transplant

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. F. the 2 doses should be taken 12 hours apart

A, B, C, D, F

A 32 year-old white female with a history of type 1 diabetes and diabetic nephropathy received a kidney transplant. The patient 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 not 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.

B

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.

B,D,E

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

A,C,D,E

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. F. mycophenolic acid is myfortic

C, F

Which of the following are induction drugs given prior to graft transplant and are used to prevent acute rejection immediately following the transplant surgery? A. Adalimumab (Humira) B Etanercept (Enbrel) C. Antithymocyte globulin D. Basiliximab (Simulect) E. Higher doses of maintenance drugs

C,D,E

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.

D

Asmine 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

B

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. Skin Cancer E. Liver cancer

D

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

A

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.

A

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.

A, C, D, E

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 IntradermalE. FluBlok

A,B

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

A,B,C

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.

A,B,D,E

Which of the following are correct brand names for everolimus? A. Afinitor B. Rapamune C. Zortress D. Myfortic E. Nulojix

A,C

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. F. It binds to CD80 and CD86 to block T-Cell costimulation

A,C,D,F *A silicone-free disposable syringe comes with the drug. *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. *Patients must have immunity to Epstein Bar Virus (seropositive) to receive belatacept; patients without immunity are at higher risk for PTLD.

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. This drug increases the risk myelosuppresion B. This drug can be associated with thrombocytosis 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.

A,D

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.

B

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 < 130/80 mmHg (or goal BP set by the transplant center) C. Blood pressure < 160/95 mmHg D. Smoking < 20 cigarettes daily E. Increased physical activity

B

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

B

What is the mechanism of action of everolimus? A. Calcineurin inhibitor B. Mammalian target of rapamycin (mTor) kinase inhibitor C. Antiproliferative agent D. Monoclonal antibodyE. Corticosteroid

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

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.

B,C

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

B,C,D

Sandra is a renal transplant patient who is doing well. It was discovered at her last clinic visit that Sandra did not receive the Zostavax 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.

C

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.

C

Choose the correct statement concerning tacrolimus and drug interactions: A. P-gp inhibitors will decrease the tacrolimus concentration B. Tacrolimus is a strong 3A4 inhibitor C. Tacrolimus is a strong 3A4 inducer D. Tacrolimus is a strong 3A4 substrate Tacrolimus is a P-gp inducer

D

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

D

Which of the following medications is a calcineurin inhibitor? A. Sirolimus B. Azathioprine C.Mycophenolate D. Tacrolimus E. Basiliximab

D

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

E

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.

E