TABLE 3.

Most common drug-drug interactions with immunosuppression medications used after liver transplant

Category	Side effects	Culprit Agents	Approach
Nephrotoxicity	AKI CKD	CNI	Use of renal sparing regimen at time of transplant Addition of a antimetabolites. to allow a lower trough target
Cardiovascular and metabolic syndrome	Diabetes	CNI |TAC > CSA), steroids	Treat based on endocrine diabetes management guidelines
	Hypertension	CNI |CSA>TACj, steroids	Treatment with nifedipine or earvedilol
	Hyperlipidemia	mTORi> CSA> TAC, steroids	mTORi dose-red jction or switching to alternative medication Use caution in using statins with CSA Pravastatin may be preferred in CSA
Bone marrow suppression	Leukopenia Neutropenia Anemia Thrombocytopenia	Antiproliferative (MPA, AZA), mTORi	Switch to a different agent or dose reduction G-CSF/G M-C5F to treat neutropenia
Gastrointestinal symptoms	Nausea and vomiting, Diarrhea	Antiproliferative (MPA. AZA)	Need to rule out other causes, can consider switching to Myfortic (enteric coated)
Neurotoxicity	Tremors, headache, seizure, delirium, mood changes, PRE5	CNI	Addition of Magnesium Switching to Envaraus for tremors [peak related) Can consider switching to cyclosporine from tacrolimus for PRES

Abbreviations: AKI: Acute Kidney Injury; CKD: Chronic Kidney Disease; CNI: Calcineurin Inhibitor; TAC: Tacrolimus; CSA: Cyclosporine; MMF: Mycophenolic acid; AZA: Azathioprine; PRES: posterior reversible encephalopathy syndrome; mTORi: Mammalian Target of Rapamycin Inhibitors; G-C5F: Granulocyte colony-stimulating factor; GM-C5F: Granulacyte-macrophage colony-stimulating factor.