Draft #13– revised april 22,2003

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7 Clinical
Guidelines
For Transplant
Medications
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The Clinical Guidelines are a statement of consensus of BC Transplant professionals regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult the Guidelines is expected to use ind ependent medical judgment in the context of individual clinical circumstances to determine any patient's care or treatment. Use of these guidelines and any information on it is at your own risk, and is subject to our Terms of Use. The electronic version of this document is the official copy for distribution. Printouts of this electronic document are considered unofficial unless authorized by BCT Quality Assurance. ALL QUESTIONS REGARDING THESE GUIDELINES SHOULD BE DIRECTED TO THE BC TRANSPLANT PHARMACIST AT: [email protected] AMB-GEN.08.009 REV 02 Effective Date: 04-July-2011 Guidebook for the Solid Organ Transplant Programme Chapter 7 7.6 Prednisone
7.6.1 INTRODUCTION
Prednisone is a synthetic corticosteroid used for its anti-inflammatory and non-specific immunosuppressive effects.
7.6.2 MECHANISM OF ACTION
Prednisone acts by stabilizing the cell wall and suppressing the body's inflammatory response  reduces activity and volume of lymphatic system (lymphocytopenia)  decreases immunoglobulin concentrations  decreases passage of immune complexes through basement membranes  possibly depresses reactivity of tissue to antigen antibody interactions
7.6.3 PHARMACOKINETICS
Prednisone is readily absorbed from the gastrointestinal tract and is bound to plasma
proteins. It is primarily metabolized by the liver to inactive metabolites, which are
excreted by the kidney.
7.6.4 THERAPEUTIC USE
Prednisone is used in conjunction with other immunosuppressive medications for transplant
rejection prophylaxis and treatment.

7.6.5 CONTRAINDICATIONS AND PRECAUTIONS
One large morning dose or alternate day therapy is less likely to suppress the hypothalamic/pituitary axis than divided daily doses. Blood pressure, weight, serum glucose, and electrolytes should be monitored routinely while patients are on corticosteroids, Patients on prolonged prednisone may require additional steroid coverage during a stressful period (i.e., infection, trauma, surgical procedure). Chronic use of steroids may suppress growth in pediatric and adolescent patients and should be used with caution. Use with caution in the elderly and patients with:  Chronic renal failure  Cirrhosis  Congestive heart failure  Diabetes mellitus  Glaucoma  Hypothyroidism  Infection  Osteoporosis  Peptic ulcer  Psychoses  Uremia Chapter 7 – Clinical Guidelines for Transplant Medications – July 2011 Guidebook for the Solid Organ Transplant Programme Chapter 7
7.6.6 ADVERSE DRUG REACTIONS
Prednisone Adverse Drug Reactions
Area of Effect
Adverse Effects
Headache, vertigo, convulsions, paresthesia, Impaired wound healing, petechiae, ecchymoses, striae, hyperpigmentation, hirsutism, acne, dermatitis, urticaria, alopecia, brittle hair Menstrual irregularities, Cushing's syndrome, growth suppression in children, diabetes mellitus, protein catabolism, hyperglycemia, glycosuria, hypernatremia, hypokalemia, hypocalcemia Nausea, vomiting, increased appetite, weight gain, peptic ulcer, pancreatitis Myopathy, osteoporosis, aseptic necrosis of femoral and humoral heads, spontaneous fractures Posterior subcapsular cataracts, increased intraocular pressure, glaucoma Chapter 7 – Clinical Guidelines for Transplant Medications – July 2011 Guidebook for the Solid Organ Transplant Programme Chapter 7
7.6.7 DRUG INTERACTIONS

Prednisone Drug Interactions
Drug Effect
Mechanism
Importance
Increased renal excretion of ASA Unknown Increased arrhythmia associated Additive Caution with hypokalemia hepatic metabolism or renal excretion of Isoniazid

Chapter 7 – Clinical Guidelines for Transplant Medications – July 2011
Guidebook for the Solid Organ Transplant Programme Chapter 7
7.6.8 DOSE AND ADMINISTRATION
Following transplant, the patient may be prescribed methylprednisolone IV. When the patient can tolerate oral medications, prednisone may be started. Give prednisone with food or milk to reduce gastric irritation.
Kidney Transplant Recipients
The administration of prednisone varies in kidney transplant recipients. Patients may be on
one of the following regimens:
Steroid avoidance: Patient receives no steroid except methylprednisolone at the time of
transplant.
Rapid steroid elimination: Prednisone is withdrawn quickly post transplant over a maximum
of 7 days.
Early Steroid Withdrawal: Prednisone is tapered and withdrawn over the first few weeks to
months, post transplant. This approach has risks and the primary transplant center should be
contacted as these patients are at high risk for acute rejection.
Late Steroid Withdrawal: Prednisone is withdrawn later than 6 months post transplant. This
is generally unsafe and has little benefit. Therefore patients who have been on steroids for
over the first six months post transplant should continue on prednisone indefinitely. The prednisone maintenance dose should be the lowest possible dose, down to a minimum of 7.5 mg on alternate days or 5 mg daily. Liver Transplant Recipients
Prednisone 20 mg (0.3 mg/kg) PO daily is usually begun on day six post transplant. Dosage is
tapered over six months so patient is usually steroid-free by six months.
Lung and Heart/Lung Transplant Recipients
Methylprednisolone is given for the first 24 hours post transplant. Prednisone is then begun at a dose of 1 mg/kg/day PO, tapering by 5 mg/day until 15 mg PO daily is reached.
7.6.9 AVAILABILITY
Prednisone is available in oral tablets of 1 mg, 5 mg, and 50 mg strengths. Prednisone is available from several drug manufacturers. Prednisolone suspension (Pediapred® Sanofi-Aventis Canada Inc.) is available in 1 mg/mL strength. Prednisone suspension is prepared at B.C.’s Children’s Hospital in 5 mg/mL strength. Chapter 7 – Clinical Guidelines for Transplant Medications – July 2011

Source: http://www.transplant.bc.ca/Clinical_Guidelines_for_Transplant_Medications/Prednisone.pdf