Appendix A — Appendix A. Drug Dosage Quick Reference Table

Version: Draft v0.1 | ⚠️ All dosages require confirmation by the clinical team

A.1 A.1 Immunosuppressive Agents

Drug Dose Route Monitoring Major Side Effects
Tacrolimus 0.03 mg/kg/h IV → oral BID IV → PO Trough level (see below) Nephrotoxicity, diabetes, neurotoxicity
Cyclosporine 5 mg/kg/day in 2 doses PO BID Trough level Nephrotoxicity, gingival hyperplasia
MMF <50kg: 500mg/day; ≥50kg: 1000mg/day PO BID CBC GI toxicity, myelosuppression
Azathioprine 1-2 mg/kg/day PO QD CBC Myelosuppression, hepatotoxicity
Prednisolone Maintenance 5 mg/day PO QD Blood glucose, bone density Osteoporosis, diabetes, infection
Methylprednisolone 500-1000 mg (intraoperative); 500 mg x 3 (pulse) IV — —
Basiliximab 20 mg Day 0 & Day 4 IV — Hypersensitivity (rare)
ATG (Thymoglobulin) 1.5 mg/kg/day x 3-5 days IV CBC (lymphocytes) Severe leukopenia, infection
Rituximab 375 mg/m² IV CD20 Infection, infusion reaction
Sirolimus 1-2 mg/day (target 5-8 ng/mL) PO QD Trough level ⚠️ Contraindicated within 3 months post-op
Everolimus 0.75 mg BID (target 3-8 ng/mL) PO BID Trough level Oral ulcers, hyperlipidemia

A.1.1 Tacrolimus Target Levels

Post-Transplant Period Trough Target (ng/mL)
0-3 months 9-12
3-6 months 8-11
> 6 months 7-10
During infection 5-7

A.2 A.2 Anti-Infective Agents

A.2.1 Antibiotics

Drug Dose Indication Notes
Piperacillin-Tazobactam 4.5 g IV q6h Perioperative empiric
Meropenem 1 g IV q8h Alternative empiric
Vancomycin 15-20 mg/kg IV q8-12h MRSA coverage Trough 15-20
TMP-SMX SS 1 tab QD or DS 3x/week PCP prophylaxis Lifelong
Azithromycin 250 mg PO QOD CLAD (BOS) Long-term

A.2.2 Antivirals

Drug Dose Indication Notes
Valganciclovir 900 mg PO QD (prophylaxis); 900 mg BID (treatment) CMV Adjust for eGFR
Ganciclovir 5 mg/kg IV q12h CMV tissue disease
Acyclovir 400 mg PO BID (prophylaxis); 10 mg/kg IV q8h (treatment) HSV/VZV
Oseltamivir 75 mg PO BID x 5 days Influenza

A.2.3 Valganciclovir Renal Dose Adjustment

eGFR (mL/min) Prophylaxis Dose Treatment Dose
≥ 60 900 mg QD 900 mg BID
40-59 450 mg QD 450 mg BID
25-39 450 mg QOD 450 mg QD
10-24 450 mg 2x/week 450 mg QOD

A.2.4 Antifungals

Drug Dose Indication Notes
Amphotericin B nebulized Institutional protocol Inhaled prophylaxis 3-6 months post-op
Voriconazole 6 mg/kg IV q12h D1 → 4 mg/kg q12h Invasive Aspergillosis ⚠️ Tac interaction
Itraconazole 200 mg PO BID Prophylaxis/treatment ⚠️ Tac interaction
Caspofungin 70 mg D1 → 50 mg/day Alternative/salvage
Amphotericin B liposomal 3-5 mg/kg/day IV Salvage Nephrotoxicity

A.3 A.3 Analgesia and Sedation

Drug Dose Use Notes
Propofol 0.5-3 mg/kg/h IV ICU sedation First-line
Dexmedetomidine 0.2-0.7 μg/kg/h IV Adjunctive sedation Facilitates weaning
Remifentanil 0.05-0.2 μg/kg/min IV ICU analgesia Ultra-short acting
Fentanyl 25-100 μg/h IV Alternative opioid
Acetaminophen 1 g IV/PO q6h (max 4g/day) Non-opioid Monitor hepatic function
Gabapentin 100-300 mg TID Neuropathic pain Renal dose adjustment
Ketamine 0.1-0.3 mg/kg/h IV Opioid-sparing Low dose

A.4 A.4 VTE Prophylaxis

Drug Dose Timing Notes
Enoxaparin 4000 IU SC QD 6-8h post-op Standard
Enoxaparin (on ECMO) 0.5 mg/kg SC BID During ECMO Vienna protocol
UFH (on ECMO) continuous IV (per aPTT) During ECMO Alternative

A.5 A.5 Other Commonly Used Medications

Drug Dose Use Notes
Norepinephrine 0.01-0.5 μg/kg/min IV Vasopressor First-line vasopressor
Dobutamine 2-10 μg/kg/min IV Inotrope
Milrinone 0.25-0.75 μg/kg/min IV Inotrope + pulmonary vasodilator
iNO 10-20 ppm Pulmonary hypertension
Furosemide 20-80 mg IV/PO Diuresis Target negative balance
Amlodipine 5-10 mg PO QD Hypertension First-line antihypertensive
Pravastatin 20-40 mg PO QHS Hyperlipidemia Minimal CYP3A interaction
Pantoprazole 40 mg PO/IV QD Acid suppression
Calcium 1200 mg/day PO Osteoporosis prevention
Vitamin D 800-1000 IU/day PO Osteoporosis prevention Target 25-OH-D > 30

A.6 A.6 Drug Interaction Alert Table

Concomitant Drug Effect on Tacrolimus Management
Voriconazole ⬆⬆⬆ Pre-emptively reduce Tac to 1/3-1/5, check level at 48-72h
Itraconazole ⬆⬆⬆ Same as above
Fluconazole ⬆⬆ May require dose reduction
Erythromycin ⬆⬆ Avoid or monitor closely
Diltiazem ⬆⬆ Avoid for antihypertensive use
Nirmatrelvir-Ritonavir ⬆⬆⬆⬆ Hold Tac, monitor closely
Rifampin ⬇⬇⬇ Contraindicated → switch to Rifabutin
Phenytoin ⬇⬇ Significant Tac dose increase required
Simvastatin Rhabdomyolysis risk Switch to Pravastatin
Grapefruit ⬆ Patient education to avoid

⚠️ This table is for quick reference only. For complete drug interaction information, consult the pharmacopoeia or a pharmacist.