Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5258_Библиотеки_им_академика_М_И_Перельмана.pdf
460
Liver transplant recipients sometimes receive retransplantation, more common
early after initial transplantation—for example, due to vascular complications—and
less commonly performed in the late period after transplantation [62]. Unlike kid-
ney transplant recipients, they do not have dialysis or other bridging therapies as
options. In patients with end-stage liver disease who are not candidates for or who
do not pursue retransplantation, symptom management will likely include address-
ing volume overload, encephalopathy, and bleeding.
Heart retransplantation is less common than kidney or liver retransplantation,
representing only 2–3% of heart transplants based on registry data [63]. The use of
mechanical circulatory support such as left ventricular assist devices is generally
not an option in the post-heart transplant setting because of anatomy, thrombosis,
and risk of infection. Given the relative infrequency of retransplantation, early
involvement with palliative care should be considered for heart transplant recipients
with graft failure. Dyspnea and volume management will be necessary to improve
quality of life.
Similar to heart transplant recipients, retransplantation is uncommon in lung
transplant recipients, representing 4–6% of lung transplants [64] and is associated
with poorer outcome compared with initial transplantation [65, 66]. Because of
these outcomes, early palliative care involvement is recommended, as the patient
will most likely need management of dyspnea as respiratory failure progresses.
Discussions of comfort-focused care and/or hospice in patients with end-stage
disease after solid organ transplantation failure is appropriate if retransplantation is
not an option or not desired.
16.7 Conclusion
Palliative care is specialized medical care for people living with serious illness that
focuses on quality of life for both the patient and family. Palliative care has been
proposed for patients with advanced organ failure beginning at diagnosis and con-
tinuing through transplant and beyond, given the associated high morbidity and
mortality awaiting transplantation and post-transplantation [4–12]. When solid
organ transplant recipients present to the outpatient clinic, it may be an opportunity
for the primary care provider to incorporate primary palliative care interventions
into their medical care. Primary palliative care interventions include advance care
planning and basic pain and symptom management. There are clinical resources
available for advance care planning, communication skills, and symptom manage-
ment. Advance care planning discussions should recur as health circumstances
change, including post-transplantation, with worsening health status, or cognitive
decline. Initiation or escalation of opioid therapy for managing refractory symp-
toms is an appropriate time to readdress patients’ goals of care. Referral to a pallia-
tive care specialist may be needed in cases of refractory symptoms, worsening
health status including graft failure, cognitive decline, approaching end of life, or
challenging decision-making when considering high-risk procedures.
K. G. Hicks et al.
461
References
1. About Palliative Care. https://www.capc.org/about/palliative- care/. Accessed 7 Oct 2024.
2. Kavalieratos D, Corbelli J, Zhang D, Dionne-Odom JN, Ernecoff NC, Hanmer J, et al.
Association between palliative care and patient and caregiver outcomes: a systematic review
and meta-analysis. JAMA. 2016;316(20):2104–14. https://doi.org/10.1001/jama.2016.16840.
3. Quill TE, Abernethy AP.Generalist plus specialist palliative care—creating a more sustainable
model. N Engl J Med. 2013;368:1173–5.
4. Wentlandt K, Weiss A, O’Connor E, Kaya E. Palliative and end of life care in solid organ
transplantation. Am J Transplant. 2017;17(12):3008–19.
5. Institute of Medicine. https://www.capc.org/topics/iom/. Accessed 7 Feb 2019.
6. Institute of Medicine: Committee on Approaching Death. Dying in America: improving indi-
vidual preferences near the end of life. Washington, DC: The National Academies Press; 2014.
7. Zehm A, Smith S, Schaefer KG, Jonas D, Bullock K, Edwards RL, Reville B, Jaramillo
C, Webb AC, Rydberg J, Merel SE.Development of objectives to inform a national stan-
dardized primary palliative care curriculum for health professions students. J Palliat Med.
2023;26(3):406–10. https://doi.org/10.1089/jpm.2022.0396. Epub 2023 Jan 6.
8. A strategy for the simultaneous provision of pre-operative palliative care for patients await-
ing liver transplantation Rossaro—2004—Transplant International—Wiley Online Library
[Internet]. [cited 8 Apr 2019]. https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1432-
2277.2004.tb00473.x
9. Scully BB, Nolley EP, Bush EL. Palliative care in lung transplantation. Ann Palliat Med.
2022;11(2):927–35.
https://doi.org/10.21037/apm- 21- 170. Epub 2021 Jun 1.
10. Freeman N, Le LW, Singer LG, Colman R, Zimmermann C, Wentlandt K.Impact of a trans-
plant palliative care clinic on symptoms for patients awaiting lung transplantation. J Heart
Lung Transplant. 2016;35(8):1037–9.
11. Larson AM, Curtis JR.Integrating palliative care for liver transplant candidates: “too well for
transplant, too sick for life.”. JAMA. 2006;295(18):2168–76.
12. Baumann AJ, Wheeler DS, James M, Turner R, Siegel A, Navarro VJ.Benet of early pallia-
tive care intervention in end-stage liver disease patients awaiting liver transplantation. J Pain
Symptom Manag. 2015;50(6):882–6.
13. Potosek J, Curry M, Buss M, Chittenden E.Integration of palliative care in end-stage liver
disease and liver transplantation. J Palliat Med. 2014;17(11):1271–7.
14. Colman R, Singer LG, Barua R, Downar J.Characteristics, interventions, and outcomes of
lung transplant recipients co-managed with palliative care. J Palliat Med. 2015;18(3):266–9.
15. Wentlandt K, Dall’Osto A, Freeman N, Le LW KE, Ross H, Singer LG, Abbey S, Clarke H,
Zimmermann C.The transplant palliative care clinic: an early palliative care model for patients
in a transplant program. Clin Transpl. 2016;30(12):1591–6. https://doi.org/10.1111/ctr.12838.
16. Wenrich MD, Curtis JR, Ambrozy DA, Carline JD, Shannon SE, Ramsey PG. Dying
patients’ need for emotional support and personalized care from physicians: perspectives of
patients with terminal illness, families, and health care providers. J Pain Symptom Manag.
2003;25(3):236–46.
17. Dow LA, Matsuyama RK, Ramakrishnan V, etal. Paradoxes in advance care planning: the
complex relationship of oncology patients, their physicians, and advance medical directives.
Clin Oncol. 2010;28(2):299–304. https://doi.org/10.1200/JCO.2009.24.6397.
18. Sudore RL, Lum HD, You JJ, Hanson LC, Meier DE, Pantilat SZ, Matlock DD, Rietjens JAC,
Korfage IJ, Ritchie CS, Kutner JS, Teno JM, Thomas J, McMahan RD, Heyland DK.Dening
advance care planning for adults: a consensus denition from a multidisciplinary delphi panel.
J Pain Symptom Manag. 2017;53:821–32.
19. Jimenez G, Tan WS, Virk AK, Low CK, Car J, Ho AHY.Overview of systematic reviews of
advance care planning: summary of evidence and global lessons. J Pain Symptom Manag.
2018;56(3):436–59.e25
16 Palliative Care intheAdult Solid Organ Transplant Recipient
462
20. Teno JM, Gruneir A, Schwartz Z, Nanda A, Wetle T.Association between advance directives
and quality of end-of-life care: a national study. J Am Geriatr Soc. 2007;55(2):189–94.
21. Detering KM, Hancock AD, Reade MC, Silvester W.The impact of advance care planning on
end of life care in elderly patients: randomised controlled trial. BMJ. 2010;340:c1345.
22. Wright AA, Zhang B, Ray A, Mack JW, Trice E, Balboni T, etal. Associations between end-
of- life discussions, patient mental health, medical care near death, and caregiver bereavement
adjustment. JAMA. 2008;300(14):1665–73.
23. Sabatino CP. The evolution of health care advance planning law and policy. Milbank
Q. 2010;88(2):211–39.
24. American Bar Association. Living wills, health care proxies, & advance health care direc-
tives [Internet]. ABA. 2019 [cited 2019 May 15]. https://www.americanbar.org/groups/real_
property_trust_estate/resources/estate_planning/living_wills_health_care_proxies_advance_
health_care_directives/
25. Molloy DW, Guyatt GH, Russo R, Goeree R, O’Brien BJ, Bedard M, etal. Systematic imple-
mentation of an advance directive program in nursing homes: a randomized controlled trial.
JAMA. 2000;283(11):1437–44.
26. Silveira MJ, Kim SYH, Langa KM.Advance directives and outcomes of surrogate decision
making before death. N Engl J Med. 2010;362(13):1211–8.
27. Veshi D, Neitzke G. Advance directives in some Western European countries: a legal and
ethical comparison between Spain, France, England, and Germany. Eur J Health Law.
2015;22(4):321–45.
28. Russell S.Paying attention to cultural context matters in advance care planning and palliative
care. Evid Based Nurs. 2019;
https://doi.org/10.1136/ebnurs- 2019- 103206.
29. Tsevat RK, Sinha AA, Gutierrez KJ, DasGupta S.Bringing home the health humanities: narra-
tive humility, structural competency, and engaged pedagogy. Acad Med. 2015;90(11):1462–5.
30. Murakami N, Baggett ND, Schwarze ML, Ladin K, Courtwright AM, Goldberg HJ, Nolley
EP, Jain N, Landzberg M, Wentlandt K, Lai JC, Shinall MC, Ufere NN, Jones CA, Lakin
JR.Top ten tips palliative care clinicians should know about solid organ transplantation. J
Palliat Med. 2022;25(7):1136–42. https://doi.org/10.1089/jpm.2022.0013. Epub 2022 Mar 11.
PMID: 35275707; PMCID: PMC9467633.
31. Rana A, Gruessner A, Agopian VG, Khalpey Z, Riaz IB, Kaplan B, etal. Survival benet of
solid-organ transplant in the United States survival benet of solid-organ transplant survival
benet of solid-organ transplant. JAMA Surg. 2015;150(3):252–9.
32. Kugler C, Gottlieb J, Warnecke G, Schwarz A, Weissenborn K, Barg-Hock H, etal. Health-
related quality of life after solid organ transplantation: a prospective, multiorgan cohort study.
Transplantation. 2013;96(3):316–23.
33. Yadav KN, Gabler NB, Cooney E, Kent S, Kim J, Herbst N, etal. Approximately one in three
US adults completes any type of advance directive for end-of-life care. Health Aff (Millwood).
2017;36(7):1244–51.
34. United Network for Organ Sharing. Transplants in the U.S. by recipient age [Internet]. https://
optn.transplant.hrsa.gov/data/view- data- reports/national- data/#. Accessed 2 Feb 2025
35. Schellinger S, Sidebottom A, Briggs L.Disease specic advance care planning for heart failure
patients: implementation in a large health system. J Palliat Med. 2011;14(11):1224–30.
36. Kirchhoff KT, Hammes BJ, Kehl KA, Briggs LA, Brown RL.Effect of a disease-specic plan-
ning intervention on surrogate understanding of patient goals for future medical treatment. J
Am Geriatr Soc. 2010;58(7):1233–40.
37. Fulmer T, Escobedo M, Berman A, Koren MJ, Hernández S, Hult A. Physicians’ views on
advance care planning and end-of-life care conversations. J Am Geriatr Soc. 2018;66(6):1201–5.
38. Lamas D, Panariello N, Henrich N, Hammes B, Hanson LC, Meier DE, etal. Advance care
planning documentation in electronic health records: current challenges and recommendations
for change. J Palliat Med. 2018;21(4):522–8.
39. https://www.cms.gov/Outreach- and- Education/Medicare- Learning- Network- MLN/
MLNProducts/Downloads/AdvanceCarePlanning.pdf
K. G. Hicks et al.
463
40. Luth EA, Manful A, Weissman JS, Reich A, Ladin K, Semco R, Ganguli I.Practice billing for
Medicare advance care planning across the USA.J Gen Intern Med. 2022;37(15):3869–76.
https://doi.org/10.1007/s11606- 022- 07404- 9. Epub 2022 Jan 26. PMID: 35083654; PMCID:
PMC9640523.
41. Hui D, Bruera E.The Edmonton symptom assessment system 25 years later: past, present, and
future developments. J Pain Symptom Manag. 2017;53(3):630–43.
42. Tick H, Nielsen A, Pelletier KR, Bonakdar R, Simmons S, Glick R, Ratner E, Lemmon RL,
Wayne P, Zador V, Pain Task Force of the Academic Consortium for Integrative Medicine and
Health. Evidence-based nonpharmacologic strategies for comprehensive pain care: the consor-
tium pain task force white paper. Explore (NY). 2018;14(3):177–211.
43. Hayward KL, Powell EE, Irvine KM, Martin JH.Can paracetamol (acetaminophen) be admin-
istered to patients with liver impairment? Br J Clin Pharmacol. 2016;81(2):210–22. https://doi.
org/10.1111/bcp.12802.
44. Davison SN, Rosielle DA.Fast Fact #208 CLINICAL CARE FOLLOWING WITHDRAWAL
OF DIALYSIS [Internet]. Palliative Care Network of Wisconsin Fast Facts. [cited 24 Apr
2019].
https://www.mypcnow.org/blank- ikz6.
45. Weissman DE.Fast Fact #37. Dyspnea at End-of-Life. Palliative Care Network of Wisconsin
Fast Facts. [cited 2019 Apr 24].
https://www.mypcnow.org/blank- mbri1
46. Benzodiazepines for the relief of breathlessness in advanced malignant and non-malignant dis-
eases in adults—Simon, ST—2016 | Cochrane Library [Internet]. [cited 2019 Jun 18]. https://
doi.org/10.1002/14651858.CD007354.pub3/full
47. Marks S, Rosielle DA.Fast Fact #200. Non-opioid antitussives. Palliative Care Network
of Wisconsin Fast Facts. [cited 2025 Jan 29].
https://www.mypcnow.org/fast- fact/
non- opioid- anti- tussives/
48. Ginsburg PM, Thuluvath PJ.Diarrhea in liver transplant recipients: etiology and management.
Liver Transpl. 2005;11:881–90. https://doi.org/10.1002/lt.20500.
49. Angarone M, Snydman DR, AST ID Community of Practice. Diagnosis and management
of diarrhea in solid-organ transplant recipients: guidelines from the American Society of
Transplantation Infectious Diseases Community of Practice. Clin Transpl. 2019:e13550.
https://doi.org/10.1111/ctr.13550.
50. Cangemi DJ, Kuo B.Practical perspectives in the treatment of nausea and vomiting. J Clin
Gastroenterol. 2019;53(3):170–8. https://doi.org/10.1097/MCG.0000000000001164.
51. Johns T, Lawrence E.Evaluation and treatment of nausea and vomiting in adults. Am Fam
Physician. 2024;109(5):417–25.
52. Leach C. Nausea and vomiting in palliative care. Clin Med (Lond). 2019;19(4):299–301.
https://doi.org/10.7861/clinmedicine.19- 4- 299. PMID: 31308107; PMCID: PMC6752233.
53. Mounsey A, Raleigh M, Wilson A.Management of constipation in older adults. Am Fam
Physician. 2015;92(6):500–4.
54. Kim J, Phongsamran P, Park S. Use of antidepressant drugs in transplant recipients. Prog
Transplant. 2004;14(2):98–104.
55. Maurer DM, Raymond TJ, David BN. Depression: screening and diagnosis. Am Fam
Physician. 2018;98(8):508–15.
56. Fast Fact #273 treating depression after heart transplantation [Internet]. Palliative Care
Network of Wisconsin Fast Facts. [cited 2019 Apr 24].
https://www.mypcnow.org/blank- ileos
57. Citalopram. In: Lexidrug database [University of Cincinnati HSL]. Waltham (MA): UpToDate
Inc.; 2025 [updated 21 January 2025; cited 29 January 2025].
58. Mullish BH, Kabir MS, Thursz MR, Dhar A.Review article: depression and the use of anti-
depressants in patients with chronic liver disease or liver transplantation. Aliment Pharmacol
Ther. 2014;40(8):880–92.
59. Shirazian S, Grant CD, Aina O, Mattana J, Khorassani F, Ricardo AC.Depression in chronic
kidney disease and end-stage renal disease: similarities and differences in diagnosis, epide-
miology, and management. Kidney Int Rep. 2016;2(1):94–107. https://doi.org/10.1016/j.
ekir.2016.09.005. eCollection 2017 Jan.
16 Palliative Care intheAdult Solid Organ Transplant Recipient
464
60. Mindfulness-based stress reduction for solid organ transplant recipients: a randomized con-
trolled trial [Internet]. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3076132/. Accessed
24 Apr 2019.
61. Lentine KL, Smith JM, Lyden GR, Miller JM, Dolan TG, Bradbrook K, Larkin L, Temple K,
Handarova DK, Weiss S, Israni AK, Snyder JJ.OPTN/SRTR 2022 annual data report: kidney.
Am J Transplant. 2024;24(2S1):S19–S118. https://doi.org/10.1016/j.ajt.2024.01.012.
62. Marudanayagam R, Shanmugam V, Sandhu B, etal. Liver retransplantation in adults: a single-
centre, 25-year experience. HPB (Oxford). 2010;12(3):217–24.
https://doi.org/10.1111/j.1477-
2574.2010.00162.x.
63. Khush KK, Cherikh WS, Chambers DC, Goldfarb S, Hayes D Jr, Kucheryavaya AY, Levvey
BJ, Meiser B, Rossano JW, Stehlik J, International Society for Heart and Lung Transplantation.
The international thoracic organ transplant registry of the International Society for Heart and
Lung Transplantation: thirty-fth adult heart transplantation report-2018; focus theme: multior-
gan transplantation. J Heart Lung Transplant. 2018;37(10):1155–68. https://doi.org/10.1016/j.
healun.2018.07.022. Epub 2018 Aug 10.
64. Harhay MO, Cherikh WS, Toll AE, Christie JD, Stehlik J, Chambers D, Hayes D Jr, Cantu
E. Epidemiology, risk factors, and outcomes of lung retransplantation: an analysis of the
International Society for Heart and Lung Transplantation Thoracic Transplant Registry. J Heart
Lung Transplant. 2022;41(10):1478–86. https://doi.org/10.1016/j.healun.2022.06.022. Epub
2022 Jul 5. PMID: 35933297; PMCID: PMC9986966.
65. Ren D, Kaleekal TS, Graviss EA, etal. Retransplantation outcomes at a large lung trans-
plantation program. Transplant Direct. 2018;4(11):e404. Published 2018 Oct 25. https://doi.
org/10.1097/TXD.0000000000000844.
66. Hall DJ, Belli EV, Gregg JA, Salgado JC, Baz MA, Staples ED, Beaver TM, Machuca
TN. Two decades of lung retransplantation: a single-center experience. Ann Thorac Surg.
2017;103(4):1076–83. https://doi.org/10.1016/j.athoracsur.2016.09.107.
K. G. Hicks et al.
465© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2025
C. J. Wong (ed.), Primary Care of the Solid Organ Transplant Recipient,
https://doi.org/10.1007/978-3-031-98076-3_17
Chapter 17
Gender-Afrming Care oftheAdult Solid
Organ Transplant Recipient
JuliaBecke, LydiaSun, andChristopherJ.Wong
17.1 Introduction
Understanding basic principles of care for gender diverse people is crucial for pri-
mary care physicians. In the context of historic disparities in care for this popula-
tion, broadening our knowledge base and practice to include the needs of transgender
people supports improved health access and outcomes.
17.1.1 Epidemiology
Estimates of the proportion of transgender or gender diverse people in the general
population vary due to differences in denitions, methodology, and study popula-
tions. Health systems-based studies using diagnostic coding report lower estimates
(0.02–0.1%), while survey-based studies are higher (0.3–0.5%); other studies that
included gender diversity (e.g., gender incongruence or gender ambivalence) found
proportions as high as 4.5% [1]. The proportion of solid organ transplant recipients
who are transgender or gender diverse has not been studied. With over 400,000
estimated living solid organ transplant recipients in the USA alone, the number who
are also transgender or gender diverse is likely to be signicant.
J. Becke (*) · C. J. Wong
Division of General Internal Medicine, Department of Medicine, University of Washington,
Seattle, WA, USA
e-mail: jhgbecke@uw.edu; cjwong@uw.edu
L. Sun
Department of Pharmacy, University of Washington, Seattle, WA, USA
e-mail: lydsun@uw.edu
466
17.1.2 Terminology
The term transgender generally refers to people whose gender identity differs from
the gender or sex they were assigned at birth. For example, a transgender man is
someone who was assigned female at birth but identies with the male gender. A
transgender woman is someone who was assigned male at birth but identies with
the female gender. However, in caring for gender diverse people, it is important to
acknowledge that gender identity may be seen as a continuum between the binary
identities of male and female. Some transgender people identify as one gender,
while others describe their gender as a more uid concept. For example, some
people identify as gender non-binary, meaning they identify as neither male or
female, independent of their assigned birth gender. Others may use a term for their
gender that describes their individual experience or is unique to their cultural
background.
Gender dysphoria is a Diagnostic and Statistical Manual of Mental Disorders-5
(DSM-5) diagnosis that specically notes (1) the incongruence between a person’s
assigned gender and their expressed or experienced gender and (2) clinically signi-
cant distress or impairment in function [2].
Gender incongruence is “characterized by a marked and persistent incongruence
between an individual’s experienced gender and the assigned sex” in the International
Statistical Classication of Diseases and Related Health Problems system (ICD-11)
[3]. It is further reclassied as part of sexual health, rather than as a disorder.
People who are transgender experience gender incongruence. Some people with
gender incongruence also have gender dysphoria, but it is important to note that not
all people who are transgender have gender dysphoria (i.e., they may not have dis-
tress or impairment in function). Furthermore, it is not necessary for a transgender
person to have gender dysphoria to receive gender-afrming care.
17.2 Gender-Afrming Care
Gender-afrming care refers to “social, psychological, behavioral or medical
(including hormonal treatment or surgery) interventions designed to support and
afrm an individual’s gender identity” [3].
Initiating and maintaining gender-afrming care is the denitive treatment for
gender dysphoria. Studies strongly suggest that gender-afrming care reduces the
burden of mental illness including suicidality in transgender people, related to gen-
der dysphoria or other mood and anxiety disorders [4, 5].
Creating a safe and welcoming environment for transgender people also creates
a better opportunity for positive clinical outcomes. Marginalization and violence
against transgender people, including the stigmatization of transgender health
needs, have contributed to poor health care access and signicant health care needs
J. Becke et al.
467
in the transgender and gender diverse population. Some basic steps in the healthcare
setting can help ensure respectful care is optimized. Misgendering is common and
can be a source of distress [6, 7]; healthcare providers should ensure use of a
patient’s identied pronouns as well as their preferred name or nickname [8]. Use
of tools in the electronic medical record to communicate the patient’s name and
pronouns to their entire care team is crucial. Understanding gender-afrming thera-
pies, including hormonal, surgical, and supportive interventions, helps build trust
and engagement in shared decision-making between the patient and the health care
team [1].
People may transition to their identied gender at any point in life. While some
children and teens may begin seeking gender-afrming care early in life, others seek
care well into adulthood. This chapter is limited to gender-afrming care for adults.
People with a solid organ transplant may have been receiving gender-afrming
treatments prior to transplant or may seek to access gender-afrming care after
transplant. Hormonal and surgical treatments used in gender-afrming care deserve
careful consideration in solid organ transplant recipients.
17.3 Medications Used inGender-Afrming Care
Some transgender people seek hormone therapy as part of their gender-afrming
care. Sex hormones of the identied gender are administered exogenously to induce
the development of desired secondary sex characteristics (Table17.1). Additional
non-hormonal medications are sometimes also used to block secondary sex charac-
teristics of the natal or assigned gender.
17.3.1 Estrogen
In transgender women, estrogen is the primary therapy to support the development
of female sexual characteristics as part of gender-afrming care. Expected changes
include breast growth, fat redistribution and skin textural changes, along with a
decrease in the size of the testes.
17.3.1.1 Dosing andTherapeutic Monitoring
Estrogen may be administered via oral, transdermal, or injectable routes. Prior to
starting gender-afrming hormone therapy, and then throughout treatment, certain
laboratory values are monitored to ensure medication safety. Estradiol levels are
typically followed every 3 months as medication is adjusted, then yearly once treat-
ment is at goal. The aim of therapy is typically to reach a target level between 50 and
17 Gender-Afrming Care oftheAdult Solid Organ Transplant Recipient
468
Table 17.1
Hormone regimens used in gender-afrming care
a
Estrogen-based regimen (transfeminine)
Estrogen
Oral or sublingual
Estradiol 2.0–6.0 mg/day
Transdermal
Estradiol transdermal patch 0.025–0.2 mg/day
Estradiol gel various Daily to skin
b
Parenteral
Estradiol valerate or cypionate 5–30mg IM every 2 weeks or
2–10mg IM every week
Anti-androgens
Spironolactone 100–300 mg/day
Cyproterone acetate 10 mg/day
c
GnRH agonist 3.75–7.50mg SQ/IM monthly
GnrH agonist depot formulation 11.25/22.5mg SQ/IM 3/6 monthly
Testosterone-based regimen (transmasculine)
Testosterone
Parenteral
Testosterone enanthate or cypionate 50–100mg IM/SQ weekly or
100–200mg IM every 2 weeks
Testosterone undecanoate 1000mg IM every 12 weeks or
750mg IM every 10 weeks
Transdermal testosterone
Testosterone gel 50–100 mg/day
Testosterone transdermal patch 2.5–7.5 mg/day
Table from Coleman, etal. reprinted with permission [1]
a
Doses are titrated up or down until sex steroid hormone levels are in the therapeutic range.
Hormone regimens do not reect all formulations that are available in all pharmacies throughout
the world. Hormone regimens may have to be adapted to what is available inlocal pharmacies
b
Amount varies depending on formulation and strength
c
Kuijpers etal. [9]
200 mg/dl, as would be the typical range for pre-menopausal cis-women.
Testosterone levels are also monitored with a common goal to suppress endogenous
levels to less than 50 ng/dL.
17.3.1.2 Drug Interactions
Estradiol has potential interactions with immunosuppressive medications
(Table17.2).
Tacrolimus and estradiol are both metabolized through the CYP450 3A4 path-
way. Estradiol can slow tacrolimus metabolism, potentially leading to excess tacro-
limus levels and associated toxicity. In some circumstances, close monitoring of
tacrolimus trough levels and renal function will be sufcient to support safe
J. Becke et al.
469
Table 17.2 Potential drug interactions between medications used in gender afrming care and immunosuppressants
Immunosuppressive medication
Gender afrming medication Tacrolimus Cyclosporine Mycophenolate Sirolimus Prednisone
Feminizing
hormone therapy
Estradiol Monitor for potential
tacrolimus toxicity
due to increased
tacrolimus
concentrations
Not well-dened;
consider monitoring
for potential increases
in serum cyclosporine
levels
None known (limited
data—see text)
None known Monitor for
increased
prednisone
toxicity
Spironolactone Use with caution.
Increased risk of
hyperkalemia and
decreased GFR
Use with caution.
Increased risk of
hyperkalemia and
decreased GFR
None known Use with caution.
Increased risk of
hyperkalemia and
decreased GFR
None known
Finasteride N/A N/A N/A N/A N/A
Progestins N/A N/A N/A N/A N/A
Leuprolide Prolonged QTc—
unknown if
combination
increases risk (see
text)
Prolonged QTc—
unknown if
combination increases
risk (see text)
N/A N/A N/A
Masculinizing
hormone therapy
Testosterone Monitor for
increased
hypertensive effect
Monitor for increase
in hepatotoxic effect
of cyclosporine
None known Monitor for
increased
hypertensive effect
Monitor for
increased side
effects, such as
acne
17 Gender-Afrming Care oftheAdult Solid Organ Transplant Recipient