Communication between the community physi- cian and the transplant center should be maintained and changes in medications and clinical events noted; emergent or elective interventions should be recorded. The recipient can play a vital role in transmitting applicable medical records to keep each party current.
9. d. b and c Substitution of insurance formulary medications or taking over-the-counter medications and herbal supplements without prior clearance from the trans- plant team may potentiate interactions between medications that can lead to complications (severe fluctuations of immmunosuppressive levels, end- organ damage; bone marrow suppression). Depending on the insurance coverage and policy specifications, many insurance packages require prior authorization before appointments and procedures are approved. Insurance stipulations also may affect the form of medication that the transplant patient receives, despite what is requested by the primary provider. In most cases, this may present little con- cern, but in some cases drug interactions can occur. Certain formulations of one pharmacological agent, such as a calcium channel blocker or a statin, can potentiate changes in immunosuppressive levels and actions, whereas other agents in the same family do not. Recipients should be aware of this possibility and should contact the physician or transplant team regarding their routine medica- tions, especially when the original prescription has been changed. Use of over-the-counter medications and herbal supplements is known to cause changes in immunosuppressive levels.