31. Transplant & Immunosuppression

Question 1

Which types of cancer are normally suppressed by a healthy immune system, and are therefore higher risk in transplant patients who are receiving strong immunosuppressant drugs?

A. Lymphoma, osteosarcoma
B. Prostate cancer, breast cancer, cervical cancer
C. Osteosarcoma, melanoma
D. Melanoma, lymphoma
E. Liver cancer

Answer 1

D. In addition to the cancer risk, the skin of patients taking transplant drugs will burn more easily. Transplant recipients need to protect their skin from the sun.

Remember LIST for immunosuppression:

Lymphoma, Infection, Skin cancer, Tuberculosis

Question 2

Sophia is an immunosuppressed transplant patient who requires a medication to prevent oral candida (thrush). Which of the following drugs should be recommended?

A. Valganciclovir
B. Acyclovir
C. Amoxicillin/Clavulanic Acid
D. Bactrim
E. Clotrimazole lozenges

Answer 2

E.

Question 3

Select the blood types that a patient with type O blood can receive without suffering a rejection due to an incompatibility blood type match. (Select ALL that apply.)

A. Type A
B. Type B
C. Type O
D. Type AB
E. Any type blood is fine.

Answer 3

C.

Type O can only receive Type O. Type O is universal donor. Type AB is universal accepter.

Question 4

SB is an immunosuppressed transplant patient who requires cytomegalovirus (CMV) prophylaxis. Which of the following would you recommend?

A. Fluconazole 200 mg daily
B. Ciprofloxacin 500 mg BID
C. Septra 1 Double Strength tablet three times a week
D. Valganciclovir 900 mg daily
E. Cephalexin 250 mg QID

Answer 4

D. Fluconazole covers fungal infections, ciprofloxacin covers bacterial infections, Septra covers pneumocystis infections, and valganciclovir covers viral infections (such as cytomegalovirus).

HSV, VZV coverage: acyclovir (Zovirax), valacyclovir (Valtrex), famciclovir (Famvir)

CMV coverage: ganciclovir (Cytovene), valganciclovir (Valcyte), cidofovir (Vistide), foscarnet (Foscavir)

Question 5

A 55-year-old female patient received a kidney transplant. She required tacrolimus for chronic immunosuppression. The tacrolimus trough blood levels remained stable over several years. In the fourth year after transplant the patient expired from complications of an acute graft rejection. The hospital pharmacist reviewed the bag of medicines brought in from the home and found the following products: DHEA, women’s multivitamin, B vitamin complex and St. John’s Wort. What is the likely explanation for the acute graft rejection?

A. St. John’s Wort increased levels of cyclosporine due to enzyme inhibition.
B. St. John’s Wort decreased levels of cyclosporine due to enzyme induction.
C. St. John’s Wort decreased levels of cyclosporine due to enzyme inhibition.
D. DHEA increased levels of cyclosporine.
E. St. John’s Wort increased levels of cyclosporine due to enzyme induction.

Answer 5

B. St. John’s Wort induces many enzymes and cannot be used with transplant drugs, birth control pills, and other CYP 450 and p-glycoprotein efflux transporter substrates.

Calcineurin Inhibitors (CNIs): suppresses cellular immunity by inhibiting T-lymphocyte activation

tacrolimus (Prograft, Astagraf XL, Hecoria): Should be taken on empty stomach to avoid variability in absorption. Trough level dose depending on transplant type. SE: hypertension and nephrotoxicity, hyperglycemia, tremor, hyperkalemia, QT prolongation. IV:PO IR ratio is 1:4. This is a CYP 3A4 and P-gp substrate (watch for DDI)

cyclosporine (Neoral, Gengraf, Sandimmune): Boxed warning (renal impairment, lymphoma, skin cancer, infection, Gengraf and Neoral cannot be used interchangeably with Sandimmune which is non-modified). SE: hypertension, nephropathy, hyperkalemia, hirsutism, gingival hyperplasia, edema, hyperglycemia, QT prolongation. 3A4 and P-gp substrate (watch for DDI)

Question 6

A patient is using cyclosporine and mycophenolate post heart transplant. What is the purpose of using immunosuppressants in heart transplant patients?

A. These drugs strengthen the transplant heart’s muscle walls.
B. These drugs stop viral pathogens from attacking the new heart.
C. These drugs lift depression when used concurrently; depression is common among transplant patients.
D. These drugs strengthen the immune system so that it can prevent an attack on the new heart.
E. These drugs weaken the immune system so that it will not attack the new heart.

Answer 6

E. Mycophenolate is a very common immunosuppressant drug used in combination with other immunosuppressants to prevent rejection of the transplanted organ. An impaired immune system necessitates infection control mechanisms, such as hand washing and staying away from sick people and crowds.

Antiproliferative Agents: inhibit T-lymphocyte proliferation by altering purine synthesis

mycophenolate (CellCept), mycophenolic acid (Myfortic): 1-1.5gm PO BID on empty stomach, these two agents are NOT interchangeable due to difference s in absorption. Boxed warning: Infection risk, lymphoma and skin cancer, congenital malformations (Pregnancy D)

SE: decreases efficacy of oral contraceptives, GI upset, diarrha, vomiting, hyper/hypotension, edema, tachycardia, pain, hyperglycemia, hyper/hypokalemia, hypomagnesemia, hypocalcemia, hypercholesterolemia, tremor, acne, infections

Question 7

Which of the following drugs are used for chronic maintenance in transplant recipients? (Select ALL that apply.)

A. Azathioprine
B. Atgam
C. Everolimus
D. Steroids
E. Tacrolimus

Answer 7

A, C, D, E. Mycophenolate is also commonly used for maintenance with a calcineurin inhibitor.

azathioprine (Azasan, Imuran), Atgam (lymphocyte immune globulin), everolimus (Zortress, Afinitor), tacrolimus (Prograf, Astagraft XL, Hecoria)

Primary maintenance drug is a calcineurin inhibitor (tacrolimus is 1st line CNI, or cyclosporine) + an antiproliferative agent (mycophenolate is 1st line, or everolimus, sirolimus, belatacept or azathioprine). Can also add on steroids (typically prednisone). If patient is low immunologic risk, the steroids will be discontinued to reduce long term adverse effects. Attacking the immune system via multiple mechanisms through different drug classes is designed to both lower toxicity and to reduce the risk of graft rejection.

Question 8

A patient received a liver transplant and is using mycophenolate mofetil. What is the brand name for mycophenolate mofetil?

A. CellCept
B. Sandimmune
C. Prograf
D. Imuran
E. Atgam

Answer 8

A. The brand name of mycophenolate mofetil is CellCept. Different salt forms are not interchangeable.

Sandimmune (cyclosporine, non-modified), Prograf (tacrolimus), Imuran (azathioprine), Atgam (lymphocyte immune globulin)

Antiproliferative Agents: inhibit T-lymphocyte proliferation by altering purine synthesis

mycophenolate (CellCept), mycophenolic acid (Myfortic): 1-1.5gm PO BID on empty stomach, these two agents are NOT interchangeable due to difference s in absorption. Boxed warning: Infection risk, lymphoma and skin cancer, congenital malformations (Pregnancy D)

SE: decreases efficacy of oral contraceptives, GI upset, diarrha, vomiting, hyper/hypotension, edema, tachycardia, pain, hyperglycemia, hyper/hypokalemia, hypomagnesemia, hypocalcemia, hypercholesterolemia, tremor, acne, infections

Question 9

Sandra is a renal transplant patient who is doing well. It was discovered at her last clinic visit that Sandra did not receive theZostavax vaccine prior to transplant. Sandra is concerned because she has a friend in her transplant support group who is suffering with herpetic neuralgia since a shingles episode. Sandra would like to be vaccinated against shingles. Select the correct response:

A. Sandra cannot receive the shingles vaccine.
B. Sandra can receive the shingles vaccine, but it cannot be given in a pharmacy; she should see her doctor.
C. The pharmacist can administer the shingles vaccine.
D. Sandra should receive Varivax instead.
E. Sandra can receive the Zostavax vaccine but she will need to stop taking her immunosuppressant medications for 48 hours prior to the vaccination.

Answer 9

A. Transplant patients cannot receive live vaccines as they will not be able to halt replication; in other words, it would be similar to injecting them with active disease.

Live vaccines are an absolute contradinication in immunosuppressed patients!

Question 10

Lynne is taking azathioprine and several other immunosuppressants to prevent rejection of a lung transplant. Which of the following medications can interact with azathioprine?

A. Torsemide
B. Allopurinol
C. Levothyroxine
D. Letrozole
E. Acetaminophen

Answer 10

B. Allopurinol will significantly increase the serum concentration of azathioprine. If the patient requires allopurinol therapy, the dose of azathioprine is lowered.

Question 11

A patient picks up a prescription from the pharmacy for tacrolimus capsules. Counseling should include all of the following points: (Select ALL that apply.)

A. Take on an empty stomach (one hour before or two hours after meals).
B. You may experience headaches, nausea, diarrhea and/or tremor.
C. Your weight, temperature and blood pressure (and blood sugar if you have diabetes) should be monitored.
D. You are at risk for infection; report at once if you develop fever or feel weak and tired. This drug increases the risk of developing lymphoma.
E. Tacrolimus is also called Neoral. There is another formulation of this drug called Sandimmune. It is important to use the same formulation.

Answer 11

A, B, C, D. Tacrolimus (Prograf, Astagraft XL, Hecoria) has many side effects, including hypertension, hyperglycemia, hyperkalemia and hypokalemia, tremor, QT prolongation and nephrotoxicity.

Calcineurin Inhibitors (CNIs): suppresses cellular immunity by inhibiting T-lymphocyte activation

tacrolimus (Prograft, Astagraf XL, Hecoria): Should be taken on empty stomach to avoid variability in absorption. Trough level dose depending on transplant type. SE: hypertension and nephrotoxicity, hyperglycemia, tremor, hyperkalemia, QT prolongation. IV:PO IR ratio is 1:4. This is a CYP 3A4 and P-gp substrate (watch for DDI)

Cardiovascular disease is the most common cause of death in transplant patients because most of these drugs cause increase BP, blood glucose, cholesterol, and weight. And so CVD must be managed in these patients.

Question 12

Which of the following drugs would be useful for prophylaxis for oral candida (thrush)? (Select ALL that apply.)

A. Fluconazole, taken by injection
B. Fluconazole, taken orally
C. Nystatin
D. Bactrim
E. Clotrimazole lozenges

Answer 12

B, C, E.

Question 13

Choose the correct statements concerning cyclosporine and drug interactions. (Select ALL that apply.)

A. Cyclosporine is a CYP 450 3A4 substrate and will interact with 3A4 inducers and inhibitors.
B. Fluoxetine, paroxetine and fluvoxamine cannot be used with cyclosporine; use St. John’s Wort if an antidepressant is required.
C. A patient using cyclosporine should attempt to avoid other drugs that are nephrotoxic.
D. Do not ingest grapefruit or grapefruit juice if using cyclosporine or tacrolimus.
E. P-gp inhibitors will increase the cyclosporine concentration and p-gp inducers will decrease the cyclosporine concentration.

Answer 13

A, C, D, E. Cyclosporine is a CYP 450 3A4 substrate and a P-gp substrate. Many drugs can increase or decrease the levels of cyclosporine, and cyclosporine can increase levels of other drugs. Always check for drug interactions. Avoid grapefruit and St. John’s Wort.

Calcineurin Inhibitors (CNIs): suppresses cellular immunity by inhibiting T-lymphocyte activation

cyclosporine (Neoral, Gengraf, Sandimmune): Boxed warning (renal impairment, lymphoma, skin cancer, infection, Gengraf and Neoral cannot be used interchangeably with Sandimmune which is non-modified). SE: hypertension, nephropathy, hyperkalemia, hirsutism, gingival hyperplasia, edema, hyperglycemia, QT prolongation. 3A4 and P-gp substrate (watch for DDI)

Question 14

Sophia is an immunosuppressed transplant patient who requires a medication to prevent pneumocystis jirovecii pneumonia. Which of the following drugs should be recommended?

A. Valganciclovir
B. Acyclovir
C. Fluconazole
D. Bactrim
E. Clotrimazole lozenges

Answer 14

D.

Pneumocystis pneumonia: CD4 < 200 cells/mm3
Toxoplasma gondii: CD4 < 100 cells/mm3
Mycobacterium avium complex (MAC): CD4 < 50 cells/mm3

Pneumocystis pneumonia: TMP/SMX 1 DS or SS PO daily
Toxoplasma gondii: TMP/SMX 1 DS PO daily
Mycobacterium avium complex (MAC): azithromycin 1200mg PO weekly (or 600mg PO twice weekly)

Question 15

All of the following warnings apply to mycophenolate except:

A. Patients receiving immunosuppressive regimens involving combinations of drugs, including CellCept, are at increased risk of developing lymphomas and other malignancies, particularly of the skin.
B. Mycophenolate can decrease efficacy of oral contraceptives.
C. Oversuppression of the immune system can also increase susceptibility to infection, including opportunistic infections, fatal infections and sepsis.
D. Patients using mycophenolate should be monitored for symptoms of leukocytosis.
E. This drug is Pregnancy Category D and can cause fetal harm when administered to a pregnant woman.

Answer 15

D. Monitor patients for leukopenia (low white blood cell counts) not leukocytosis (high white blood cell counts). Symptoms of infection could indicate a low white blood cell count. Patients should be seen right away if they experience symptoms of infection: fever, chills, sore throat, cough or unexplained bruising or bleeding.

Antiproliferative Agents: inhibit T-lymphocyte proliferation by altering purine synthesis

mycophenolate (CellCept), mycophenolic acid (Myfortic): 1-1.5gm PO BID on empty stomach, these two agents are NOT interchangeable due to difference s in absorption. Boxed warning: Infection risk, lymphoma and skin cancer, congenital malformations (Pregnancy D)

SE: decreases efficacy of oral contraceptives, GI upset, diarrha, vomiting, hyper/hypotension, edema, tachycardia, pain, hyperglycemia, hyper/hypokalemia, hypomagnesemia, hypocalcemia, hypercholesterolemia, tremor, acne, infections

Question 16

Which of the following medications is a calcineurin inhibitor?

A. Sirolimus
B. Azathioprine
C.Mycophenolate
D. Tacrolimus
E. Basiliximab

Answer 16

D. Cyclosporine (Neoral, Gengraf, Sandimmune) and tacrolimus (Prograf, Astagraft XL, Hecoria) are calcineurin antagonists (blockers).

sirolimus (Rapamune) - mTOR inhibitor

azathioprine (Imuran, Azasan) - antiproliferative agent

mycophenolate (CellCept) - antiproliferative agent

basiliximab (Simulect) - IL-2 receptor antagonist

Question 17

Which of the following are induction drugs given prior to graft transplant and are used to prevent acute rejection immediately following the transplant surgery? (Select ALL that apply.)

A. Adalimumab (Humira)
B. Antithymocyte globulin
C. Higher doses of the same drugs used for maintenance
D. Basiliximab (Simulect)
E. Etanercept (Enbrel)

Answer 17

B, C, D. Enbrel and Humira are not used for transplant rejection, although they are immunosuppressants. They are used for rheumatoid arthritis and occasionally for other autoimmune conditions.

Induction immunosuppressant therapy is given before or at the time of transplant to prevent acute rejection during the early post-transplant period by providing high degree of immune suppression. The most commonly used induction agent is basiliximab (IL-2 receptor antagonist of T cells). Higher risk patients may require the addition of the lymphocyte-depleting agent rabbit antithymocyte globulin (Atgam)

Afterwards, we switch over to a calcineurin inhibitor (CNI) at therapeutic dose. Tacrolimus is used more than cyclosporine.

Question 18

A female patient with end stage renal disease secondary to hypertension has been using Fosamax, erythropoietin, cholecalciferol, cyclosporine, Coreg, prednisone and hydrocodone. Since she began taking this regimen she developed hypertension. Which of the medications could be contributing to increased blood pressure levels?

A. Prednisone, erythropoietin, alendronate, hydrocodone
B. Prednisone, erythropoietin, alendronate, cyclosporine
C. Prednisone, cyclosporine, hydrocodone
D. Prednisone, cyclosporine, cholecalciferol
E. Prednisone, cyclosporine, erythropoietin

Answer 18

E. Prednisone, cyclosporine and erythropoietin can all cause hypertension.

cyclosporine (Neoral, Gengraf, Sandimmune) - CNI

Question 19

Patient counseling for renal transplant patients should include all of the following: (Select ALL that apply.)

A. Never skip or change your medication without approval from your healthcare provider; any change can cause your body to reject the transplant.
B. Protect and cover your skin from the sun. You will be more likely to burn. Do not use tanning booths.
C. Do not use acetaminophen for analgesia (pain) or for headaches. It is preferable to use an over-the-counter medicine such as naproxen.
D. Monitor your health at home and keep daily records of your blood glucose (if diabetes or if it has been high), blood pressure, temperature and weight.
E. Do not use live vaccines, and avoid contact with anyone who has recently received the oral polio or nasal influenza (flu) vaccine.

Answer 19

A, B, D, E. Do not use NSAIDs (if renal transplant) and do not use over-the-counter or herbal medicines without checking first with the pharmacist.

Cardiovascular disease is the most common cause of death in transplant patients because most of these drugs cause increase BP, blood glucose, cholesterol, and weight. And so CVD must be managed in these patients.

Higher risk of cancer in transplant patients because the drugs suppressive immune system which is involved in protecting use from lymphoma and skin cancer. Remember LIST (lymphoma, infection, skin cancer, tuberculosis)

Question 20

Which of the following are correct brand names for everolimus? (Select ALL that apply.)

A. Afinitor
B. Rapamune
C. Zortress
D. Myfortic
E. Nulojix

Answer 20

A, C. The brand names of everolimus are Afinitor and Zortress.

Rapamune (sirolimus) - mTOR inhibitor

Myfortic (mycophenolic acid) - antiproliferative agent

Nulojix (belatacept) - mTOR inhibitor

Question 21

Sandra is a renal transplant patient who is adherent with her medications and diet and physical activity regimens. She is doing well. The only current complications are anemia and elevated cholesterol levels, which are both being treated. A tuberculin skin test was ordered. The induration was 8 mm, which is positive for Sandra’s degree of immune suppression. The chest x-ray and signs and symptoms are all negative. Select the correct treatment option that should be added to Sandra’s medications at this time:

A. Atovaquone
B. Rifampin, Isoniazid, Pyrazinamide and Ethambutol
C. Isoniazid
D. Sulfamethoxazole and Trimethoprim
E. Valganciclovir

Answer 21

C. She will need to take pyridoxine (vitamin B6) with the isoniazid.

Question 22

A patient has recently received a renal transplant. The clinical pharmacist that leads the drug management group in the transplant division will counsel the patient. First, general information regarding transplant medications will be provided. Which of the following are correct recommendations? (Select ALL that apply.)

A. It is important to get enough sunlight in order to feel good post-transplant. If you spend time in the sun longer than 2 hours, use a sunscreen of at least 30 SPF.
B. You will need to get your transplant drug levels in your blood monitored. The blood draw must be taken at the “peak” level, which is within 1-2 hours after you have taken your morning dose.
C. Do not make any medication changes without authorization.
D. On days when the level of the drug in your body is being measured, it is important to take your medication after you had your blood drawn (not before). It is important to measure the lowest (trough) level of drug in your blood.
E. Protect your skin from the sun at all times. You can burn more easily. And, transplant patients have a higher risk of getting skin cancer. Proper sun protection is essential.

Answer 22

C, D, E.

Cardiovascular disease is the most common cause of death in transplant patients because most of these drugs cause increase BP, blood glucose, cholesterol, and weight. And so CVD must be managed in these patients.

Higher risk of cancer in transplant patients because the drugs suppressive immune system which is involved in protecting use from lymphoma and skin cancer. Remember LIST (lymphoma, infection, skin cancer, tuberculosis)

Question 23

Choose the correct statements concerning tacrolimus and drug interactions:

A. Tacrolimus is a strong CYP 450 3A4 inducer
B. Tacrolimus is a P-gp inducer
C. P-gp inhibitors will decrease the tacrolimus concentration
D. Tacrolimus is a CYP 450 3A4 substrate
E. Tacrolimus is a strong CYP 450 3A4 inhibitor

Answer 23

D. Tacrolimus and cyclosporine are both CYP 450 3A4 and P-gp substrates; it is important to use extreme caution with inducers or inhibitors. Inhibitors, including grapefruit, will increase the drug concentration and increase toxicity. Inducers will decrease the drug concentration and could result in graft rejection.

Calcineurin Inhibitors (CNIs): suppresses cellular immunity by inhibiting T-lymphocyte activation

tacrolimus (Prograft, Astagraf XL, Hecoria): Should be taken on empty stomach to avoid variability in absorption. Trough level dose depending on transplant type. SE: hypertension and nephrotoxicity, hyperglycemia, tremor, hyperkalemia, QT prolongation. IV:PO IR ratio is 1:4. This is a CYP 3A4 and P-gp substrate (watch for DDI)

Question 24

Jasmine is a thin, white female patient. She has been using prednisone 10 mg daily for at least several months. The pharmacist understands the many risks are associated with long-term steroid use and scans the patient’s profile to check for this recommended agent:

A. An anticholinergic
B. A bisphosphonate
C. Estrogen
D. An acetylcholinesterase inhibitor
E. Progesterone

Answer 24

B. Long-term corticosteroid use depletes bone density. Bisphosphonate therapy may be recommended to preserve bone density. All patients receiving agents that weaken bone should have optimal calcium and vitamin D intake.

Question 25

A female patient with end stage renal disease secondary to lupus received a renal transplant. She has been using cholecalciferol, CellCept, carvedilol, prednisone, tacrolimus, quetiapine, sertraline and ferrous sulfate. Since she began taking this regimen, her fasting blood glucose has risen from an average of 100 mg/dL to a current average of 160 mg/dL. Which of the medications are likely contributing to the increased blood glucose levels? (Select ALL that apply.)

A. Cholecalciferol
B. Quetiapine
C. Tacrolimus
D. Prednisone
E. Sertraline

Answer 25

B, C, D. Carvedilol may be having some effect as well; the others would be having a definitive effect.

quetiapine (Seroquel)

tacrolimus (Prograft, Astagraf XL, Hecoria) - CNI

sertraline (Zoloft) - SSRI

Question 26

A 32 year-old white female with a history of type 1 diabetes and diabetic nephropathy received a kidney transplant. She has been prescribed cyclosporine. Which of the following statements regarding cyclosporine solution is correct?

A. It can be diluted with orange juice or apple juice.
B. It should be administered from a plastic or styrofoam cup.
C. It should be stored in the refrigerator.
D. This medication can also be mixed with grapefruit juice.
E. It is not hepatically metabolized.

Answer 26

A. Instruct patients to take the prescribed amount of the cyclosporine oral solution from the container using the dosing syringe supplied and transfer the solution to a glass of orange or apple juice, which is preferably at room temperature. Stir well and drink all at once. Do not allow diluted oral solution to stand before drinking. Use a glass container (not plastic). Rinse the glass with more liquid to ensure that the total dose is consumed.

cyclosporine (Neoral, Gengraf, Sandimmune): Boxed warning (renal impairment, lymphoma, skin cancer, infection, Gengraf and Neoral cannot be used interchangeably with Sandimmune which is non-modified). SE: hypertension, nephropathy, hyperkalemia, hirsutism, gingival hyperplasia, edema, hyperglycemia, QT prolongation. 3A4 and P-gp substrate (watch for DDI)

Question 27

Tacrolimus and cyclosporine are not used together in order to reduce the risk of this additive/synergistic toxicity:

A. Lymphoma
B. Gastric perforation
C. Hepatotoxicity
D. Nephrotoxicity
E. Neuropathy

Answer 27

D. Both agents are associated with nephrotoxicity, particularly when used in high doses. Drugs with the same mechanism of action are generally not used together. The use of mycophenolate or another adjuvant allows lower doses of the calcineurin inhibitor, and this lowers the risk of nephrotoxicity. It is still a major risk.

Calcineurin Inhibitors (CNIs): suppresses cellular immunity by inhibiting T-lymphocyte activation

tacrolimus (Prograft, Astagraf XL, Hecoria): Should be taken on empty stomach to avoid variability in absorption. Trough level dose depending on transplant type. SE: hypertension and nephrotoxicity, hyperglycemia, tremor, hyperkalemia, QT prolongation. IV:PO IR ratio is 1:4. This is a CYP 3A4 and P-gp substrate (watch for DDI)

cyclosporine (Neoral, Gengraf, Sandimmune): Boxed warning (renal impairment, lymphoma, skin cancer, infection, Gengraf and Neoral cannot be used interchangeably with Sandimmune which is non-modified). SE: hypertension, nephropathy, hyperkalemia, hirsutism, gingival hyperplasia, edema, hyperglycemia, QT prolongation. 3A4 and P-gp substrate (watch for DDI)

Question 28

A pharmacist will counsel a patient beginning CellCept therapy. Which of the following counseling points are correct regarding mycophenolate? (Select ALL that apply.)

A. Take on an empty stomach.
B. Do not take antacids or multivitamins at the same time. These need to be separated by at least two hours. Do not take with Questran or Welchol.
C. If you cannot tolerate the medicine on an empty stomach, you can take with a light meal if less than 300 calories.
D. Take every 12 hours, such as 8AM and 8PM.
E. If you are unable to swallow the Cellcept capsule, you can open the capsule and sprinkle the contents on applesauce.

Answer 28

A, B, D. If the patient is not able to swallow tablets or capsules, the healthcare provider can prescribe an oral suspension. Do not open CellCept capsules.

Antiproliferative Agents: inhibit T-lymphocyte proliferation by altering purine synthesis

mycophenolate (CellCept), mycophenolic acid (Myfortic): 1-1.5gm PO BID on empty stomach, these two agents are NOT interchangeable due to difference s in absorption. Boxed warning: Infection risk, lymphoma and skin cancer, congenital malformations (Pregnancy D)

SE: decreases efficacy of oral contraceptives, GI upset, diarrha, vomiting, hyper/hypotension, edema, tachycardia, pain, hyperglycemia, hyper/hypokalemia, hypomagnesemia, hypocalcemia, hypercholesterolemia, tremor, acne, infections

Question 29

Jermaine is taking mycophenolate to prevent organ rejection of a kidney transplant. Which of the following statements regarding mycophenolate is correct?

A. CellCept and Myfortic can be used interchangeably.
B. This medication is safe to take during pregnancy.
C. Mycophenolate mofetil is CellCept.
D. Mycophenolate capsules should be stored in the refrigerator.
E. Mycophenolate cannot be used with tacrolimus.

Answer 29

C. Mycophenolate delayed release (Myfortic) cannot be interchanged with CellCept. They are both dosed twice daily, and taken on an empty stomach.

Antiproliferative Agents: inhibit T-lymphocyte proliferation by altering purine synthesis

mycophenolate (CellCept), mycophenolic acid (Myfortic): 1-1.5gm PO BID on empty stomach, these two agents are NOT interchangeable due to difference s in absorption. Boxed warning: Infection risk, lymphoma and skin cancer, congenital malformations (Pregnancy D)

SE: decreases efficacy of oral contraceptives, GI upset, diarrha, vomiting, hyper/hypotension, edema, tachycardia, pain, hyperglycemia, hyper/hypokalemia, hypomagnesemia, hypocalcemia, hypercholesterolemia, tremor, acne, infections

Question 30

What is the mechanism of action of everolimus?

A. Calcineurin inhibitor
B. Mammalian target of rapamycin (mTor) kinase inhibitor
C. Antiproliferative agent
D. Monoclonal antibody
E. Corticosteroid

Answer 30

B. Mammalian target of rapamycin kinase inhibitors (everolimus and sirolimus) are called mTor inhibitors–and these “inhibitors” have many drug interactions.

mTOR kinase inhibitor: inhibits T-lymphocyte activation and proliferation; may be synergistic with CNIs

everolimus (Zortress, Aflinitor): Boxed warning (infection, lymphoma, skin cancer, reduce dose of cyclosporine when use concomitantly, renal thrombosis, not for heart transplant). SE: peripheral edema, constipation, hypertension, hyperglycemia, hyperlipidemia, delayed wound healing, pneumonitis.

sirolimus (Rapamune), belatacept (Nulojix): used less commonly, just know they are mTOR inhibitors.

Question 31

Cardiovascular disease is the major cause of death in transplant recipients. This is challenging considering that the anti-rejection drugs contribute to weight gain and metabolic syndrome. Select the correct goals for a renal transplant patients:

A. BMI < 18.5 kg/m2
B. Blood pressure should be well controlled per ADA goals: < 140/90 mmHg (or goal BP set by the transplant center)
C. Blood pressure < 160/95 mmHg
D. Smoking < 20 cigarettes daily
E. Increased physical activity

Answer 31

B. Smoking should be discontinued. The blood pressure goals are set by the transplant center and may be lower; most transplants are renal and the one kidney the patient has must be protected.

Question 32

A 64-year-old man underwent liver transplantation because of cirrhosis (hepatitis B virus and alcoholism) and hepatocellular carcinoma. He was started on several immunosuppressive medications including azathioprine, sirolimus and prednisone for maintenance therapy. Which vaccines should be avoided in this patient? (Select ALL that apply.)

A. FluMist
B. Zostavax
C. Pneumovax 23
D. Fluzone Intradermal
E. FluBlok

Answer 32

A, B. Transplant recipients are taking medications that suppress the immune system. Administering a live vaccine could result in the disease that you are vaccinating against since the immune system may not be able to halt replication. Avoid the use of live vaccines. The more common live vaccines include the intranasal flu mist vaccine, measles, mumps, rubella, Varivax(chickenpox) and the herpes zoster vaccine Zostavax (shingles).

Question 33

Select the correct instructions for a patient using CellCept:

A. Take once daily on an empty stomach.
B. Take twice daily on an empty stomach, 12 hours apart.
C. Take three times daily on an empty stomach, 8 hours apart.
D. Take twice daily, with food, 12 hours apart.
E. Any of the above dosing regimens is acceptable.

Answer 33

B. CellCept is taken twice daily on an empty stomach. Missed doses can cause a graft rejection. Transplant medications are scheduled at specific times to keep the level stable and therapeutic.

Antiproliferative Agents: inhibit T-lymphocyte proliferation by altering purine synthesis

mycophenolate (CellCept), mycophenolic acid (Myfortic): 1-1.5gm PO BID on empty stomach, these two agents are NOT interchangeable due to difference s in absorption. Boxed warning: Infection risk, lymphoma and skin cancer, congenital malformations (Pregnancy D)

SE: decreases efficacy of oral contraceptives, GI upset, diarrha, vomiting, hyper/hypotension, edema, tachycardia, pain, hyperglycemia, hyper/hypokalemia, hypomagnesemia, hypocalcemia, hypercholesterolemia, tremor, acne, infections

Question 34

Jerry, a 54 year-old African American male, presented with severe hypertension and renal failure. He underwent a renal transplant and was discharged on tacrolimus and prednisolone. He developed seizures from the use of tacrolimus and was changed to cyclosporine. Which of the following side effects are likely with cyclosporine therapy?

A. Elevated blood glucose
B. Nephrotoxicity
C. QT-prolongation
D. Alopecia
E. Hypotension

Answer 34

A, B, C. Renal dysfunction and hypertension are the most common concerns with the use of cyclosporine. Drug interactions are a significant concern.

cyclosporine (Neoral, Gengraf, Sandimmune): Boxed warning (renal impairment, lymphoma, skin cancer, infection, Gengraf and Neoral cannot be used interchangeably with Sandimmune which is non-modified). SE: hypertension, nephropathy, hyperkalemia, hirsutism, gingival hyperplasia, edema, hyperglycemia, QT prolongation. 3A4 and P-gp substrate (watch for DDI)

Question 35

A patient will be receiving azathioprine as part of her chronic immunosuppressive regimen. She has received a kidney transplant from an unknown donor. Which of the following statements are correct? (Select ALL that apply.)

A. One of the brand names of azathioprine is Imuran.
B. The use of immunosuppressive agents can cause skin cancer and lymphomas; both these cancer types are partially suppressed by a strong immune system.
C. Azathioprine is most commonly used as an induction agent, or in acute rejection.
D. Patients with genetic deficiency of thiopurine methyltransferase (TPMT) will be more sensitive to the drug and will likely require lower doses.
E. Patients with the HLA-1502 genotype cannot use this drug.

Answer 35

A, B, D. The other brand name for azathioprine (in addition to Imuran) is Azasan. This drug is used for immune suppression for a variety of immune or inflammatory disorders.

azathioprine (Azasan, Imuran): Boxed warning (lymphoma, hematologic toxicities). Genetic deficiency of thiopurine methyltransferase (TPMT) increases the risk of myelosuppression and may require lower dose.

Question 36

A transplant recipient is receiving the maintenance agent belatacept (Nulojix). Which statements concerning belatacept are correct? (Select ALL that apply.)

A. A silicone-free disposable syringe comes with the drug.
B. Nulojix is available in oral formulation only.
C. Post-transplant lymphoproliferative disorder (PTLD), a condition that can happen when lymphocytes grow out of control due to immunesuppression, can occur with use of belatacept and is a boxed warning for the drug.
D. Patients must have immunity to Epstein Bar Virus (seropositive) to receive belatacept; patients without immunity are at higher risk for PTLD.
E. Patients self-administer Nulojix.

Answer 36

A, C, D. Belatacept (Nulojix) is an infusion given in a medical office, using the silicone-free disposal syringe that comes with the drug.

Question 37

Select the blood types that a patient with type B blood can receive without suffering a rejection due to an incompatibility blood type match. (Select ALL that apply.)

A. Type A
B. Type B
C. Type O
D. Type AB
E. Any type blood is fine.

Answer 37

B, C.

Question 38

Choose the correct statement/s regarding cyclosporine formulations: (Select ALL that apply.)

A. Sandimmune can be interchanged with Neoral but not with Gengraf.
B. Cyclosporine is available as Neoral capsules, which have improved absorption.
C. A formulation of cyclosporine is available to treat excessive lacrimation.
D. A formulation of cyclosporine called Restasis is available to treat dry eyes; if used, the patient must be diligent to avoid contamination due to eye infection risk.
E. Cylosporine (and tacrolimus) require monitoring of the trough levels.

Answer 38

B, D, E. Neoral capsules have better absorption; they are not interchangeable with Sandimmune. Sandimmune cannot be interchanged with other formulations.

cyclosporine (Neoral, Gengraf, Sandimmune): Boxed warning (renal impairment, lymphoma, skin cancer, infection, Gengraf and Neoral cannot be used interchangeably with Sandimmune which is non-modified; modified Gengraf and Neoral have better absorption than Sandimmune). SE: hypertension, nephropathy, hyperkalemia, hirsutism, gingival hyperplasia, edema, hyperglycemia, QT prolongation. 3A4 and P-gp substrate (watch for DDI)