Transplant Meds
Page updated spring 2021.
Disclaimer: Medicine is an ever-changing science. We have been witnessing changes in diagnostic and therapeutic modalities and guidelines during last several years. We have used sources believe to be reliable for purpose of this website. However, due to possibility of human error or changes in medicine, readers are required to confirm the information provided in this website with other sources. Readers are specially required to read all parts of the product information sheet included in the package of each drug they plan to administer and follow those instructions. Readers are also needed to follow instructions of FDA and other regulatory bodies and their own department in this regard. Doses need to be adjusted per manufacturer and FDA publications. This website serves as a general framework. We and other users would adjust the approach per departments policies and patients situation.
Thymoglobulin
Induction:
Follow institutional protocols.
FDA:
1.5 mg/kg of body weight, IV, administered daily for 4 to 7 days
Acute cellular rejection:
Follow institutional protocols.
FDA:
1.5 mg/kg of body weight, IV, administered daily for 7 to 14 days
Premedication:
Corticosteroids, acetaminophen, and Diphenhydramine.
Dose reduction:
Dose should be reduced by one-half if the white blood cell (WBC) count is between 2,000 and 3,000 cells/mm3 or if the platelet count is between 50,000 and 75,000 cells/mm3 .
Stopping the treatment:
Stopping the treatment should be considered if the WBC count falls below 2,000 cells/mm3 or if the platelet count falls below 50,000 cells/mm
Alemtuzumab (Campath)
Induction:
30 mg, IV, one dose intraoperatively.
Acute cellular rejection: 30 mg, IV
Premedication:
Corticosteroids, acetaminophen, and Diphenhydramine
Basiliximab (Simulect)
Induction:
20 mg IV POD 0 and 4.
Premedication:
Acetaminophen, and Diphenhydramine.
Methylprednisolone (SoluMedrol)
Induction:
40-1000 mg/day, IV, for the first few days, per institutional protocols, followed by oral prednisone tapers.
Acute cellular rejection:
125-1000 mg/day x 3-5 days
IVIG
Antibody-mediated rejection:
Low dose after each plasma exchange
100 mg/kg or 10 g
High dose after course of plasma exchange: 2 g/kg
High dose one time dose: 2 g/kg
Premedication:
Acetaminophen, and Diphenhydramine.
Rituximab (Rituxan)
Antibody-mediated rejection:
375 mg/m2 , IV, once weekly for 1-5 doses.
Premedication:
Acetaminophen, and Diphenhydramine.
Some center also give Famotidine and IV Corticosteroids.
Bortezomib
1.3 mg/m2 , IV, on day 1, 4, 7, and 10.
Premedication:
Some centers give methylprednisolone 100 mg on day 1 and 4 and 50 mg on day 7 and 10.
Tacrolimus (Prograf)
Kidney transplant:
Follow institutional protocols.
Lexi-Comp:
0.1 mg/kg/day, PO, in combination with other meds per policies; titrate to target trough concentrations. Administer in 2 divided doses, given every 12 hours.
Liver transplant:
Follow institutional protocols.
Lexi-Comp:
0.1 mg/kg/day, PO, in 2 divided doses, given every 12 hours in combination with other meds per policies; Titrate to target trough concentrations.
Sublingual administration:
Sublingual to oral dosing ratio:1:2.
IV administration:
0.03 to 0.05 mg/kg/day as a continuous infusion. Titrate to target trough concentrations.
IV to oral dosing ratio: 1:3 in 24 hours.
Tacrolimus (Envarsus)
Prograf (IR) to Envarsus (ER) ratio:
1: 0.7 (1: 0.85 in African Americans)
Administer once daily, PO.
Cyclosporine (Gengraf, Neoral, SandIMMUNE)
Modified Cyclosporine (Neoral/Gengraf) is more commonly used.
Cyclosporine (modified)
Follow institutional protocols.
Lexi-Comp:
Kidney txp: 9 ± 3 mg/kg/day, PO, in 2 divided doses.
Liver txp: 8 ± 4 mg/kg/day, PO, in 2 divided doses.
Titrate to target trough concentrations.
Sirolimus (Rapamune)
Follow institutional protocols.
Lexi-Comp:
Kidney transplant:
Low-to-moderate immunologic risk:
<40 kg: Loading dose: 3 mg/m2 PO, on day 1, followed by 1 mg/m2 once daily in combination with other meds per policies.
≥40 kg: Loading dose: 6 mg PO, on day 1; followed by: 2 mg once daily in combination with other meds per policies.
High immunologic risk:
Loading dose: Up to 15 mg on day 1; followed by: 5 mg/day in combination with other meds per policies.
Start when wound healing is satisfactory.
Titrate to target trough concentrations.
Everolimus (Zortress)
Follow institutional protocols.
Lexi-Comp:
Kidney transplant:
0.75 mg twice daily- in combination with other meds per policies.
Liver transplant:
1 mg twice daily in combination with other meds per policies;
If trough is <3 ng/mL: Double total daily dose
If trough >8 ng/mL on 2 consecutive measures: Decrease dose by 0.25 mg twice daily.
Start when wound healing is satisfactory.
Titrate to target trough concentrations.
Belatacept (Nulojix)
Kidney transplant:
Follow institutional protocols.
Lexi-Comp:
10 mg/kg, IV, on POD 0 and on POD4.
Then, 10 mg/kg at the end of week 2, week 4, week 8, and week 12
Then, 5 mg/kg, IV, every 4 weeks beginning at the end of week 16
Mycophenolate Mofetil (CellCept)
1 g, PO, twice daily
IV administration:
IV and oral doses are equivalent.
Mycophenolate Sodium (Myfortic)
720 mg, PO, twice daily
Enteric-coated
Myfortic to CellCept:
Myfortic 180 mg is considered equivalent to CellCept 250 mg
Prednisone
5-60 mg /day, PO.
Perform Prednisone taper after Methylprednisolone taper, per institutional policies.
Valganciclovir (Valcyte)
Prophylaxis:
900 mg once daily
Treatment:
900 mg twice daily until symptom resolution and 1 or 2 consecutive weekly undetectable CMV viral load samples are obtained
Ganciclovir (Cytovene)
Prophylaxis:
5 mg/kg/dose every 24 hours
Treatment:
5 mg/kg/dose IV every 12 hours until resolution of symptoms and 1 or 2 consecutive undetectable CMV viral load samples are obtained
Acyclovir (Zovirax)
Prophylaxis:
200 mg, PO, 3 to 5 times daily for 3 to 6 months after transplantation
Trimethoprim-Sulfamethoxazole (Bactrim, Septra)
Prophylaxis:
1 single-strength tablet once daily
or
1 double-strength tablet 3 times weekly
Fluconazole (Diflucan)
Prophylaxis:
400 mg (6 mg/kg), PO/ IV, given perioperatively and continued once daily postoperatively. Duration, per institutional policies.
Treatment:
Candida cystitis:
200 mg (3 mg/kg), PO, once daily for 2 weeks
Candida pyelonephritis:
200 to 400 mg (3 to 6 mg/kg), PO, once daily for 2 weeks
Nystatin (Bio-Statin)
Prophylaxis:
Swish and swallow 5 ml (500000 units) oral suspension 3 times daily for 2-3 weeks.