Liver transplantation is much more than a simple operation, so it is important to know all necessary to have an optimal comfort of lifestyle.

Your responsibilities:

In order to get a maximum good result and to feel well you must:

  1. Know everything about your drugs: doses, time of taking, the reason – why exactly you take them.
  2. Follow strictly the time schedule of your medications and make changes only if they are authorized by your physician.
  3. Keep a regular contact with the team of physicians caring for your health after transplantation.
  4. Control regularly the blood laboratory tests, body weight, blood pressure and your body temperature in the manner prescribed by your physician from the team.
  5. Follow a healthy lifestyle with a balanced nutritional diet, regular physical exercises and routine tests.



The regular intake of medicines is one of the most important responsibilities you will have after leaving hospital.

What you should know about your drugs:

  • The trademark and the generic name of the drug are always different. The generic name is the general one uncommitted with the pharmaceutical producer. There are different trade names for a single product, i.e.: Tacrolimus and Prograf are one and the same drug. Tacrolimus is a generic name and Prograf is a trade one.
  • The reason for taking each prescribed drug: One drug often is used for different reasons, and you should be always informed why you take the specific medicine. For example, fluconazole is a drug used for treatment of fungal infections, but it can be used for increasing the blood level of tacrolimus thus maintaining its action.
  • How does each tablet or capsule look like. You must be able to recognize the medicines by color, form and size. Many drugs have similar outlook – you should inspect them carefully in order to be sure you’ve taken the right one.
  • When to take each medicine. Some drugs like these responsible for the good acceptance of your new healthy liver – tacrolimus and/or cyclosporine – must be taken every day exactly at the same time in order their blood levels to be monitored correctly.
  • How to take each medicine. Probably you take most of the drugs by swallowing them. Sometimes, especially in children, some of the pills are divided or splintered and mixed with food or liquid in order to be better absorbed. Your physician will discuss with you how to take each tablet or capsule, as breaking the integrity of some medicines lowers their efficacy.
  • For how long each medicine is prescribed. Some drugs are prescribed only for 7-14 days, like antibiotics for example. Others – like immunosuppressants or anti-rejection drugs – are usually prescribed to life. The intake of some drugs could be stopped or changed depending on the occurrence of side effects.
  • The most frequent side effects. Each drug has side effects, but they do not apply to all people who use it. You must know the most frequent side effects of the medicines you take and what to do to relieve them.
  • Special instructions for the intake of some medicines. You should be aware which medicines can be taken with food or on an empty stomach and which ones cannot be taken in combination with other drugs.
  • What to do if you are late, miss or forget to take one dose. If you are too late with the drug intake or you have missed it, whatever the cause, including vomiting, do not hesitate to inform your physician. After he asks you several questions about your current health status, he will advise you what to do.
  • How to order your medicines. Your physician in charge or the coordinator from the transplantation team will help you with the order so it is the most convenient for you. You must be sure you have drugs for one month ahead before leaving hospital.
  • What is the price of your medicines. It is important to know your financial responsibility for your drugs so you can plan your future. Some of them can be fully paid from the Health Insurance Fund in Bulgaria, for others you have to pay part of the total price.

Call you coordinator from the transplantation team if:

  1. You are not able to take your medicines because you have nausea or you vomit, you have diarrhea and you’re worried you don’t absorb them.
  2. You feel unusual reactions or you have side effects from the medicines.
  3. You have to take Analgin and/or Ibuprofen because of fever or medicine against cough, herbal supplements or whatever you haven’t discussed with your physician.

Storing your medicines:

Keep your medicines in the original packaging or in your own boxes, but be sure the caps are tightly closed. Store them in a dry and cold place, away from direct sunlight. Don’t leave them in the bathroom, because humidity can affect the efficacy of some of them. Do not put the drugs in a fridge except you have special instructions for this. Choose a safe place, out of the reach of children and pets. It is good to keep several doses of your main drug against rejection at different places in case of emergency.

  1. Anti-rejection medicines:


(Prograf ®)

Aim: Tacrolimus is used for prevention or treatment of organ rejection after liver transplantation. It helps the body to accept the foreign organ through suppression of the cells of the immune system. Tacrolimus can be used separately or in combination with other drugs from this group.

Dosage: Tacrolimus is available in 0.5mg (yellow), 1mg (white) and 5mg (rose) capsules. It is usually dosed twice a day. The doses must be taken every 12 hours.

The intake of Tacrolimus should be at the same time each day in order constant and stable level of immunosuppression to be established.

Side effects: The side effects of Tacrolimus vary and are usually linked with the blood levels of the medicine. They are more often seen when the levels are high, especially in the first weeks of treatment.

The most frequent side effects:

  1. From the nervous system – neurotoxicity /most often at levels above 15/ and usually resolves when the drug levels in blood are decreased. The high levels of Tacrolimus can cause headache, insomnia (problems in falling asleep), stiffness and numbness of hands and legs, tremor, or increased sensitivity towards bright or flashing light. Difficulties in speaking (aphasia) and seizures are quite rare side effects but there are registered cases occurred at very high levels of the drug.
  2. Kidney dysfunction – nephrotoxicity: Tacrolimus can affect the kidneys by constriction of the small arteries, called arterioles. When this happens, the patients have high blood pressure, high levels of potassium and low of magnesium and/or impaired renal functional tests (increased urea and creatinine (BUN) in blood).
  3. Infections: If you take Tacrolimus your immune system is suppressed. As the natural ability of the organism to fight infection is reduced, it may be more likely to develop such diseases. The risk of infections is the highest when the blood levels of Tacrolimus are high, usually in the first three months after the transplantation.
  4. Others: nausea, diarrhea, elevated blood glucose, hair loss.

Additional information:

Do not change the dose or the way you take Tacrolimus without the knowledge of your physician. Monitoring the levels of the medicine will happen more and more rarely in the post-transplant period: first they are measured daily, then weekly, monthly and after a year once per several months.

Tacrolimus levels should be measured one or two hours before taking your dose, or in other words said 10-12 hours after the previous dose. This is called the lowest level and is the lowest level of Tacrolimus which in fact is in the blood. For example, if you take Tacrolimus at 8:00 and 20:00 o’clock your level should be the lowest between 6 and 8 o’clock in the morning.

Food can affect the level of the medicine in the blood. Food consumption within two hours after you take Tacrolimus can lower its level with 30%. It is advisable not to eat one hour before and two hours after taking Tacrolimus. You should not eat grapefruit or drink grapefruit juice while you take Tacrolimus as the substances in this fruit can hinder the enzymes which degrade the medicine and thus affect its action. Grapefruit’s products and most of the herbs as well increase the levels of the medication. All forms of grapefruit and drinks containing significant amount of grapefruit juice should be avoided.

Some medicines interact with Tacrolimus and some rules should be followed for their intake:

Two hours after Tacrolimus: sucralfate, magnesium oxide, magnesium gluconate.

Two to four hours after Tacrolimus: sodium bicarbonate.

Tacrolimus interacts with other drugs which leads to higher or lower levels. Always discuss with a physician from the transplantation team before starting a new drug.

If you have missed one dose of Tacrolimus, take it as soon as you find this. If it is close to the time of the next intake, omit it and continue with the usual dose schedule.

Store the capsules at room temperature and out of the reach of children and pets.

If you plan to get pregnant, discuss the use of Tacrolimus with your hepatologist and obstetrician.

To be continued…