OverviewOverview

• Immunosuppressive drugs

• Cardiovascular disease & hyperlipidemia

• Hypertension

• Diabetes

• Vaccines

• Immunosuppressive drugs

• Cardiovascular disease & hyperlipidemia

• Hypertension

• Diabetes

• Vaccines

Immunosuppressive DrugsImmunosuppressive Drugs

• Corticosteroids

• Antiproliferative agents

– Azathioprine

– Mycophenolate mofetil (MMF)

– Mycophenolic acid (MPA)

• Corticosteroids

• Antiproliferative agents

– Azathioprine

– Mycophenolate mofetil (MMF)

– Mycophenolic acid (MPA)

• Calcineurin inhibitors

– Cyclosporine

– Tacrolimus

• mTOR inhibitors

– Sirolimus

– Everolimus

• Calcineurin inhibitors

– Cyclosporine

– Tacrolimus

• mTOR inhibitors

– Sirolimus

– Everolimus

Mycophenolate Mofetil (Cellcept®)Mycophenolate Mofetil (Cellcept®)

• Prodrug converted to active moiety mycophenolic acid (MPA)

• Typical Dose: 1000mg BID

• Monitoring: CBC, MPA levels +/-

• Prodrug converted to active moiety mycophenolic acid (MPA)

• Typical Dose: 1000mg BID

• Monitoring: CBC, MPA levels +/-

Mycophenolic Acid (Myfortic®)Mycophenolic Acid (Myfortic®)

• Enteric coated product that provides active moiety

• Typical Dose: 720mg BID

• Monitoring: CBC, MPA levels +/-

• Enteric coated product that provides active moiety

• Typical Dose: 720mg BID

• Monitoring: CBC, MPA levels +/-

Adverse Effects of MMF & MPAAdverse Effects of MMF & MPA

• Gastritis, anorexia, cramping, diarrhea

• Neutropenia, thrombocytopenia, anemia

• Trend toward incidence of infections

– CMV, HSV

• Progressive multifocal leukoencephalopathy (PML) - rare

• Gastritis, anorexia, cramping, diarrhea

• Neutropenia, thrombocytopenia, anemia

• Trend toward incidence of infections

– CMV, HSV

• Progressive multifocal leukoencephalopathy (PML) - rare

Practical Tips for MMF & MPAPractical Tips for MMF & MPA

• Take with food

• Do not crush, cut or chew tablets (MPA)

• Transplant center may reduce dose, split into TID dosing, or convert to MPA

• Equimolar dosing

– 500mg MMF = 360mg MPA

• Do not take with iron

• Take with food

• Do not crush, cut or chew tablets (MPA)

• Transplant center may reduce dose, split into TID dosing, or convert to MPA

• Equimolar dosing

– 500mg MMF = 360mg MPA

• Do not take with iron

Calcineurin InhibitorsCalcineurin Inhibitors

• Tacrolimus (Prograf®, FK506)

– Usual Starting Dose• 0.05mg/kg q 12 hours

• Cyclosporine (Sandimmune®, Neoral®, Gengraf®)

– Usual Starting Dose• 2.5mg/kg q 12 hours

• Dose adjustment

– By the transplant center based on drug level

• Tacrolimus (Prograf®, FK506)

– Usual Starting Dose• 0.05mg/kg q 12 hours

• Cyclosporine (Sandimmune®, Neoral®, Gengraf®)

– Usual Starting Dose• 2.5mg/kg q 12 hours

• Dose adjustment

– By the transplant center based on drug level

Adverse Effects of Calcineurin InhibitorsAdverse Effects of Calcineurin Inhibitors• Cyclosporine > Tacrolimus

– Hypertension and hyperlipidemia

– Gingival hyperplasia, hirsutism

• Tacrolimus > Cyclosporine

– Hyperglycemia, neurotoxicity, and GI side effects

– Alopecia

• Tacrolimus ~ Cyclosporine

– Nephrotoxicity (Serum Cr)

– Hyperkalemia

– Hypomagnesemia

• Cyclosporine > Tacrolimus

– Hypertension and hyperlipidemia

– Gingival hyperplasia, hirsutism

• Tacrolimus > Cyclosporine

– Hyperglycemia, neurotoxicity, and GI side effects

– Alopecia

• Tacrolimus ~ Cyclosporine

– Nephrotoxicity (Serum Cr)

– Hyperkalemia

– Hypomagnesemia

Calcineurin Inhibitor MonitoringCalcineurin Inhibitor Monitoring

• Drug levels (12-hr trough drug level)

• BUN, creatinine, electrolytes, Mg

• Blood sugar, lipid profile, blood pressure

• CNS toxicity (tremor, headache, seizures)

• Drug levels (12-hr trough drug level)

• BUN, creatinine, electrolytes, Mg

• Blood sugar, lipid profile, blood pressure

• CNS toxicity (tremor, headache, seizures)

mTOR Inhibitor: Sirolimus (Rapamune®)mTOR Inhibitor: Sirolimus (Rapamune®)

• Typical dose

– 6-15mg loading dose, then 2-5mg/day maintenance dose (once daily)

• Monitoring

– 24-hr trough level (goal 5-15ng/mL)• Check levels 5-7 days after dose adjustments

– Lipid profile, CBC

• Dose adjustment

– By the transplant center based on drug level

• Typical dose

– 6-15mg loading dose, then 2-5mg/day maintenance dose (once daily)

• Monitoring

– 24-hr trough level (goal 5-15ng/mL)• Check levels 5-7 days after dose adjustments

– Lipid profile, CBC

• Dose adjustment

– By the transplant center based on drug level

Adverse Effects of SirolimusAdverse Effects of Sirolimus

• Hyperlipidemia (cholesterol and TGs)

• Hypertension

• Thrombocytopenia, leukopenia, anemia

• Constipation, diarrhea, nausea

• Impaired wound healing

• Hyperlipidemia (cholesterol and TGs)

• Hypertension

• Thrombocytopenia, leukopenia, anemia

• Constipation, diarrhea, nausea

• Impaired wound healing

Cyclosporine, Tacrolimus, and Sirolimus InteractionsCyclosporine, Tacrolimus, and Sirolimus Interactions

• Decreased immunosuppressive drug levels by induction of CYP3A4

– Antibiotics• Rifampin

• Nafcillin

– Anti-convulsants• Phenobarbital, phenytoin, and carbamazepine

– Herbs• St. John’s Wort

• Decreased immunosuppressive drug levels by induction of CYP3A4

– Antibiotics• Rifampin

• Nafcillin

– Anti-convulsants• Phenobarbital, phenytoin, and carbamazepine

– Herbs• St. John’s Wort

Cyclosporine, Tacrolimus, and Sirolimus Interactions Cyclosporine, Tacrolimus, and Sirolimus Interactions

• Increased immunosuppressive drug levels by inhibition of CYP3A4

– Antihypertensives: verapamil, diltiazem

– Azole Antifungals: e.g., fluconazole

– Antibacterial: erythromycin, clarithromycin

– Antiretroviral: ritonavir, nelfinavir

– Anti-arrhythmic: amiodarone

– Other: grapefruit/ grapefruit juice

• Increased immunosuppressive drug levels by inhibition of CYP3A4

– Antihypertensives: verapamil, diltiazem

– Azole Antifungals: e.g., fluconazole

– Antibacterial: erythromycin, clarithromycin

– Antiretroviral: ritonavir, nelfinavir

– Anti-arrhythmic: amiodarone

– Other: grapefruit/ grapefruit juice

Complications of ImmunosuppressionComplications of Immunosuppression

• Cardiovascular disease (CVD)

• Hypertension

• Dyslipidemia

• Diabetes

• Renal failure

• Cardiovascular disease (CVD)

• Hypertension

• Dyslipidemia

• Diabetes

• Renal failure

• Infection

• Anemia

• Osteoporosis

• Malignancy

• Gout

• Infection

• Anemia

• Osteoporosis

• Malignancy

• Gout

CVD in Transplant RecipientsCVD in Transplant Recipients

• Prevalence:

– Kidney transplant recipient• 5 yr risk of CV event with hyperlipidemia: 12%

• 5 yr CV mortality with hyperlipidemia: 5%

• 5 yr mortality (all cause): 8 -15%

– Heart or liver transplant recipient• 5 yr mortality (all cause): 25%

• Prevalence:

– Kidney transplant recipient• 5 yr risk of CV event with hyperlipidemia: 12%

• 5 yr CV mortality with hyperlipidemia: 5%

• 5 yr mortality (all cause): 8 -15%

– Heart or liver transplant recipient• 5 yr mortality (all cause): 25%

CVD in Transplant RecipientsCVD in Transplant Recipients

• Many patients die of CVD with an otherwise functioning transplant

– e.g., 40% of kidney transplant patients die with a functioning kidney

• Many patients die of CVD with an otherwise functioning transplant

– e.g., 40% of kidney transplant patients die with a functioning kidney

Risk Factors for CVD are Highly Prevalent in Transplant RecipientsRisk Factors for CVD are Highly Prevalent in Transplant Recipients

• Prevalence in kidney transplant patients:

– Hypertension 80%

– Hypercholesterolemia 80%

– Diabetes Mellitus 55%

– Obesity 30%

– Smoking 20%

• Prevalence in kidney transplant patients:

– Hypertension 80%

– Hypercholesterolemia 80%

– Diabetes Mellitus 55%

– Obesity 30%

– Smoking 20%

Reasons for Hyperlipidemia in Transplant RecipientsReasons for Hyperlipidemia in Transplant Recipients

• Reflects incidence in general population

– DM, obesity, lifestyle

• Diabetes and atherosclerosis contributes to end organ failure necessitating transplant

• Increased incidence of DM after transplantation

– Weight gain after organ transplant

– Use of prednisone and tacrolimus

• Direct effect of immunosuppressive agents

• Reflects incidence in general population

– DM, obesity, lifestyle

• Diabetes and atherosclerosis contributes to end organ failure necessitating transplant

• Increased incidence of DM after transplantation

– Weight gain after organ transplant

– Use of prednisone and tacrolimus

• Direct effect of immunosuppressive agents

Immunosuppressive Drugs Contribute to HyperlipidemiaImmunosuppressive Drugs Contribute to Hyperlipidemia

• Increased LDL-C

– Cyclosporine > prednisone

• Lower HDL-C

– Cyclosporine > prednisone

• Increased triglycerides

– Sirolimus > prednisone

• Increased LDL-C

– Cyclosporine > prednisone

• Lower HDL-C

– Cyclosporine > prednisone

• Increased triglycerides

– Sirolimus > prednisone

Hyperlipidemia in Transplant RecipientsHyperlipidemia in Transplant Recipients

• Why treat?

– Statins are effective in reducing CV mortality

– Transplant recipients are at high risk for CV events

• What is the data in transplant recipients?

– Excluded from large hyperlipidemia trials

– Recent randomized prospective studies in transplant pts are just beginning to demonstrate reductions in CV events

• Why treat?

– Statins are effective in reducing CV mortality

– Transplant recipients are at high risk for CV events

• What is the data in transplant recipients?

– Excluded from large hyperlipidemia trials

– Recent randomized prospective studies in transplant pts are just beginning to demonstrate reductions in CV events

Management of Hyperlipidemia: NCEP (ATPIII) GuidelinesManagement of Hyperlipidemia: NCEP (ATPIII) Guidelines

• Therapeutic lifestyle changes (TLC)

– Diet, weight loss, physical activity

• Drug therapy

– HMG CoA reductase inhibitors

– Bile acid sequestrants

– Fibric acid derivatives

– Omega 3 fatty acids

• Therapeutic lifestyle changes (TLC)

– Diet, weight loss, physical activity

• Drug therapy

– HMG CoA reductase inhibitors

– Bile acid sequestrants

– Fibric acid derivatives

– Omega 3 fatty acids

Management of HyperlipidemiaManagement of Hyperlipidemia

• HMG-CoA reductase inhibitors (statins)–preferred for LDL-C

– Low dose pravastatin or simvastatin are generally well tolerated in transplant patients

– Increased risk of myopathy & rhabdomyolysis when combined with cyclosporine or tacrolimus

• Bile acid sequestrants e.g. cholestyramine

– Reduces LDL-C but may increase triglycerides

– May interfere with immunosuppressive drug absorption

• HMG-CoA reductase inhibitors (statins)–preferred for LDL-C

– Low dose pravastatin or simvastatin are generally well tolerated in transplant patients

– Increased risk of myopathy & rhabdomyolysis when combined with cyclosporine or tacrolimus

• Bile acid sequestrants e.g. cholestyramine

– Reduces LDL-C but may increase triglycerides

– May interfere with immunosuppressive drug absorption

Management of HyperlipidemiaManagement of Hyperlipidemia

• Fibric acid derivatives e.g. gemfibrozil

– More effective for hypertriglyceridemia

– Avoid combining with a statin in patients on cyclosporine or tacrolimus

• Omega 3 fatty acids

– Useful for hypertriglyceridemia

– Decreased risk of rhabdomyolysis when combined with CSA or tacrolimus

• Fibric acid derivatives e.g. gemfibrozil

– More effective for hypertriglyceridemia

– Avoid combining with a statin in patients on cyclosporine or tacrolimus

• Omega 3 fatty acids

– Useful for hypertriglyceridemia

– Decreased risk of rhabdomyolysis when combined with CSA or tacrolimus

Hyperlipidemia SummaryHyperlipidemia Summary

• Immunosuppressive medications contribute to hyperlipidemia

• Transplant recipients should be screened yearly and 2-3 months after changes in therapy that affect lipid levels

• NCEP guidelines should be followed as a guide to therapy; transplant recipients should be considered high risk

– LDL-C < 100 mg/dl is optimal

• Immunosuppressive medications contribute to hyperlipidemia

• Transplant recipients should be screened yearly and 2-3 months after changes in therapy that affect lipid levels

• NCEP guidelines should be followed as a guide to therapy; transplant recipients should be considered high risk

– LDL-C < 100 mg/dl is optimal

Hyperlipidemia SummaryHyperlipidemia Summary

• HMG-Co reductase inhibitors (statins) should be used as first line therapy to lower LDL-C after lifestyle changes

• Monitor for myopathy and rhabdomyolysis

• HMG-Co reductase inhibitors (statins) should be used as first line therapy to lower LDL-C after lifestyle changes

• Monitor for myopathy and rhabdomyolysis

Risk Factors for Developing HTN in Transplant RecipientRisk Factors for Developing HTN in Transplant Recipient

• Obesity

• Ethnicity/Race

• Genetics

• Immunosuppressive medications

– Cyclosporine > tacrolimus, steroids

• Preexisting hypertension

• Development of renal failure

• Obesity

• Ethnicity/Race

• Genetics

• Immunosuppressive medications

– Cyclosporine > tacrolimus, steroids

• Preexisting hypertension

• Development of renal failure

Hypertension in Organ Transplant RecipientsHypertension in Organ Transplant Recipients

• Effective antihypertensive treatment

– Reduces target organ damage

– Decreases cardiovascular events

– Promotes long-term allograft and patient survival

• Effective antihypertensive treatment

– Reduces target organ damage

– Decreases cardiovascular events

– Promotes long-term allograft and patient survival

Management of HypertensionManagement of Hypertension

• JNC-7 Guidelines

• Life style modifications

– Diet – including salt reduction

– Weight management

– Increased physical activity

– Moderation of alcohol consumption

• Medications

• JNC-7 Guidelines

• Life style modifications

– Diet – including salt reduction

– Weight management

– Increased physical activity

– Moderation of alcohol consumption

• Medicationswww.nhlbi.nih.gov/guidelines/hypertension

Calcium Channel Blockers (CCBs)Calcium Channel Blockers (CCBs)

• Dihydropyridine:

– amlodipine, felodipine, nifedipine

• Non-dihydropyridine:

– verapamil, diltiazem

• Dihydropyridine:

– amlodipine, felodipine, nifedipine

• Non-dihydropyridine:

– verapamil, diltiazem

CCB Adverse EffectsCCB Adverse Effects

• Gingival hyperplasia

• Peripheral edema

• Decreased heart rate (verapamil & diltiazem)

• Increases immunosuppressant drug levels (verapamil & diltiazem)

• Gingival hyperplasia

• Peripheral edema

• Decreased heart rate (verapamil & diltiazem)

• Increases immunosuppressant drug levels (verapamil & diltiazem)

Beta BlockersBeta Blockers

• Cardioselective preferred - metoprolol, atenolol

• Beneficial in patients with heart failure or post MI

• Adverse effects

– Bradycardia

– Significant sinus bradycardia or heart block when combined with non-dihydropyridine CCB

– May increase bronchospasm

• Cardioselective preferred - metoprolol, atenolol

• Beneficial in patients with heart failure or post MI

• Adverse effects

– Bradycardia

– Significant sinus bradycardia or heart block when combined with non-dihydropyridine CCB

– May increase bronchospasm

ACE Inhibitors (ACEI)/ Angiotension II Receptor Blockers (ARBs)ACE Inhibitors (ACEI)/ Angiotension II Receptor Blockers (ARBs)

• Long acting ACEI preferred

• Especially beneficial in:

– Patients with heart failure or post MI

– Patients with kidney disease and proteinuria

• ARBs can be used for ACEI-induced cough

• Long acting ACEI preferred

• Especially beneficial in:

– Patients with heart failure or post MI

– Patients with kidney disease and proteinuria

• ARBs can be used for ACEI-induced cough

ACEI/ARBs Adverse EffectsACEI/ARBs Adverse Effects

• May decrease renal function, especially if renal artery stenosis present

• May contribute to anemia

• May cause hyperkalemia, esp. with tacrolimus, cyclosporine

• ACEI may lead to cough

• May decrease renal function, especially if renal artery stenosis present

• May contribute to anemia

• May cause hyperkalemia, esp. with tacrolimus, cyclosporine

• ACEI may lead to cough

Alpha-1 BlockersAlpha-1 Blockers

• Long acting agents preferred

– e.g. doxazosin, terazosin

• Often used as add-on therapy

• Beneficial in patients with BPH

• Adverse effects:

– First dose hypotension: begin with low dose at bed time

– Increased risk for orthostatic hypotension

• Long acting agents preferred

– e.g. doxazosin, terazosin

• Often used as add-on therapy

• Beneficial in patients with BPH

• Adverse effects:

– First dose hypotension: begin with low dose at bed time

– Increased risk for orthostatic hypotension

DiureticsDiuretics

• Low dose thiazide diuretics preferred

– e.g. HCTZ (12.5-25mg)

• Beneficial in patients with edema or resistant hypertension

• May be ineffective with severe renal disease

• Adverse effects:

– May cause volume depletion and elevate creatinine, BUN

– May cause hypokalemia

• Low dose thiazide diuretics preferred

– e.g. HCTZ (12.5-25mg)

• Beneficial in patients with edema or resistant hypertension

• May be ineffective with severe renal disease

• Adverse effects:

– May cause volume depletion and elevate creatinine, BUN

– May cause hypokalemia

Hypertension SummaryHypertension Summary

• Common in transplant patients

• Follow JNC7 guidelines for the mgmt. of HTN, beginning with lifestyle changes

• Many will require combination drug therapy

• Monitor for side effects and drug interactions

• Contact transplant center or hypertension specialist for difficult cases

• Common in transplant patients

• Follow JNC7 guidelines for the mgmt. of HTN, beginning with lifestyle changes

• Many will require combination drug therapy

• Monitor for side effects and drug interactions

• Contact transplant center or hypertension specialist for difficult cases

Diabetes MellitusDiabetes Mellitus

• Increasing in the general population

– Diagnostic criteria redefined

– Increased obesity

• More common after transplant

– Immunosuppressive drug therapy

• Incidence of new onset diabetes

– Renal transplant 4-25%

– Liver transplant 2.5-25%

• In Hepatitis C patients 40-60%

• Increasing in the general population

– Diagnostic criteria redefined

– Increased obesity

• More common after transplant

– Immunosuppressive drug therapy

• Incidence of new onset diabetes

– Renal transplant 4-25%

– Liver transplant 2.5-25%

• In Hepatitis C patients 40-60%

Working DefinitionsWorking Definitions

• Diabetes mellitus

– FPG ≥ 126mg/dL OR

– Random plasma glucose level ≥ 200mg/dL and symptoms of diabetes

• Impaired fasting glucose (IFG)

– FPG ≥ 100mg/dL and < 126mg/dL

• Diabetes mellitus

– FPG ≥ 126mg/dL OR

– Random plasma glucose level ≥ 200mg/dL and symptoms of diabetes

• Impaired fasting glucose (IFG)

– FPG ≥ 100mg/dL and < 126mg/dL

Risk FactorsRisk Factors

• African American, Hispanic, Native American

• Family history

• Pre-transplant glucose intolerance

• Obesity or presence of other components of metabolic syndrome

• Age > 40 years

• HCV infection, CMV infection

• Immunosuppressant medications

– Prednisone, tacrolimus > cyclosporine

• African American, Hispanic, Native American

• Family history

• Pre-transplant glucose intolerance

• Obesity or presence of other components of metabolic syndrome

• Age > 40 years

• HCV infection, CMV infection

• Immunosuppressant medications

– Prednisone, tacrolimus > cyclosporine

Consequences of Diabetes MellitusConsequences of Diabetes Mellitus

• Infection

• Microvascular complications

– Neuropathy, nephropathy, retinopathy

• Macrovascular complications

– CVD

• Infection

• Microvascular complications

– Neuropathy, nephropathy, retinopathy

• Macrovascular complications

– CVD

Treatment GoalsTreatment Goals

• In general, should follow established guidelines

• Blood glucose goals

– A1c < 7% (not always accurate after blood transfusions, hemolysis, or anemia)

– FPG 70-130mg/dL

– Postprandial <180mg/dL

• Blood pressure <130/80 mmHg

• LDL <100mg/dL

• In general, should follow established guidelines

• Blood glucose goals

– A1c < 7% (not always accurate after blood transfusions, hemolysis, or anemia)

– FPG 70-130mg/dL

– Postprandial <180mg/dL

• Blood pressure <130/80 mmHg

• LDL <100mg/dL

.

Diabetes Care 2007: 30:S4-S41; www.oqp.med.va.gov/cpg/cpg.htm

Treatment StrategiesTreatment Strategies

• Non-pharmacologic

– Counseling on weight control, diet, and exercise

• Pharmacologic

– Oral or insulin monotherapy

– Combination therapy

• Altering immunosuppressive regimens (in consultation with the transplant center)

• Non-pharmacologic

– Counseling on weight control, diet, and exercise

• Pharmacologic

– Oral or insulin monotherapy

– Combination therapy

• Altering immunosuppressive regimens (in consultation with the transplant center)

Sulfonylureas (Glipizide, Glyburide)Sulfonylureas (Glipizide, Glyburide)

• Pros

– Does not require injection

• Cons

– Less effective in patients on high dose prednisone

– Risk for hypoglycemia lower with glipizide than glyburide

• Pros

– Does not require injection

• Cons

– Less effective in patients on high dose prednisone

– Risk for hypoglycemia lower with glipizide than glyburide

Biguanides (Metformin)Biguanides (Metformin)

• Pros

– Beneficial in obese patients with insulin resistance

• Cons

– Increased risk of lactic acidosis with renal impairment

– Use with extreme caution in transplant patients, as renal function can change rapidly

• Pros

– Beneficial in obese patients with insulin resistance

• Cons

– Increased risk of lactic acidosis with renal impairment

– Use with extreme caution in transplant patients, as renal function can change rapidly

Insulin Insulin

• Pros– Allows for tight glucose control– Easy to titrate– NPH insulin’s onset and duration follows blood

glucose rise caused by steroids• Cons

– Patients have to learn to self inject– Risk of severe hypoglycemia– Often requires multiple injections– Requires intensive blood glucose monitoring

• Pros– Allows for tight glucose control– Easy to titrate– NPH insulin’s onset and duration follows blood

glucose rise caused by steroids• Cons

– Patients have to learn to self inject– Risk of severe hypoglycemia– Often requires multiple injections– Requires intensive blood glucose monitoring

Immunosuppressive Alterations by Transplant CenterImmunosuppressive Alterations by Transplant Center

• Possible options

– Taper or discontinue steroids

– Decrease calcineurin inhibitor dose

– Change tacrolimus to cyclosporine

• Possible options

– Taper or discontinue steroids

– Decrease calcineurin inhibitor dose

– Change tacrolimus to cyclosporine

Diabetes SummaryDiabetes Summary

• Diabetes is common in the transplant population

• Goals for the diabetic transplant patient should follow standard guidelines

• Treating diabetes is important for preventing complications & promoting survival

• Insulin and glipizide are safe first-line agents for post-transplant patients

• Diabetes is common in the transplant population

• Goals for the diabetic transplant patient should follow standard guidelines

• Treating diabetes is important for preventing complications & promoting survival

• Insulin and glipizide are safe first-line agents for post-transplant patients

Vaccines in Solid Organ Recipients: General PrinciplesVaccines in Solid Organ Recipients: General Principles

• Transplant recipients are more susceptible to infections, including those that can be prevented by vaccination

• Optimal time to vaccinate is before transplantation

• After transplantation

– Killed vaccines are less effective

– Live viral vaccines are contraindicated

• Transplant recipients are more susceptible to infections, including those that can be prevented by vaccination

• Optimal time to vaccinate is before transplantation

• After transplantation

– Killed vaccines are less effective

– Live viral vaccines are contraindicated

Vaccines in Solid Organ Recipients: General PrinciplesVaccines in Solid Organ Recipients: General Principles

• Seasonal, periodic or booster doses of common killed vaccines should be administered after transplant

• Vaccines required for specific risk factors or for travel should be given after consultation with transplant center or ID specialist

• Seasonal, periodic or booster doses of common killed vaccines should be administered after transplant

• Vaccines required for specific risk factors or for travel should be given after consultation with transplant center or ID specialist

Inactivated (Killed) VaccinesInactivated (Killed) Vaccines• Inactivated Influenza vaccine

– Yearly during influenza season

• Pneumococcal vaccine

– 2 doses with the second dose after 5 yr

• Tetanus/Diptheria

– Td every 10 years as booster

– Tdap should be given once instead of Td if pt hasn’t previously received it AND is <65 yrs

• Hepatitis A and B

– If not previously immunized

• Inactivated Influenza vaccine

– Yearly during influenza season

• Pneumococcal vaccine

– 2 doses with the second dose after 5 yr

• Tetanus/Diptheria

– Td every 10 years as booster

– Tdap should be given once instead of Td if pt hasn’t previously received it AND is <65 yrs

• Hepatitis A and B

– If not previously immunized

Live Vaccines Contraindicated Live Vaccines Contraindicated

• MMR• Nasal influenza• Oral Polio• Oral typhoid• Rotavirus• Varicella• Zoster

• Household contacts who receive a live vaccine present a risk to the transplant patient

• MMR• Nasal influenza• Oral Polio• Oral typhoid• Rotavirus• Varicella• Zoster

• Household contacts who receive a live vaccine present a risk to the transplant patient

Long Term Health of the Transplant RecipientLong Term Health of the Transplant Recipient

• Optimize length and quality of life for Veterans

• Transplant Center focuses on long term immunosuppression and monitoring transplant function

• Primary Care Team focuses on preventive healthcare and management of common problems

• Optimize length and quality of life for Veterans

• Transplant Center focuses on long term immunosuppression and monitoring transplant function

• Primary Care Team focuses on preventive healthcare and management of common problems

When to Contact the Transplant CenterWhen to Contact the Transplant Center

• Dysfunction of the transplanted organ

• Immunosuppressive drug-related issues

• Life threatening infections

• Malignancy

• Major organ failure

• Dysfunction of the transplanted organ

• Immunosuppressive drug-related issues

• Life threatening infections

• Malignancy

• Major organ failure

VANTS Calls

September 4, 2008October 28, 2008

1-800-767-1750Access code: 86360#

VANTS Calls

September 4, 2008October 28, 2008

1-800-767-1750Access code: 86360#