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7 Cards in this Set
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TC is a 44 year old male who is currently post-op day 7 from a deceased donor kidney transplant. His end-stage renal disease was secondary to uncontrolled hypertension. The team is planning on discharging the patient, but he still has not achieved therapeutic tacrolimus levels. Current Meds: Tacrolimus 6 mg PO, BID Mycophenolate sodium 360 mg PO, TID Prednisone 15 mg PO, Daily Septra SS 1 tablet PO, MWF Metoprolol 50 mg PO, BID Clonidine 0.1 mg Patch Once weekly Famotidine 20 mg PO, Daily Magnesium Oxide 400 mg PO, BID Vitals: BP 150/90 mm Hg HR 95 beats/min Drug levels: POD-3 Tacrolimus - <1 ng/mL POD-4 Tacrolimus - <1 ng/mL POD-5 Tacrolimus - <1 ng/mL POD-6 Tacrolimus - <1 ng/mL POD-7 Tacrolimus - <1 ng/mL
What is the therapeutic tacrolimus range that we should be targeting for this patient? a. 20 – 40 ng/mL b. 1- 3 ng/mL c. 5 – 15 ng/mL d. 15 – 20 ng/mL |
c. 5 – 15 ng/mL
a.Incorrect: This would be considered a supratherapeutic level with increased incidence of adverse effects. b. Incorrect: This would be subtherapeutic in this patient. c. Correct: This would be the therapeutic range for this patient. Early after transplant we would target 10 – 15 and over time decrease to 5-10. d. Incorrect: Once again this would be supratherapeutic for this patient. We would not be targeting levels this high. |
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The transplant nephrologist approaches you and asks for your recommendation on adding a drug to the patient’s medication regimen to increase this patient’s tacrolimus level. Based on all of the patients information which of the following drugs would be most appropriate to add for this purpose?
a. Lisinopril b. Diltiazem c. Rifampin d. Furosemide |
b. Diltiazem
a. Incorrect: Lisinopril has no interactions with tacrolimus and would not increase the level. b. Correct: Diltiazem is an inhibitor of CYP450 iso-enzymes and can be used to increase tacrolimus levels in this patient. It will be important to monitor vitals. This patient’s blood pressure is currently mildly elevated and the heart rate is on the high end of normal. c. Incorrect: Rifampin will have the opposite effect by inducing CYP iso-enzymes leading to decreased tacrolimus levels d. Incorrect: Furosemide has no interactions with tacrolimus and would not increase the level. |
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Which of the following medications that the patient is currently receiving might be leading to the subtherapeutic tacrolimus levels?
a. Clonidine b. Magnesium oxide c. Metoprolol d. Prednisone |
b. Magnesium oxide
a. Incorrect: A clonidine patch does not interact with tacrolimus and would not lead to decreased levels. b. Magnesium oxide c. Metoprolol d. Prednisone |
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You perform a review of the patient’s medications and notice that you need to contact the doctor because the patient is not receiving prophylaxis for which of the following?
a. HIV and MRSA b. RSV and Aspergillus sp c. CMV and Thrush d. Influenza (live vaccine) and Thrush |
c. CMV and Thrush
a. Incorrect: Patients do not receive prophylaxis for HIV. Patients may receive antibiotics against MRSA if they were recently exposed or are high risk. b. Incorrect: Patients do not receive prophylaxis for RSV or aspergillus. c. Correct: All kidney transplant patients typically receive CMV prophylaxis for 3-6 months post transplant. In addition, all patients will receive thrush prophylaxis until the steroid dose falls below 5-10 mg daily. d. Incorrect: Patients do not receive prophylaxis for influenza by live vaccine. |
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Which of the following are potential adverse reactions of cyclosporine?
A.Nephrotoxicity B.Hypertension C.Disorientation D.All the above |
D.All the above
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Which of the following is/are associated with mTOR inhibitors such as Rapamune (sirolimus)?
A.Decreased heart rate B.Hyperlipidemia C.Headaches D.Constipation |
B.Hyperlipidemia
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Which of the following complications can be reversed with a dosage reduction of cyclosporine?
A.Nephrotoxicity B.Hypertension C.Disorientation D.All the above can be reversed with a dosage reduction E.None of the above are reversible. |
D.All the above can be reversed with a dosage reduction
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