Microsoft powerpoint - transplantmeds.ppt

University of MN Medical Center, Fairview – I. Describe prescription drug interactions with common immunosuppressants, cholesterol-lowering agents, steroids, antivirals and Bactrim.
medication interactions and which OTCs to avoid – III. Describe herbal medications that may be harmful and what interactions have been described in the literature. • Immunosuppressants
• Steroids
• Cholesterol-lowering agents-Statins
• Antivirals- Cytomegalovirus (CMV) and
• Antibiotics-Pneumocystis carinii
• Prescription Drugs Which INCREASE CsA • Calcium Channel Blockers: diltiazem, nicardipine,
• Antifungals: fluconazole, itraconazole, ketoconazole,
• Antibacterials: macrolides (erythromycin, clarithromycin,
• Glucocorticoids: methylprednisolone
• Other: birth control pills, glipizide, amiodarone, allopurinol,
bromocriptine, colchicine, metoclopramide, propafenone, tacrolimus, sirolimus – Prescription Drugs Which DECREASE CsA • Antibacterials: rifampin, nafcillin, IV Bactrim
• Anticonvulsants: carbamazepine, phenobarbital,
• Antiplatelets: ticlopidine
• Other: octreotide, orlistat
– Prescription Drugs that INCREASE FK levels: • Calcium Channel Blockers: diltiazem,
• Anitfungals: clotrimazole, fluconazole,
• Antimicrobials: (macrolides) erythromycin,
• Prokinetic Agents: metoclopramide, cisapride
• Other: bromocriptine, cimetidine, CsA, ethinyl -
estradiol, methylprednisolone, omeprazole, nefazodone, danazol • Anticonvulsants: carbamazepine, phenobarbital, – Be aware that use of the following agents WITH tacrolimus can worsen/induce kidney dysfunction: gentamicin, tobramycin, amphotericin B, cisplatin and cyclosporine.
– Prescription Drugs That INCREASE Rapa
• Calcium Channel Blockers: Diltiazem,
• Antifungals: ketoconazole, fluconazole,
• Antimicrobials: rifampin, clarithromycin,
• Other: cisapride, metoclopramide, bromocriptine,
– Prescription Drugs That DECREASE Rapa
• Anticonvulsants: carbamazepine, phenobarbital,
• Antibiotics: rifabutin
– Sirolimus levels increase by 80% when taken – Sirolimus levels increase by 230% when given at the SAME time as cyclosporine capsules – Sirolimus levels increase by 67-86% when given at the SAME time as cyclosporine oral solution • Cholestyramine, Antacids with aluminum and – Prescription medications which INCREASE
Azathioprine: Allopurinol
– Other: Azathioprine can cause your INR to
go DOWN if you are on warfarin. You may need higher doses of warfarin.
– *Azathioprine is a potent bone marrow suppressant, any drug with the potential to suppress bone marrow activity such as Bactrim, ganciclovir, cyclophosphamide, MTX may worsen this.
– HMG-CoA Reductase Inhibitors (Statins): itraconazole, ketoconazole, CYCLOSPORINE, erythromycin, gemfibrozil, niacin, warfarin – Statin levels DECREASED by antacids, bile • Prescription medications that REDUCE
steroid concentrations: phenytoin,
phenobarbital and rifampin
• Prescription medications that
INCREASE steroid concentrations:
birth control pills, cyclosporine,
ketoconazole
ganciclovir/valganciclovir can worsen kidney toxicity • Prescription medications which
INCREASE ganciclovir/valganciclovir
levels: Mycophenolate
• Bactrim is an antibacterial which tends to affect • Prescription medications whose levels are INCREASED when given with Bactrim: Digoxin, phenytoin, glipizide, glyburide, metformin, methotrexate, procainamide, ganciclovir, valganciclovir, warfarin • Prescription medications whose levels are • *Bactrim given with ACE inhibitors can cause or worsen hyperkalemia (high potassium levels) – Non-Steroidal AntiInflammatories (NSAIDS): • Used long term, this class of medications has the potential to affect platelet function, reduce kidney function and cause stomach bleeding. This class of medications is NOT to be used with warfarin • Allergies
– diphenhydramine (Benedryl®), clemastine (Tavist), chlorpheniramine (Chlor-Trimeton®), loratidine (Claritin®) • Antihistamines are completely safe and have very few drug interactions. Be aware that allergy products which contain pseudoephedrine should be avoided. Many of them end in the letter “D”such as Tavist-D. The “D” stands for decongestant which usually means pseudoephedrine.
• Cough/Cold/Congestion
• Be advised that almost ALL cold/flu preparations and any OTC product that has the word “Sinus” in its name most likely contains the decongestant, pseudoephedrine (Pseudofed®). • Pseudoephedrine is a sympathomimetic which can cause your heart rate to increase and your blood pressure to go up.
• When you have a cold, avoid “cold” preparations with pseudoephedrine and instead use nasal sprays like Afrin® and pain relievers such as Tylenol®.
– Upset stomach, heartburn
– Antacids (Maalox, Tums) are safe to use EXCEPT when taking them with MMF or CsA.
Separate immunosuppressants and antacids by
at least 2 hours.
– Zantac®, Pepcid® and Axid® are all safe to use but please avoid Tagamet as this drug
interacts with many medications especially
warfarin.
– Use antacids, Zantac, Pepcid, Axid, Prevacid/ Prilosec with CAUTION if you are taking itraconazole. Itraconazole is absorbed in your stomach ONLY if your stomach is very acidic.
• Diarrhea
• Be very cautious about using OTC antidiarrheal medications when you are experiencing diarrhea. Diarrhea in an immunosuppressed patient can be caused by numerous infectious agents and should be treated promptly by a physician. This is especially true if the diarrhea is accompanied by vomiting, a fever, severe dehydration and significant weight loss.
• Diarrhea caused by antibiotic usage can be reduced by eating yogurt or taking acidophilus preparations.
• Diet Aids/Caffeine
– Please avoid ALL diet aid products that pharmacies sell over the counter. These all contain stimulants which will cause your heart rate and blood pressure to soar! – Caffeine ingestion can lead to an increase in heart rate and blood pressure as well. Caffeine is also found in many migraine medications including Excedrin®.
• Herbs, enzymes, glandulars, amino acids, etc are • Supplements may give truthful info on effects on body or function, but must make disclaimer that FDA hasn’t evaluated the claim and is not intended for prevention, cure or treatment of disease • Purity, accuracy of labeling unregulated • Androstenedione (synthetic androgen)
• Chapparal (used to stop the aging process): liver
• Comfrey (used as an antiinflammatory): liver tox
• DHEA (synthetic androgen)
• Digitalis
• Dong Quai (used for menstrual flow): may be
• Ma Huang (used for energy):increases heart rate,
BP, has been known to cause heart attacks/stroke – Germander, Kava kava, Licorice Extracts, Life
Root: can cause liver toxicity
– Mistletoe: liver toxicity
– White Willow (herbal source of aspirin)
– Yohimbe (used for impotence): can increase heart
– Echinacae and Astralgalus should be avoided due
to their potential to stimulate the immune system – Guarana, Kola nut: sources of caffeine
• Co-Enzyme Q-may decrease INR while on
• Chamomile-may increase INR if on warfarin
• Feverfew-has antiplatelet activity, avoid with
• Garlic- has antiplatelet activity, avoid with warfarin
• Gingko- has antiplatelet activity, avoid with
• Glucosamine/Chondroitin
• Grapeseed Extract
• Milk Thistle
• Peppermint Oil
• Pygeum
• Saw Palmetto
• Slippery Elm
• St. John’s Wort-AVOID taking if you are on other
antidepressants. AVOID if you are taking CYCLOSPORINE. St. John’s Wort causes CsAlevels to DROP substantially! Lowers Dig levels • Valarian-avoid other agents which aid sleep
Insufficient
• Alpha-lipoic Acid
• American Centaury
• Avena Sativa Extract
• Barley Grass
• Bee pollen: avoid if allergic to bees
• Bee propolis
• Beet Powder
• Betaine
• Bilberry
• Black cohosh
• Black radish
• Blueberry
• Blue Green Algae
• Bromelain
• Cats Claw
• Cayenne Pepper: Avoid in pregnancy, can
• Chaste Berry: Avoid in pregnancy/lactation
• Choline
• Creatine: do not use if on protein restriction
• Dandelion: avoid if gallbladder obstructed
• Evening Primrose: may interact with warfarin
• Eyebright
• Fennel Seed
• Fenugreek- may increase INR if on warfarin
• Goldenseal: Avoid in pregnancy/lactation
• Ginseng: may increase INR while on warfarin,
avoid if you are on MAOIs, avoid in preg/lactation, avoid in psychotic and bipolar disorders • Green tea: avoid if on warfarin! This tea contains
• Hawthorn: avoid if on ACE-inhibitors/digoxin
• Ho-shou-wu tea
• Inositol
• Lutein
• Lycopene
• Melatonin
• Mexican wild yam: avoid in pregnancy/lactation
• Nettle root
• Oyster extract
• PABA: may interact with sulfa antibiotics
• Parsley (volatile oil should be avoided in
• Passion Flower
• Pumpkin Seed
• Quercitin
• Rutin
• Schisandra/Schizandra
• Shark cartilage: avoid in pregnancy
• Siberian ginseng
• Soy extracts
• Tumeric
• Wheat Grass, Wood betony
– Be advised that the following medications can NOT be taken safely if you are consuming grapefruit juice: • Calcium Channel Blockers: felodipine,
• Immunosuppressants: Cyclosporine-causes
levels to go UP by 67%!, tacrolimus-causes levels to double! • Statins: Lovastatin, atorvastatin, pravastatin,
simvastatin-all are increased by grapefruit juice • Seizure/Psych Meds: Buspirone, carbamazepine,
• Others: Cisapride, methadone, sildenafil

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