1. Neoral
2. Tacrolimus
3. Rapamune
4. Corticosteroids
5. Azathioprine
6. Cellcept
7. Myfortic
8. Zenapax
9. Simulect

When your body detects the liver graft as a foreign body, your immune system will start an attack against this “invader”. Immunosuppressive drugs weaken the response of your immune system and prevent rejection of liver transplant. However, immunosuppressive drugs also may make you more susceptible to infections. The dose of immunosuppressive drugs required to preserve functioning transplanted organ will be reduced in the first months following the surgery, resulting in decreased risk of infection. However, the immune system will need to be suppressed even after long years of transplant surgery. Therefore, you should not skip a dose or reduce the amount of drugs without consulting your doctor first.

Not all the patients undergone a liver transplant surgery use all the drugs. Therefore you should not worry if any of the immunosuppressive drugs is not included in your regimen.

The general information provided below should not be considered your physician’s opinion and specialty but only complementary. Consult your physician for further details.

Many side effects of the drugs listed below may be removed by temporary reduction or cessation of the drug. However, the drug must not be reduced ceased without clear instructions of your physician.

If you have any doubts when you are pregnant, immediately consult your doctor or transplant team.

Neoral / Cyclosporine (Sandimmune / Neoral )

The effectiveness of cyclosporine results from inhibition of activation of T-lymphocytes (a type of white blood cell), preventing attacks to your new liver. Neoral is often orally administrated in combination with azathioprine and/or corticosteroids. The concentration of cyclosporine circulating in your body can be measured by a blood test and the results can be used when determining when and how to adjust the dose if necessary.

Neoral Use

1. Neoral is taken daily with milk or apple juice at the same time of the day every 12 hours.
2. On the check visit day, deliver the first sample before Neoral dose (C0) and the second after the 2 hours of Neoral dose.
3. Do not store the cyclosporine in the fridge. Store your drugs away from daylight in a cool and dry place.
4. Neoral may interact with certain drugs used frequently. You must consult your doctor or transplant team before taking a new drug.

Side effects: Side effects include renal function anomalies, high blood pressure, gumhyperplasia, high blood glucose, hirsutism, and tremor. Most of these side effects can be avoided or reduced by reducing the dosage. You may not experience all or most of these side effects. The side effects will diminish in time when the dose is reduced.

Tacrolimus

As with cyclosporine, tacrolimus blocks the activation of T-lymphocytes and prevents them from attacking your new liver. Tacrolimus is often administrated in combination with azathioprine and/or corticosteroids. The concentration of tacrolimus circulating in your body can be measured by a blood test and the results can be used when determining when and how to adjust the dose if necessary.

Tacrolimus Use (capsules)

1. Tacrolimus is taken daily with milk or apple juice at the same time of the day every 12 hours.
2. On the check visit day, give your blood sample before taking Tacrolimus dose.
3. The capsules should be taken at least 1 hour or 2-3 hours before the meal, or after 2-3 hours.

Side Effects: Side effects include renal dysfunction, high blood pressure, sleep disturbances, high levels of blood glucose, numbness and tingling of hands and feet, and tremor. Tacrolimus may interact with certain drugs used frequently. You must consult your doctor or transplant team before taking a new drug.Most of these side effects can be avoided or reduced by reducing the dosage. You may not experience all or most of these side effects. The side effects will diminish in time when the dose is reduced.Rapamune (SIROLIMUS) Sirolimus is a mTOR inhibitor that inhibits the B and T lymphocytes, white blood cells, responsible for rejection. Its activity is different from Neoral and Tacrolimus and thus does not cause most side effects of these drugs such as renal toxicity, diabetes, and high blood pressure. The concentration of sirolimus circulating in your body can be measured by a blood test and the results can be used when determining when and how to adjust the dose if necessary.

How to Use: This tablet is (usually) taken once a day at the same time with or without meals. If cyclosporine is also prescribed with sirolimus for you, take this drug four hours after taking the dose of cyclosporine.

Side Effects: The most common side effects include nausea, diarrhea, oral ulcer, and acne. The levels of blood cholesterol and triglyceride may elevate but this elevation is regulated in time. Also, blood platelet or white blood cell counts have been reported to decrease. Most of these side effects can be avoided or reduced by reducing the dosage.

Missed Dose: If you miss a dose of sirolimus, take the missed dose as soon as you remember. If it is almost time for the next dose, skip the missed dose and take your next dose at the regular time. Do not take two doses of sirolimus.

Corticosteroids (Wysolone – Prednisolone)

Prednisolone is a corticosteroid that can be used lifelong for immunosuppression to prevent organ rejection, or for treatment of rejection with higher doses. The corticosteroids are naturally produced in the body in the cycle of 24 hours. You should take your corticosteroid drug in the morning to match with your natural rhythm of your body.

Use of Corticosteroids: Take your tablets with meals. If you take the tablets once a day, take it with breakfast in the morning.

Side Effects

Short-term side effects of corticosteroids include the followings:

1. Increased susceptibility to infections and poorly healed wounds
2. Suppression of response to normal fever and other symptoms of infection
3. Increased blood glucose particularly in patients with diabetes

Side effects of corticosteroids are related to long-term use of doses. When taken high doses, increased appetite and weight, change in distribution of body fat (development of cushinglike features – swollen face, rounding back), thinned skin and bones, muscle weakness, high blood pressure, gastritis, ulcer, reflux, diabetes, cataract, and increased formation of acnes.

Although this list may appear fearsome, these side effects will be very rare with relatively lower doses of corticosteroids used recently.

Azathioprine

Azathioprine acts by inhibiting ability of cells to divide. It is always used in combination with other immunosuppressant agents.

Use of Azathioprine: You may take the tablets at any time during the day but try to take your medicine at the same time of the day.

Side Effects: Adequate low doses of Azathioprine are safe to prevent organ rejection in most people. Cells of bone marrow are often divided and very susceptible to effects of azathioprine. The susceptibility of patients using azathioprine to infections may increase, and their hemoglobin, white blood cell or platelet counts may reduce. If the drug is ceased temporarily, the effects of azathioprine on bone marrow can be reversed.

Cellcept (Mycophenolate Mofetil)

Cellcept suppresses proliferation of lymphocytes which are critical to rejection (organ rejection).

Cellcept Use: Take this drug as prescribed, an hour before the meals on an empty stomach or two hours after the meals, twice a day. Swallow the capsule whole. Do not crush, chew or open the capsules.

Side Effects: This drug may cause dizziness, drowsiness, headache, nausea, vomiting, diarrhea, gas, tremor, change in mood, or vision changes. In addition, it may reduce the white blood cell or platelet counts in the blood. The physicians usually deal with these side effects by temporarily reducing the dose, or discontinuation of the drug.

Missed dose: If you miss a dose of cellcept, take the missed dose as soon as you remember. If it is almost time for the next dose, skip the missed dose and take your next dose at the regular time. Do not take two doses of cellcept to make up.

Myfortic

Myfortic has recently been developed as a new enteric coating formulation of the drug described above (mikofenolate sodium) to protect the upper digestive system thus reduce the stomach disturbance caused by Cellcept.

Zenapax (Daclizumab – Injection)

This medicine is a human monoclonal antibody binding IL2 receptor on the active lymphocytes. The drug inhibits the significant effect of IL2 receptors on proliferation of cells (lymphocytes), which causes rejection, and blocks the rejection (organ rejection). When administrated with other conventional drugs, this improves the role of these drugs in preventing rejection of organ transplant.

How to Use: This drug is first diluted in a saline solution in an appropriate proportion and then IV administrated. Administrate it 24 hours before the transplant, every 14 days, each in 15-minute period and 2-5 doses.

Side Effects: Nausea, vomiting, or stomach disturbance may occur. Also, allergic reactions (rash, itching, difficulty in breathing), headache, dizziness, chest pain, swollen arms or legs, cough, inadequate healing of wounds, and muscle pain have been reported.

Storage: The vials should be stored in the refrigerator at 2-8°C away from the direct daylight. It should not be shaken or frozen.

Simulect (Basiliximab – Injection)

This medicine is a murine-human chimeric antibody binding IL2 receptor on the active lymphocytes. The drug inhibits the significant effect of IL2 receptors on proliferation of cells (lymphocytes), which causes rejection, and blocks the phenomenon of rejection (organ rejection). When administrated with other conventional drugs, this improves the role of these drugs in preventing rejection of organ transplant.

How to Use: This drug is first diluted in a saline solution in an appropriate proportion and then IV administrated. It usually delivered in two doses: The first dose is delivered in two hours before the transplant surgery and the second dose is delivered 4 days after the surgery.

Side Effects: Nausea, vomiting, or stomach disturbance may occur. Also, allergic reactions (rash, itching, difficulty in breathing), headache, dizziness, fever, inadequate healing of wounds, visual problems, changes in the mood, irregular pulse have been reported.

Storage: The vials should be stored in the refrigerator at 2-8°C away from the direct daylight. It should not be shaken or frozen.