For those in need of an organ transplant, knowing the post-surgical protocol is important.
Emory Transplant Center physician Dr. Ram Subramanian discusses the importance of anti-rejection medication in organ transplants.
Selected Podcast
Post-Organ Transplant: Life on Anti-Rejection Medication
Featuring:
Learn more about Dr. Subramanian
Ram Mohan Subramanian, FCCM, FCCP, AGAF
Dr. Subramanian is Associate Professor of Medicine and Surgery, and the Medical Director of Liver Transplantation. In his dual role as a transplant hepatologist and an intensivist, Dr. Subramanian is involved in the inpatient care of patients before and after liver transplantation. His clinical and research interests are focused on critical care issues related to hepatic failure and liver transplantation.Learn more about Dr. Subramanian
Transcription:
Bill Klaproth (Host): Antirejection medications are a fact of life for patients following organ transplantation. And here to talk about post-organ transplant, life on antirejection medication, is Dr. Ram Subramanian, Associate Professor of Medicine and Surgery and the Medical Director of Liver Transplantation at Emory University School of Medicine. Dr. Subramanian, thank you for your time. Why is antirejection medication needed?
Ram Mohan Subramanian, FCCM, FCCP, AGAF (Guest): So, the patient who undergoes an organ transplant is getting a foreign organ from another human being. So, that is recognized as foreign by the recipient’s immune system and so it is very important that a who patient receives an organ transplant takes antirejection medications in order to prevent rejection of the transplanted organ.
Host: And how long does someone need to stay on antirejection medication? Is that something they are on for life?
Dr. Subramanian: It is. It is on for life. So, there’s always a finite risk of rejection irrespective of how long the patient is post-transplant. So, we have folks who are twenty years out from liver transplant who are still requiring some degree of antirejection medicine.
Host: Alright, so let me ask you this. So, over time, is there a reduction in the dosage?
Dr. Subramanian: Yes, that’s a good question. So, you are right. The risk of rejection is higher the closer you are to transplantation. And so, we maintain the level of antirejection medicines higher, for example, for liver transplant within in the first six months after liver transplantation and after that we are able to wean the dose of antirejection medication as we progressively go farther and farther away from the transplant.
Host: Are there common side effects of antirejection medication and after time, such a long period of time taking this antirejection medication; do problems occur because of that?
Dr. Subramanian: So, we – there are side effects of antirejection medications. So, the – one good example is - which is the backbone of a lot of immunosuppressive therapy, is a drug called tacrolimus the trade name is Prograf. So, that can cause a few side effects. Number one, the antirejection medicine is suppressing the immune system of the patient who has undergone transplant. So, that automatically puts the patient at higher risk for infections, infectious complications. So, that’s something we are always monitoring for in these patients with regard to their follow up care. The second category of complications and again related to tacrolimus, this specialty drug I mentioned, is noninfectious in nature. And for example, tacrolimus can cause high blood pressure, it can cause adverse effects on kidney function, it can cause gout, it can cause some blood cell issues. So, there is a host of other side effects that we have to monitor for when these patients go on these kinds of medications.
Host: So, does someone on antirejection medication need to come in for follow up visits?
Dr. Subramanian: So, they have to come in for follow up visits very regularly. In fact, when we transplant somebody in the fresh postoperative period, in the first couple of months; we see them almost every one to two weeks. And for the first month after transplant, we get labs – blood tests on them even three times a week. So, the intensity of follow up is highest right after transplant and then it slowly can be decreased but they have to follow up with us at some regular basis in the post-transplant period.
Host: So, what happens if a patient misses his or her medication for a period of time or just says alright, I’m done. I don’t need this anymore, I’m going to stop taking it. I think I know the answer, but what happens if a person does that?
Dr. Subramanian: So, that’s a bad idea. So, the patient is at risk for rejection of the organ. So, that’s something that we definitely advise the patient not to do. The symptoms of rejection can be subtle. And depending on how long they abstain from taking their medication; if it’s a prolonged period of time; for example, for the liver transplant patient; they can start developing jaundice. They can start developing abnormal liver function tests and so that’s something we definitely recommend against with regard to the patient taking care of themselves.
Host: Right, so it’s imperative that the person stay on the medication. So, before discharge, what do you do to teach the patient about the drugs and get that message across?
Dr. Subramanian: So, we take that very seriously in fact, we have dedicated transplant pharmacists and the rest – other members of the care provider team that sit down with the patient and their family and review all the medications that the patient is getting discharged on including the antirejection meds and we go over every medicine to make sure they know what the medicine looks like, what is the frequency at which they are supposed to take it every day and when to take it, at what time of the day they should take it so, there’s some very detailed teaching that goes into training the patient and their family before discharge.
Host: And what about refills? Are those automatic? It seems like drugs that are so important like these; seems like automatic refills would be necessary. Is that something that happens?
Dr. Subramanian: They are, they are. So, we have systems in place where we have dedicated pharmacies identified for each patient prior to discharge so that we make sure the patient has a steady supply of medicines and refills to prevent any break, any lag in them taking their medications.
Host: So, since this is a lifelong process; someone is on antirejection medication for life; what about interactions with other drugs or alcohol or potentially even foods? Does that happen?
Dr. Subramanian: So, that’s a good question. We do have – any medicine for that matter, has potential interactions with other medications. But we do our very best at the time of discharge to make sure that we minimize the risk of any drug-drug interactions. We also make them aware of potential foods or drinks that can interact with these antirejection medications. For example, grapefruit juice is a good example which can interact and effect the absorption and the levels of antirejection meds. So, that’s a good example of something that we advise the patients not to take. Alcohol is something else that we advise against. It is – we have given these patients a life saving organ transplant with regard to for example liver transplant; and so, we are very clear about abstaining from alcohol. Because that can adversely affect the liver function as well.
Host: Absolutely. That just makes sense. And Dr. Subramanian is there anything else we should know about antirejection medication following an organ transplant?
Dr. Subramanian: I think you have hit all the important issues. The one thing I would like to maybe close with is that I just saw somebody in clinic, thirty years after liver transplant and that was somebody who is really compliant with their antirejection medication and so it just speaks to the fact that if a patient takes care of himself or herself and is compliant with their antirejection medications; this could result in a long period of life after something as complex as a liver transplant.
Host: Well that’s a great way to end this and a terrific point. Dr. Subramanian, thank you so much for your time. For more information, please visit www.emoryhealthcare.org/
Bill Klaproth (Host): Antirejection medications are a fact of life for patients following organ transplantation. And here to talk about post-organ transplant, life on antirejection medication, is Dr. Ram Subramanian, Associate Professor of Medicine and Surgery and the Medical Director of Liver Transplantation at Emory University School of Medicine. Dr. Subramanian, thank you for your time. Why is antirejection medication needed?
Ram Mohan Subramanian, FCCM, FCCP, AGAF (Guest): So, the patient who undergoes an organ transplant is getting a foreign organ from another human being. So, that is recognized as foreign by the recipient’s immune system and so it is very important that a who patient receives an organ transplant takes antirejection medications in order to prevent rejection of the transplanted organ.
Host: And how long does someone need to stay on antirejection medication? Is that something they are on for life?
Dr. Subramanian: It is. It is on for life. So, there’s always a finite risk of rejection irrespective of how long the patient is post-transplant. So, we have folks who are twenty years out from liver transplant who are still requiring some degree of antirejection medicine.
Host: Alright, so let me ask you this. So, over time, is there a reduction in the dosage?
Dr. Subramanian: Yes, that’s a good question. So, you are right. The risk of rejection is higher the closer you are to transplantation. And so, we maintain the level of antirejection medicines higher, for example, for liver transplant within in the first six months after liver transplantation and after that we are able to wean the dose of antirejection medication as we progressively go farther and farther away from the transplant.
Host: Are there common side effects of antirejection medication and after time, such a long period of time taking this antirejection medication; do problems occur because of that?
Dr. Subramanian: So, we – there are side effects of antirejection medications. So, the – one good example is - which is the backbone of a lot of immunosuppressive therapy, is a drug called tacrolimus the trade name is Prograf. So, that can cause a few side effects. Number one, the antirejection medicine is suppressing the immune system of the patient who has undergone transplant. So, that automatically puts the patient at higher risk for infections, infectious complications. So, that’s something we are always monitoring for in these patients with regard to their follow up care. The second category of complications and again related to tacrolimus, this specialty drug I mentioned, is noninfectious in nature. And for example, tacrolimus can cause high blood pressure, it can cause adverse effects on kidney function, it can cause gout, it can cause some blood cell issues. So, there is a host of other side effects that we have to monitor for when these patients go on these kinds of medications.
Host: So, does someone on antirejection medication need to come in for follow up visits?
Dr. Subramanian: So, they have to come in for follow up visits very regularly. In fact, when we transplant somebody in the fresh postoperative period, in the first couple of months; we see them almost every one to two weeks. And for the first month after transplant, we get labs – blood tests on them even three times a week. So, the intensity of follow up is highest right after transplant and then it slowly can be decreased but they have to follow up with us at some regular basis in the post-transplant period.
Host: So, what happens if a patient misses his or her medication for a period of time or just says alright, I’m done. I don’t need this anymore, I’m going to stop taking it. I think I know the answer, but what happens if a person does that?
Dr. Subramanian: So, that’s a bad idea. So, the patient is at risk for rejection of the organ. So, that’s something that we definitely advise the patient not to do. The symptoms of rejection can be subtle. And depending on how long they abstain from taking their medication; if it’s a prolonged period of time; for example, for the liver transplant patient; they can start developing jaundice. They can start developing abnormal liver function tests and so that’s something we definitely recommend against with regard to the patient taking care of themselves.
Host: Right, so it’s imperative that the person stay on the medication. So, before discharge, what do you do to teach the patient about the drugs and get that message across?
Dr. Subramanian: So, we take that very seriously in fact, we have dedicated transplant pharmacists and the rest – other members of the care provider team that sit down with the patient and their family and review all the medications that the patient is getting discharged on including the antirejection meds and we go over every medicine to make sure they know what the medicine looks like, what is the frequency at which they are supposed to take it every day and when to take it, at what time of the day they should take it so, there’s some very detailed teaching that goes into training the patient and their family before discharge.
Host: And what about refills? Are those automatic? It seems like drugs that are so important like these; seems like automatic refills would be necessary. Is that something that happens?
Dr. Subramanian: They are, they are. So, we have systems in place where we have dedicated pharmacies identified for each patient prior to discharge so that we make sure the patient has a steady supply of medicines and refills to prevent any break, any lag in them taking their medications.
Host: So, since this is a lifelong process; someone is on antirejection medication for life; what about interactions with other drugs or alcohol or potentially even foods? Does that happen?
Dr. Subramanian: So, that’s a good question. We do have – any medicine for that matter, has potential interactions with other medications. But we do our very best at the time of discharge to make sure that we minimize the risk of any drug-drug interactions. We also make them aware of potential foods or drinks that can interact with these antirejection medications. For example, grapefruit juice is a good example which can interact and effect the absorption and the levels of antirejection meds. So, that’s a good example of something that we advise the patients not to take. Alcohol is something else that we advise against. It is – we have given these patients a life saving organ transplant with regard to for example liver transplant; and so, we are very clear about abstaining from alcohol. Because that can adversely affect the liver function as well.
Host: Absolutely. That just makes sense. And Dr. Subramanian is there anything else we should know about antirejection medication following an organ transplant?
Dr. Subramanian: I think you have hit all the important issues. The one thing I would like to maybe close with is that I just saw somebody in clinic, thirty years after liver transplant and that was somebody who is really compliant with their antirejection medication and so it just speaks to the fact that if a patient takes care of himself or herself and is compliant with their antirejection medications; this could result in a long period of life after something as complex as a liver transplant.
Host: Well that’s a great way to end this and a terrific point. Dr. Subramanian, thank you so much for your time. For more information, please visit www.emoryhealthcare.org/