What are immunosuppressant drugs?

They are prescribed medications given to solid organ transplanted patients to protect their ‘new’ liver. The immune system in our body protects our body by producing antibodies to fight foreign bodies and germs that cause illnesses or infections. Unfortunately, it also sees the transplanted organ as a foreign body and it will try to attack (reject) it. This complication of rejecting the ‘new’ liver is fatal to the transplanted patient. To prevent this, immunosuppressant drugs are given to suppress the immune system and producing lesser antibodies to attack it. Most immunosuppressant drugs are taken long-term.

Medications After Liver Transplant

Immediately upon transplant, immunosuppressant drugs are administered through IV so as to prevent the onset of rejection. During your hospital stay, your transplant coordinator will explain the medications that you will have to take for life together with general medicines and supplements, and a medication schedule that is part of the post-transplant file. You will learn:

1. The name and purpose of each medication;
2. When to take each medication;
3. How to take each medication;
4. How long to continue taking each medication;
5. Side effects of each medication;
6. What to do if you forget to take a dose;
7. When to refill your medications;
8. How and where to obtain your medications and
9. What to avoid while taking the medications.

Some of these medications are used in many different combinations to prevent rejection of your new liver. These medications can have adverse reactions and produce side effects. Some side effects are more common than others. However, knowing and discussing the potential side effects in advance can be helpful in the management of them. Before your discharge from the hospital, your transplant coordinator, the transplant nurse and the pharmacist will give you a comprehensive pamphlet on the medications, the dosages and expectations.

DRUG	FUNCTION	SIDE EFFECTS
Sandimmune/ Neoral/ Sandimmune Microemulsion (Cyclosporine)	An immunosuppressant; Prevents rejection of liver; Capsule or syrup form	Seizures Headaches Confusion Tremors Numbness, tingling and/ or pain extremities of hands/ arms/ legs/ feet and mouth Hot flushes Swollen gums (gum hypertrophy) Difficulty in speaking High blood pressure (hypertension) Increased potassium in bloodstream, leading to irregular heartbeat Elevated cholesterol levels Fluid retention Low urine output (kidney toxicity) Excessive growth of body hair Oily skin Diarrhoea Muscle and joint pain
Prograf (Tacrolimus/ FK 506)	An immunosuppressant; Prevents rejection of liver; Capsule form	Seizures Headaches Confusion Tremors Numbness, tingling and/ or pain extremities of hands/ arms/ legs/ feet and mouth Hot flushes Swollen gums (gum hypertrophy) Difficulty in speaking High blood pressure (hypertension) Loss of appetite Nausea High blood sugar (if you are diabetic, you may require alteration of your diabetic medication)
Sirolimus Oral Solution (Rapamune)	An immunosuppressant; Prevents rejection of organ; Given to patient with liver cancer with aim of decreasing the risk of recurrence; Prescribed only after the 1st month as it impairs wound healing; Liquid form	Headache Nausea/ Vomitting Hyperlipidaemia High cholesterol or triglyceride levels Low white blood cell count Low platelet count Low red blood cell count (anaemia) High blood pressure (hypertension) Diarrhoea Acne/ rash Abdominal/ back pain
Prednisolone	Steroid; Prevents rejection of the liver; Capsule form	High blood pressure (hypertension) High blood sugar stomach irritation (if you are diabetic, you may require alteration of your diabetic medication) Insomnia Mood swings (irritability, depression) Stomach irritation/ ulceration Weak muscle/ muscle loss Bloated face Fluid and salt retention (feeling bloated, swollen ankles) Increased appetite/ weight gain Skin easily bruised or sunburnt Acne Cataracts Brittle dry hair
Imuran (Azathioprine)	An immunosuppressant; Prevents rejection of organ; Given in addition to cyclosporine	Low white blood cells count Easy bruising Mouth ulcers Hair loss
Mycophenolate Mofetil	Cellcept; Prevents rejection of the liver; Given only if patient exhibits intolerance of cyclosporine	Stomach irritation Pancreatitis Abnormal liver function tests Low white blood cell count Low red blood cell count (anaemia) Low platelet count Headaches Nausea Poor appetite/ weight loss Diarrhoea

In the ACLDT, we utilize a variety of agents that target novel pathways. Our immunosuppression protocols utilize combination of these agents which allows lower dosing and least side effects. In special circumstances, we utilize induction therapy using Simulect® to reduce the likelihood of subsequent rejection at the same time avoiding the early toxicity of calcineurin inhibitors. Simulect® or basiliximab is a monoclonal antibody (IgG1K) produced by recombinant DNA technology. It binds to and blocks interleukin-2 receptor á-chain (also known as CD25 antigen) on the surface of activated T-lymphocytes. This prevents the body's own lymphocytes from attacking the newly transplanted liver.



Optimal iatrogenic immunosuppression is the level of drug therapy that achieves graft acceptance with least suppression of systemic immunity. Although not entirely eliminated, the spectrum of toxicities is minimized. Achieving this goal may vary widely and depend on timing, dosing and selection of immunosuppressive medications.

These drugs are absorbed within your intestines. Therefore continuous vomitting and diarrhoea may result in poor absorption leading to possibility of rejection. If you vomit within 1 hour of taking your medications, you must take them again. If you vomit more than 1 hour later, then you do not need to retake them.

Diarrhoea can be a side effect of some of your medications but it may also indicate that you have an intestinal infection that should be treated. If you continue to vomit and are unable to hold down your medications and/ or have diarrhoea, you must contact your transplant coordinator immediately.



When you are scheduled to do blood tests at the clinic, please do not take your immunosuppressant drugs beforehand. This is because your dosage is determined by your blood level and these drugs may distort your blood level results. Take your immunosuppressant drugs after your blood is drawn. If you accidentally take your immunosuppressant drugs, please inform our clinic to postpone your lab tests to the next day. Depending on your lab results during your follow-up visits, the immunosuppressive drugs are reduced and finely adjusted in time. The cost of maintenance medications is dramatically reduced and the side effects of these agents become negligible over time.

Ideally, immunosuppressant drugs should be taken 12 hours apart to maintain steady blood levels. Missing your immunosuppressant drugs can trigger a rejection episode. Therefore, if you take your immunosuppressants late, it is advisable that you should have at least 8 hours between your current dose and the next dose to minimise side effects.

You should never double up any of your immunosuppressants to attempt to make up for the missed doses.

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