Solid organ transplantation

Patients are usually managed with a combination of immunosuppressant agents namely: a calcineurin inhibitor, an antiproliferative agent and prednisolone.

1-2g daily in divided doses.

Tacrolimus has a narrow therapeutic index and it is vital that patients are not switched between formulations. Therefore, care must be taken to prescribe and dispense by BRAND name to avoid potential toxicity or potential graft rejection.

100micrograms/kg/day in 2 divided doses (dose adjusted according to trough levels).

100micrograms/kg/day in one dose (dose adjusted according to trough levels).

Prednisolone therapy is usually reduced over the initial few months post-transplant and patients are maintained on minimal steroid dose (usually 5mg daily), a calcineurin inhibitor and an antiproliferative agent.

Initial dose is 20mg daily, reduced over time to usual maintenance dose 5mg daily.

Patients are usually managed with a combination of immunosuppressant agents namely: a calcineurin inhibitor, an antiproliferative agent and prednisolone.

1mg/kg/day.

100micrograms/kg/day in 2 divided doses (dose adjusted according to trough levels).

100micrograms/kg/day in one dose (dose adjusted according to trough levels).

Initial dose is 20mg daily, reduced over time to usual maintenance dose 5mg daily.

Prescribing Notes:

Tacrolimus has a narrow therapeutic index and it is vital that patients are not switched between formulations. Therefore, care must be taken to prescribe and dispense by BRAND name to avoid potential toxicity or potential graft rejection.
There are different oral formulations of tacrolimus:
- Immediate release capsule taken twice daily, Adoport and Prograf are the preparations recommended for use.
- Prolonged release capsule, Advagraf or Dailiport; taken once daily.
- Several other generic brands exist but are not recommended.
Patients should only be changed from one preparation to another, under supervision of a transplant specialist.
Target trough levels vary depending on indication and time since transplant and are sampled prior to drug administration.
Tacrolimus is appropriate for shared care arrangements to facilitate the seamless transfer of individual patient care from secondary care to general practice.
Seek specialist advice for the use of tacrolimus in pregnancy
Azathioprine should not be given in combination with allopurinol due to myelosuppression.
Patients should be warned to report any signs or symptoms of bone marrow suppression i.e. infection, bruising and bleeding.
If gastro-intestinal side-effects of mycophenolate are troublesome, then the daily dose may be reduced and/or split into 3 or 4 times daily by specialist.
Mycophenolate mofetil is appropriate for a shared care arrangement to facilitate the seamless transfer of individual patient care from secondary care to general practice.
Mycophenolic acid gastro-resistant tablets can be used in renal transplantation if gastrointestinal side effects are found to be a problem. This should be initiated by a transplant specialist but is appropriate for a shared care arrangement to facilitate the seamless transfer of individual patient care from secondary care to general practice.
Mycophenolic acid 720mg is approximately equivalent to mycophenolate mofetil 1g but the two should not be considered interchangeable.
Mycophenolate is contra-indicated in pregnancy. Female patients of childbearing potential receiving mycophenolate should always use contraception. In addition, male patients or their female partners are recommended to use reliable contraception - seek specialist advice.
For patients with swallowing difficulties prednisolone oral solution or soluble tablets may be considered. Prednisolone tablets may be dispersed in water as an alternative to soluble tablets or oral solution preparations. This is an off-label use but more cost-effective option. Refer to local board policies on the use of unlicensed (and off-label) medicines for further guidance.
Prednisolone oral solution 5mg/5ml, single dose unit presentation should not be prescribed for doses exceeding 30mg daily.
Where a prolonged course of steroids is prescribed, gastric protection is recommended and blood sugar monitoring may be advisable.
For NHS Lothian patients, the Edinburgh renal unit (Edren) website may contain helpful information. Protocols can also be located on the Edinburgh Transplant Centre website which may be of help.

History Notes

28/11/2024

Removal of 'Prednisolone 5mg soluble tablets' and updates to associated prescribing notes - ERFC Dec 2024.

13/06/2024

Addition of Dailiport, ERFC March 24.

01/03/2023

East Region Formulary content agreed.

View all

Patients are usually managed with a combination of immunosuppressant agents namely: a calcineurin inhibitor, an antiproliferative agent and prednisolone.

1-2g daily in divided doses.

100micrograms/kg/day in 2 divided doses (dose adjusted according to trough levels).

100micrograms/kg/day in one dose (dose adjusted according to trough levels).

Initial dose is 20mg daily, reduced over time to usual maintenance dose 5mg daily.

Patients are usually managed with a combination of immunosuppressant agents namely: a calcineurin inhibitor, an antiproliferative agent and prednisolone.

1mg/kg/day.

100micrograms/kg/day in 2 divided doses (dose adjusted according to trough levels).

100micrograms/kg/day in one dose (dose adjusted according to trough levels).

Initial dose is 20mg daily, reduced over time to usual maintenance dose 5mg daily.

Prescribing Notes:

Tacrolimus has a narrow therapeutic index and it is vital that patients are not switched between formulations. Therefore, care must be taken to prescribe and dispense by BRAND name to avoid potential toxicity or potential graft rejection.
There are different oral formulations of tacrolimus:
- Immediate release capsule taken twice daily, Adoport and Prograf are the preparations recommended for use.
- Prolonged release capsule, Advagraf or Dailiport; taken once daily.
- Several other generic brands exist but are not recommended.
Patients should only be changed from one preparation to another, under supervision of a transplant specialist.
Target trough levels vary depending on indication and time since transplant and are sampled prior to drug administration.
Tacrolimus is appropriate for shared care arrangements to facilitate the seamless transfer of individual patient care from secondary care to general practice.
Seek specialist advice for the use of tacrolimus in pregnancy
Azathioprine should not be given in combination with allopurinol due to myelosuppression.
Patients should be warned to report any signs or symptoms of bone marrow suppression i.e. infection, bruising and bleeding.
If gastro-intestinal side-effects of mycophenolate are troublesome, then the daily dose may be reduced and/or split into 3 or 4 times daily by specialist.
Mycophenolate mofetil is appropriate for a shared care arrangement to facilitate the seamless transfer of individual patient care from secondary care to general practice.
Mycophenolic acid gastro-resistant tablets can be used in renal transplantation if gastrointestinal side effects are found to be a problem. This should be initiated by a transplant specialist but is appropriate for a shared care arrangement to facilitate the seamless transfer of individual patient care from secondary care to general practice.
Mycophenolic acid 720mg is approximately equivalent to mycophenolate mofetil 1g but the two should not be considered interchangeable.
Mycophenolate is contra-indicated in pregnancy. Female patients of childbearing potential receiving mycophenolate should always use contraception. In addition, male patients or their female partners are recommended to use reliable contraception - seek specialist advice.
For patients with swallowing difficulties prednisolone oral solution or soluble tablets may be considered. Prednisolone tablets may be dispersed in water as an alternative to soluble tablets or oral solution preparations. This is an off-label use but more cost-effective option. Refer to local board policies on the use of unlicensed (and off-label) medicines for further guidance.
Prednisolone oral solution 5mg/5ml, single dose unit presentation should not be prescribed for doses exceeding 30mg daily.
Where a prolonged course of steroids is prescribed, gastric protection is recommended and blood sugar monitoring may be advisable.
For NHS Lothian patients, the Edinburgh renal unit (Edren) website may contain helpful information. Protocols can also be located on the Edinburgh Transplant Centre website which may be of help.

History Notes

28/11/2024

Removal of 'Prednisolone 5mg soluble tablets' and updates to associated prescribing notes - ERFC Dec 2024.

13/06/2024

Addition of Dailiport, ERFC March 24

01/03/2023

East Region Formulary content agreed.

View all

Patients are usually managed with a combination of immunosuppressant agents namely: a calcineurin inhibitor and an antiproliferative agent.

1-2g daily in divided doses.

100micrograms/kg/day in 2 divided doses (dose adjusted according to trough levels).

100micrograms/kg/day in one dose (dose adjusted according to trough levels).

Patients are usually managed with a combination of immunosuppressant agents namely: a calcineurin inhibitor and an antiproliferative agent.

1mg/kg/day.

100micrograms/kg/day in 2 divided doses (dose adjusted according to trough levels).

100micrograms/kg/day in one dose (dose adjusted according to trough levels).

Prescribing Notes:

Tacrolimus has a narrow therapeutic index and it is vital that patients are not switched between formulations. Therefore, care must be taken to prescribe and dispense by BRAND name to avoid potential toxicity or potential graft rejection.
There are different oral formulations of tacrolimus:
- Immediate release capsule taken twice daily, Adoport and Prograf are the preparations recommended for use.
- Prolonged release capsule, Advagraf or Dailiport; taken once daily.
- Several other generic brands exist but are not recommended.
Patients should only be changed from one preparation to another, under supervision of a transplant specialist.
Target trough levels vary depending on indication and time since transplant and are sampled prior to drug administration.
Tacrolimus is appropriate for shared care arrangements to facilitate the seamless transfer of individual patient care from secondary care to general practice.
Seek specialist advice for the use of tacrolimus in pregnancy
Azathioprine should not be given in combination with allopurinol due to myelosuppression.
Patients should be warned to report any signs or symptoms of bone marrow suppression i.e. infection, bruising and bleeding.
If gastro-intestinal side-effects of mycophenolate are troublesome, then the daily dose may be reduced and/or split into 3 or 4 times daily by specialist.
Mycophenolate mofetil is appropriate for a shared care arrangement to facilitate the seamless transfer of individual patient care from secondary care to general practice.
Mycophenolic acid gastro-resistant tablets can be used in renal transplantation if gastrointestinal side effects are found to be a problem. This should be initiated by a transplant specialist but is appropriate for a shared care arrangement to facilitate the seamless transfer of individual patient care from secondary care to general practice.
Mycophenolic acid 720mg is approximately equivalent to mycophenolate mofetil 1g but the two should not be considered interchangeable.
Mycophenolate is contra-indicated in pregnancy. Female patients of childbearing potential receiving mycophenolate should always use contraception. In addition, male patients or their female partners are recommended to use reliable contraception - seek specialist advice.
For NHS Lothian patients, the Edinburgh renal unit (Edren) website may contain helpful information. Protocols can also be located on the Edinburgh Transplant Centre website which may be of help.

History Notes

13/06/2024

Addition of Dailiport, ERFC March 24

01/03/2023

East Region Formulary content agreed.

Patients are usually managed with a combination of immunosuppressant agents namely: a calcineurin inhibitor, an antiproliferative agent and prednisolone.

1mg/kg/day.

2mg twice a day in patients <70kg, and 3mg twice a day for patients > 70kg (dose adjusted according to trough levels).

4mg once a day in patients <70kg, and 6mg once a day for >70kg (dose adjusted according to trough levels).

Prednisolone therapy is usually reduced over the initial few months post-transplant and patients are maintained on a calcineurin inhibitor and an antiproliferative agent.

Initial dose is 20mg daily, reduced over time and usually stopped.

Patients are usually managed with a combination of immunosuppressant agents namely: a calcineurin inhibitor, an antiproliferative agent and prednisolone.

1-2g daily in divided doses.

2mg twice a day in patients <70kg, and 3mg twice a day for patients > 70kg (dose adjusted according to trough levels).

4mg once a day in patients <70kg, and 6mg once a day for >70kg (dose adjusted according to trough levels).

Prednisolone therapy is usually reduced over the initial few months post-transplant and patients are maintained on a calcineurin inhibitor and an antiproliferative agent.

Initial dose is 20mg daily, reduced over time and usually stopped.

Patients are usually managed with a combination of immunosuppressant agents namely: a calcineurin inhibitor, an antiproliferative agent and prednisolone.

1mg/kg/day.

Ciclosporin can be considered as an alternative to tacrolimus. Ciclosporin has a narrow therapeutic index and it is vital that patients are not switched between formulations. Therefore, care must be taken to prescribe and dispense by BRAND name to avoid potential toxicity or potential graft rejection.

As per specialist advice.

Prednisolone therapy is usually reduced over the initial few months post-transplant and patients are maintained on a calcineurin inhibitor and an antiproliferative agent.

Initial dose is 20mg daily, reduced over time and usually stopped.

Patients are usually managed with a combination of immunosuppressant agents namely: a calcineurin inhibitor, an antiproliferative agent and prednisolone.

1-2g daily in divided doses.

As per specialist advice.

Prednisolone therapy is usually reduced over the initial few months post-transplant and patients are maintained on a calcineurin inhibitor and an antiproliferative agent.

Initial dose is 20mg daily, reduced over time and usually stopped.

Prescribing Notes:

There are different oral formulations of tacrolimus:
- Immediate release capsule taken twice daily, Adoport and Prograf are the preparations recommended for use.
- Prolonged release capsule, Advagraf; taken once daily.
- Prolonged release tablets, Envarsus, taken once daily
- Granules for oral suspension Modigraf; taken twice daily.
Several other generic brands exist but are not recommended.
Ciclosporin is available as brand Neoral and several generic preparations (Capimune, Capsorin, Deximune). Only Neoral should be prescribed for transplant patients.
Ciclosporin is used in other non-transplant indications and generic preparations may be used in these circumstances.
Patients should only be changed from one preparation to another, under supervision of a transplant specialist.
Target trough levels vary depending on indication and time since transplant and are sampled prior to drug administration.
Ciclosporin and tacrolimus are appropriate for shared care arrangements to facilitate the seamless transfer of individual patient care from secondary care to general practice.
Seek specialist advice for the use of tacrolimus in pregnancy
Azathioprine should not be given in combination with allopurinol due to myelosuppression.
Patients should be warned to report any signs or symptoms of bone marrow suppression i.e. infection, bruising and bleeding.
If gastro-intestinal side-effects of mycophenolate are troublesome, then the daily dose may be reduced and/or split into 3 or 4 times daily by specialist.
Mycophenolate mofetil is appropriate for a shared care arrangement to facilitate the seamless transfer of individual patient care from secondary care to general practice.
Mycophenolic acid gastro-resistant tablets can be used in renal transplantation if gastrointestinal side effects are found to be a problem. This should be initiated by a transplant specialist but is appropriate for a shared care arrangement to facilitate the seamless transfer of individual patient care from secondary care to general practice.
Mycophenolic acid 720mg is approximately equivalent to mycophenolate mofetil 1g but the two should not be considered interchangeable.
Mycophenolate is contra-indicated in pregnancy. Female patients of childbearing potential receiving mycophenolate should always use contraception. In addition, male patients or their female partners are recommended to use reliable contraception - seek specialist advice.
For patients with swallowing difficulties prednisolone oral solution or soluble tablets may be considered. Prednisolone tablets may be dispersed in water as an alternative to soluble tablets or oral solution preparations. This is an off-label use but more cost-effective option. Refer to local board policies on the use of unlicensed (and off-label) medicines for further guidance.
Prednisolone oral solution 5mg/5ml, single dose unit presentation should not be prescribed for doses exceeding 30mg daily.
Where a prolonged course of steroids is prescribed, gastric protection is recommended and blood sugar monitoring may be advisable.
For NHS Lothian patients, the Edinburgh renal unit (Edren) website may contain helpful information. Protocols can also be located on the Edinburgh Transplant Centre website which may be of help.

History Notes

28/11/2024

Removal of 'Prednisolone 5mg soluble tablets' and updates to associated prescribing notes - ERFC Dec 2024.

01/03/2023

East Region Formulary content agreed.

Potent non-calcineurin inhibitor used in renal transplantation 500microgram tablet is not bioequivalent to the 1mg and 2mg tablets. Multiplies of 500microgram tablets should not be used as a substitute for other tablet strengths.

As per specialist advice.

To reduce the incidence of acute rejection in pancreas, kidney/pancreas and kidney transplantations.

Initially 20mg, administered within 2 hours before transplant surgery, followed by 20mg after 4 days, dose to be administered after surgery, withhold second dose if severe hypersensitivity or graft loss occurs.

Part of induction regimen for islet transplantation. Alemtuzumab 30mg/1ml solution for infusion vials (Campath brand) is an unlicensed medicine available sourced on a named patient basis and may also be considered for specialist use only.

Prescribing Notes:

Sirolimus is a potent non-calcineurin inhibiting immunosuppressant used in solid organ transplantation. It is given as an adjunct to, or substitute for, a calcineurin inhibitor in patients with tacrolimus/ciclosporin implicated allograft pathology. It should be administered 4 hours after tacrolimus/ciclosporin; dose should be adjusted according to blood concentrations.
Sirolimus is appropriate for a shared care arrangement to facilitate the seamless transfer of individual patient care from secondary care to general practice.
Basiliximab is a monoclonal antibody that prevents T-lymphocyte proliferation. It is given in hospital in accordance with a protocol to reduce the incidence of acute rejection in pancreas, kidney/pancreas and kidney transplantations.
Alemtuzumab is a monoclonal antibody that produces profound T-lymphocyte depletion. It is approved for use off label as part of induction regimen for islet transplantation.

History Notes

01/03/2023

East Region Formulary content agreed.