Managing your Medicines after Kidney Transplant Surgery Information for patients and families

You must take anti-rejection medicines every day to keep your new kidney working. When you skip doses, your body starts attacking the new kidney. It will be rejected and will no longer work.

These medicines can have potentially serious side effects. Read this document to learn about the possible side effects of each of your medicines.

These side effects can be distressing, but don’t be discouraged. There are things you can do to help manage the side effects. Remember that most people can tolerate the medicines very well. Talk to the team at the transplant clinic if you have any concerns.

Important things to remember

• Never stop your medicines or make changes by yourself.

• Do not take any medicines, supplements, herbs or vitamins without consulting your transplant team. These can interfere with the way anti-rejection medicines work.

• If you are prescribed medicine by other health care providers, ask them to check if the new medicine will interfere with your anti-rejection medicines. Bring a complete list of your medicines to all medical appointments.

73529 Dev. June16 2016 www.stmichaelshospital. com/programs/renaltransplant/ Pg 1 of 20 What if I need antibiotics?

Call the Transplant Clinic to find out if the antibiotic is safe to take with your anti- rejection medicines. If a doctor or dentist prescribes a medicine from the list below, please ask them to call the transplant clinic to discuss an alternative. These antibiotics are not safe for you: • Erythromycin (Eryc®) or Erythrocin • Clarithromycin (Biaxin®) • Rifampin (Rifadin®, Rofact®) • Ketoconazole

How do I keep track of my new medicines?

In the hospital, you will get a schedule to show you how to take your medicines. Use this calendar to keep track of your medicines.

Get comfortable with organizing your new medicines before you leave the hospital. If you do not fully understand how to take your medicines, please ask. We are here to help you.

Here are some ideas for keeping your medicines organized:

• Use a pill box to sort your medicines once a week.

• Ask your drugstore pharmacist, a family member or friend to help you sort your medicines. Your drugstore may be able to make blister packs for you, so that your medicines are already sorted by time of day, morning, noon or night.

• Set an alarm on your cell phone to remind you when to take your medicine.

• Bring a list of your medicines with you to all your medical appointments so you can write down any changes.

Pg 2 of 20 www.stmichaelshospital. com/programs/renaltransplant/ What should I do if I miss a dose of my medicine?

Take your medicine as soon as you remember that you missed taking it. However, if it is almost time for the next dose, never double the dose. For example, if you usually take Myfortic at 10 a.m. and 10 p.m. and you remember at supper that you did not take the morning dose, just take the normal evening dose.

If you vomit, take the medicine again if: • you can see the whole pill, or • you vomited less than 1 hour after taking the medicine

Otherwise, do not take it again.

Where do I get my medicines?

When you leave the hospital, you will get a prescription for a one-month supply of medicines. At the transplant clinic, you will get a prescription with enough refills for one year.

Always order your refills at the pharmacy at least 1 week before you run out of pills. You must get your cyclosporine (Neoral) at the St. Michael’s Prescription Care Centre. You can get other medicines at a pharmacy close to your home.

It is your responsibility to make sure you have enough medicine to last until your next appointment. The best time to get your prescription is at your clinic appointment. The transplant clinic does not renew prescriptions over the phone or on a walk-in basis.

You should continue to take medicines for other conditions such as diabetes, seizure disorders, heart or lung disease. Follow the instructions for these medicines from your family doctor or other specialist.

www.stmichaelshospital. com/programs/renaltransplant/ Pg 3 of 20 How much do I have to pay for my new medicines?

Anti-rejection medicines can cost up to $10,000 a year without drug insurance. If the burden of paying for medicines is too much, ask the transplant social worker for help.

What should I do with my medicines from before?

The doctors in the hospital will decide which of your old medicines you continue to take and which ones you should stop. Make sure they have a complete list of your medicines when you come to the hospital. Do not throw your old medicines in the garbage, in your toilet, or flush down the drain. This is bad for our environment. Take them back to your pharmacy to dispose of the medicines safely.

How should I store my medicines?

• Store your medicines in a location that is cool, dry and not in direct sunlight.

• It is a good idea to store your medicine in a location that you will easily see and remember to take them.

• Anti-rejection medicines are toxic. Keep them out of reach of children and pets.

• Women who are or may be pregnant should not handle your medicines.

Pg 4 of 20 www.stmichaelshospital. com/programs/renaltransplant/ Common transplant medicines

Tacrolimus (Advagraf®) What it’s for: Preventing rejection How to take it:

• Once daily at the same time every day, in the morning • May be taken with or without food but you must be consistent from day to day • Do not open, cut or break the capsules • Take only AFTER blood is drawn on days you are due for blood work • Dose will be adjusted based on your blood work results • Never eat/drink grapefruit, pomelo or Seville orange for as long as you are taking this medicine

What it looks like:

0.5 mg 1 mg 3 mg 5 mg Side effects: • Infections, higher chance of cancer • Increased risk of diabetes and high blood sugar • High blood pressure • Hand tremors, headache • Kidney toxicity • Hair thinning • High potassium levels, low magnesium levels

Other important information: Your medicine dosage may change frequently based on blood work results. You should have a supply of the 1 mg strength capsules at home to make it easier for you to change the dose. Tacrolimus can interact with many other medicines.

• Ask other healthcare provider(s) to check if newly prescribed medicines will interact with tacrolimus. • Double check with your transplant pharmacist if you are unsure about taking a new medicine. www.stmichaelshospital. com/programs/renaltransplant/ Pg 5 of 20 Cyclosporine (Neoral®) What it’s for: Preventing rejection How to take it:

• Take twice a day at 8 a.m. and 8 p.m. • On blood work days, make sure you get blood drawn exactly 2 hours after taking the medicine. Try to be as exact as you can. • Dose will be adjusted based on your blood work results • Do not take the medicine out of the foil package until you are ready to take it. Air and light will damage the pills. • Never eat/drink grapefruit, pomelo or Seville orange for as long as you are taking this medicine

What it looks like:

25 mg 50 mg 100 mg Side effects: • Infections, higher chance of cancer • Gum swelling • Increased risk of diabetes • High blood pressure, high cholesterol • Gout • Acne • Headaches • Too much hair on the face • Kidney toxicity • High potassium • Mild tremors

Pg 6 of 20 www.stmichaelshospital. com/programs/renaltransplant/ Other important information: Your medicine dosage may change frequently based on blood work results. You should have a supply of the 25 mg strength capsules at home to make it easier for you to change the dose.

You must fill cyclosporine prescription at the hospital outpatient pharmacy (Prescription Care Centre 416-864-5110).

Cyclosporine can interact with many other medicines.

• If you use more than one pharmacy, make sure the pharmacist is aware that you are on cyclosporine. • Ask other healthcare provider(s) to check if newly prescribed medicines will interact with cyclosporine. • Double check with your transplant pharmacist if you are unsure about taking a new medicine.

www.stmichaelshospital. com/programs/renaltransplant/ Pg 7 of 20 Mycophenolate Sodium (Myfortic®) or Mycophenolate Mofetil (CellCept®) What it’s for: Preventing rejection How to take it:

• Starting dosage is 2 tablets (720 mg Myfortic® or 1000 mg CellCept®) twice daily spaced 12 hours apart • Can also be taken 1 tablet (360 mg Myfortic® or 500 mg CellCept®) four times a day to reduce stomach upset • May take with or without food • Do not cut or break any tablets • Do NOT take any calcium, iron, magnesium or antacid products within 2 hours of this medicine

What it looks like:

Myfortic® 360 mg Myfortic® 180 mg CellCept® 500 mg CellCept® 250 mg Side effects: • Infections, higher chance of cancer • Diarrhea • Nausea, vomiting, stomach pain, heartburn • Low number of white blood cells

Other important information: This medicine causes birth defects. If you are considering becoming pregnant, please speak to your transplant doctor first.

Pg 8 of 20 www.stmichaelshospital. com/programs/renaltransplant/ Prednisone What it’s for: Preventing rejection How to take it:

• Take once daily in the morning with food • Prednisone is available in different strengths – make sure you know the dosage you should be taking

What it looks like:

Appearance may differ depending on the brand. 5 mg 50 mg Side effects: • Infections, higher chance of cancer • Increased risk of diabetes and high blood sugar • High blood pressure, too much fluid, ‘puffy’ ankles or face • Weight gain, increased appetite • Mood changes, difficulty sleeping • Weakening of bone, hip pain • Stomach ulcers or bleeding in the stomach • Cataracts, glaucoma • Easy bruising

www.stmichaelshospital. com/programs/renaltransplant/ Pg 9 of 20 Cotrimoxazole, Sulfamethoxazole-Trimethoprim (Sulfatrim®, Bactrim®, or Septra®)

What it’s for: Prevents infection (anti-rejection medicines make your immune system weaker) How to take it:

• Take 400/80 mg (1 tablet) once a day at the same time • Can be taken with or without food • Take with a large glass of water each time

What it looks like:

Appearance may differ depending on the brand. 400/80 mg 800/160 mg Side effects: • High potassium levels • Low number of white blood cells, platelets • Rash, skin becoming more sensitive to the sun • Stomach discomfort

Other important information: This medicine should be taken for 1 year after transplant

Pg 10 of 20 www.stmichaelshospital. com/programs/renaltransplant/ Dapsone What it’s for: Prevents infection (anti-rejection medicines make your immune system weaker) How to take it:

• Take 100 mg (1 tablet) once a day at the same time • Can be taken with or without food

What it looks like:

Appearance may differ depending on the brand. 100 mg Side effects: • Anemia (may cause damage to red blood cells) • Low number of white blood cells, platelets • Rash • Stomach discomfort

Other important information: • This medicine should be taken for 1 year after transplant • It is safe to use by patients with sulfa allergy • This medicine is not covered by Ontario Drug Benefit. If you have trouble paying for the medicine, contact the transplant pharmacist to get special approval for you

www.stmichaelshospital. com/programs/renaltransplant/ Pg 11 of 20 Pantoprazole (Pantoloc® or Tecta®), Rabeprazole (Pariet®) What it’s for: Prevents acid reflux (‘heartburn’) and stomach ulcers while on high dose prednisone How to take it:

• Take each morning approximately ½ hour before eating breakfast

What it looks like:

Appearance may differ depending on the brand. Pantoprazole 40 mg Rabeprazole 20 mg Side effects: • Well tolerated with short term use • Higher risk of low magnesium level, C. difficile infection, pneumonia, bone fracture with long term use

Other important information: Talk to your transplant doctor, nurse or pharmacist about if you can stop this medicine once you are on low-dose prednisone.

Pg 12 of 20 www.stmichaelshospital. com/programs/renaltransplant/ Valganciclovir (Valcyte®) What it’s for: Prevent CMV or EBV infection (anti-rejection medicines make your immune system weaker) How to take it:

• Must be taken with food • Take with the same meal every day

What it looks like:

450 mg Side effects: • Low number of white blood cells or platelets • Anemia

Other important information: • This medicine should be taken for 3-6 months after transplant. • As your kidney function improves, the dosage of this medicine may increase (to compensate for the extra amount removed by the kidneys). Your transplant doctor will instruct you. • This medicine is not covered by Ontario Drug Benefit. If you have trouble paying for the medicine, contact the transplant pharmacist to get special approval for you

www.stmichaelshospital. com/programs/renaltransplant/ Pg 13 of 20 What about over the counter medicines?

Over-the-counter (OTC) medicines are medicines that you can choose yourself in the drug store without a prescription from your doctor. They are used to help relieve various symptoms like headaches, pain, cough and allergies. If your symptoms do not improve in 2 or 3 days, start to get worse, or if you have a fever or chills, contact your doctor.

The information below tells you which medicines you can take and which medicines you should not take. Always follow the directions carefully and ask your doctor or pharmacist if you have any questions.

For pain, fever, and body aches:

Do not take non-steroidal anti-inflammatory drugs (NSAIDs) because they harm the kidney and can make high blood pressure worse. Some common NSAIDs are • ibuprofen (Advil®, Motrin®) • naproxen (Aleve®)

Avoid high doses of salicylates as they may also cause kidney problems. It is generally safe to use a low dose Aspirin (81 mg or 325 mg once daily) for prevention of heart disease and stroke.

For people with kidney transplants, acetaminophen (Tylenol®) is the best medicine for pain or fever. Do not take more than 4,000 mg a day (or 2,000 mg if you have liver disease). Many pain and cold medicines have acetaminophen, so check the labels for the dose in each medicine.

Pg 14 of 20 www.stmichaelshospital. com/programs/renaltransplant/ For sneezing, itching, and runny nose:

Antihistamines work well and are safe to use. They can make some people feel sleepy. The ones that cause the least sleepiness are: • loratadine (Claritin®) • fexofenadine (Allegra®) • cetirizine (Reactine®)

Diphenhydramine (Benadryl®) and chlorpheniramine are best used only as needed and at bedtime because they can cause drowsiness, dry mouth, blurry vision, and constipation. Talk to your doctor before using an antihistamine if you have glaucoma, an enlarged prostate or trouble urinating.

Avoid combination (multi-symptom) cold, sinus, and flu products. It is better to treat each symptom separately.

For nasal and sinus congestion:

Nose sprays work best for congestion. Nasal sprays such as oxymetazoline (Afrin®) or xylometazoline (Otrivin®) should not be used for more than 3 days. Using them for longer than 3 days can cause more congestion.

Sodium chloride nasal sprays can also help with congestion and are safe to use.

You should not use oral decongestants, such as pseudoephedrine (Sudafed®) and phenylephrine (Sudafed® PE) because they can raise your blood pressure. Make sure to check the list of active ingredients on the container, since pseudoephedrine and phenylephrine can be found in many cough and cold medicines.

www.stmichaelshospital. com/programs/renaltransplant/ Pg 15 of 20 For sore throat:

Most throat lozenges are safe to use. Look for sugar-free products if you have diabetes.

For cough and chest congestion:

If you have chest congestion or a productive cough, Guaifenesin (Robitussin®DM Chest Congestion) is recommended.

For a dry cough, the cough suppressant dextromethorphan (Delsym DM®, Vicks NyQuil Cough Liquid®) can be used.

Vicks® VapoRub ointment and Vicks® VapoSteam are different types of products that can temporarily relieve cough and chest congestion.

If you have diabetes, look for sugar-free and alcohol-free products.

For diarrhea:

Loperamide (Imodium®) can be used for short-term treatment of diarrhea. It should not be used for more than 48 hours.

Avoid Pepto-Bismol® and Kaopectate® because they can cause kidney problems.

If your diarrhea is caused by an infection, do not treat it with OTC products.

If your diarrhea is heavy, bloody, or lasts for more than a day, contact the Transplant Clinic or family doctor for help.

Pg 16 of 20 www.stmichaelshospital. com/programs/renaltransplant/ For constipation:

The following products can be used: • Metamucil® (take your medicines at least 4 hours before or 2 hours after dose) • docusate (Soflax®, Colace®) • bisacodyl (Dulcolax®) • senna (Senokot®) • milk of magnesia • polyethylene glycol (PegaLAX®, Lax-A-Day®) • docusate with senna (Senokot-S®)

You should not use stimulant laxatives (docusate, bisacodyl, and senna) for more than one week. Long-term use may cause dependence, long-term diarrhea, and changes in your electrolytes.

For dry eyes and eye irritation:

Artificial tears eye drops are recommended for the symptoms of dry eyes and eye irritation.

For stomach upset and heartburn:

Stomach upset can be treated with: • calcium carbonate (TUMS®, Rolaids®) • ranitidine (Zantac®) • famotidine (Pepcid AC®)

Do not to take medicines that have calcium or magnesium at the same time you take immunosuppressants such as mycophenolate (Cellcept® or Myfortic®). Take these medicines at least 4 hours before, or 2 hours after the immunosuppressants.

If you are having loose stools, avoid products containing magnesium because they can make diarrhea worse. They may also cause your magnesium levels to get too high. www.stmichaelshospital. com/programs/renaltransplant/ Pg 17 of 20 For gas:

Simethicone (Gas-X®) is recommended for gas symptoms.

If you have diabetes, you should avoid using Beano®. Using Beano® will give you an extra 2 to 6 grams of carbohydrates for every 100 grams of food. Beano® is used to prevent, not treat, gas symptoms.

What about herbal products?

If you were taking herbal medicines or dietary supplements before your transplant, ask your pharmacist to review them after the transplant. Many herbal products can interact with transplant medicines. You should not take Ginseng, St. John’s Wort, or Echinacea.

Pg 18 of 20 www.stmichaelshospital. com/programs/renaltransplant/ MEDICINE SCHEDULE

Name: Date:

Allergies:

Name of Medicine What it’s for Dose When I take it Prescriber

30 Bond Street, Toronto, ON M5B 1W8 Canada 416.864.6060 stmichaelshospital.com

www.stmichaelshospital. com/programs/renaltransplant/ Pg 19 of 20 St. Michael’s cares about your health. For reliable health information, visit our Patient and Family Learning Centre, Room 6-004, 6th floor, Cardinal Carter Wing, or find us online atwww.stmichaelshospital.com/learn

This information is not intended as a substitute for professional medical care. Ask your healthcare provider about this information if you have questions.

73529 Dev. June16 2016

Pg 20 of 20 www.stmichaelshospital. com/programs/renaltransplant/