antagonists
2) antithymocyte globulin (higher risk of rejection)
3) maintenance drugs at higher doses

Question 6

Maintenance immunosuppressants

Answer 6

1) CNI (1st tacrolimus; 2nd cyclosporine)
2) Adjuvants w/ CNIs
- antiproliferative agents (mycophenolate or azathioprine) -mTOR inhibitors (everolimus or sirolimus)
- belatacept
3) Steroids

Question 7

azathioprine is metabolized by

Answer 7

xanthine oxidase inhibitors

*avoid allopurinol and febuxostat

Question 8

Highest risk of nephrotoxicity

Answer 8

tacrolimus and cyclosporine

Question 9

Highest risk of increased BG

Answer 9

tacrolimus
steroids
cyclosporine
mTOR inhibitors (everolimus, sirolimus)

Question 10

Highest risk of worsened lipid parameters

Answer 10

mTOR inhibitors (everolimus, sirolimus)
steroids
cyclosporine

Question 11

Highest risk of increased BP

Answer 11

tacrolimus
cyclosporine
steroids

Question 12

All transplant patients must self-monitor for symptoms of infection:

Answer 12

1) Fever of 100.4F (38C) or higher (lower in elderly), chills
2) Cough, more sputum or change in color, sore throat
3) Pain with passing urine, ear or sinus pain
4) Mouth sores or a wound that does not heal

Question 13

Important vaccines

Answer 13

1) inactivated influenza - annually
2) inactivated pneumococcal (1st PCV13; 2nd PPSV23 - 8 weeks later); then PPSV23 5 years later
3) Varicella - pretransplant ONLY; pt’s close contacts too

**no live vaccines given POST-transplant

Question 14

Organ transplant complications

Answer 14

1) infection risk - prophylactic drugs used in HIV against OI
2) cancer risk - skin cancer is common (use sunscreen)
3) acute rejection - use high-dose steroids
4) CVD - metabolic syndrome (BP, BG, lipid, wt)

Question 15

Opportunistic Infections in Transplant patients

Answer 15

1) pneumocystis jirovecii pneumonia
2) Candida
3) CMV