Kidney Transplant Kidney transplant Anti-rejection drugs

Anti-Rejection Drug Interactions: The Complete List of Foods, Medicines and Supplements to Watch — Grapefruit, Pomelo, Paxlovid, NSAIDs, Herbs and Vaccines (v1.1, updated 2026-10-13)

Beyond CKD October 13, 2026 24 min read

What "fights" with tacrolimus, cyclosporine, sirolimus, mycophenolate and azathioprine after a kidney transplant? A red/amber/orange-graded list of 60+ foods, herbs, supplements, prescription drugs and vaccines, with practical habits, a version history and 21 references.

Version v1.1 | Updated 13 October 2026 (v1.0 first edition same day; v1.1 adds "2b. Deep dive"). Compiled from prescribing information, the KDIGO transplant care guideline, the American Society of Transplantation (AST) vaccination guideline and peer-reviewed literature (listed at the end) by a non-physician site owner. Not medical advice. Your regimen, doses and target levels are individual — ask your transplant team or pharmacist before adding or stopping any medicine or supplement.

Why anti-rejection drugs are so easily "disturbed"

Most anti-rejection drugs used after kidney transplant share two traits: a narrow therapeutic window (slightly too high damages the kidney, slightly too low invites rejection) and metabolism through the liver enzyme CYP3A4 and the intestinal transporter P-glycoprotein (P-gp). Any food, drug or herb that inhibits or induces these pathways swings blood levels widely. First know which class you take:

Class	Common names	Main pathway	Biggest risk
Calcineurin inhibitors (CNI)	Tacrolimus (Prograf, Advagraf, Envarsus XR), Cyclosporine (Neoral)	CYP3A4, P-gp	High level → kidney toxicity, high potassium, tremor; low level → rejection
mTOR inhibitors	Sirolimus (Rapamune), Everolimus (Certican/Zortress)	CYP3A4, P-gp	As above; plus poor wound healing, mouth ulcers, high lipids
Antimetabolites	Mycophenolate (CellCept, Myfortic), Azathioprine (Imuran)	Glucuronidation, renal excretion; AZA via xanthine oxidase	Absorption blocked by antacids/iron; AZA + urate-lowering drugs → bone-marrow suppression
Corticosteroids	Prednisolone, Methylprednisolone	CYP3A4 (less sensitive)	Blood sugar, blood pressure, bone, infection
Biologics	Belatacept (Nulojix, IV)	Protein catabolism, almost no CYP interactions	Infection; contraindicated if EBV-seronegative

1. Food and drink

1-1 🔴 Avoid completely

Food	Effect	Notes
Grapefruit, grapefruit juice	Tacrolimus/cyclosporine/sirolimus levels rise (up to 2–5×)	Furanocoumarins irreversibly inhibit gut CYP3A4; one glass lasts 24–72 h — "taking the dose the next day" does not help
Pomelo	Same	The classic Mid-Autumn Festival cause of tacrolimus spikes in Asia; Japanese case report of pomelo-induced toxicity
Seville (bitter) orange, marmalade	Same	Sweet oranges and mandarins are not a problem
Star fruit (carambola), incl. juice and candied	Neurotoxicity in impaired kidneys (intractable hiccups, confusion, seizures); may inhibit CYP3A4	Contraindicated for all CKD, dialysis and transplant patients
St John's wort	Tacrolimus/cyclosporine/sirolimus levels fall 30–60% → rejection	Common in "natural antidepressant" supplements and herbal teas; takes ~2 weeks to wash out
Alcohol + extended-release tacrolimus (Advagraf/Envarsus/Astagraf XL)	Alcohol accelerates release — a full day's dose dumps at once	Label warning: avoid alcohol around dosing; less critical with immediate-release Prograf but still not advised

1-2 🟡 Use caution

Food	Effect	Advice
Pomegranate, pomegranate juice	Case reports of raised tacrolimus	Occasional small amounts OK; no daily juice
High-fat meals	Tacrolimus absorption falls (AUC −~30%); sirolimus absorption rises	What matters is consistency — same relation to food every day, or trough levels are meaningless
High-potassium foods (banana, orange juice, tomato, potato, salt substitutes/low-sodium soy sauce)	Tacrolimus/cyclosporine themselves raise potassium; salt substitutes use potassium chloride	Potassium limits are looser than on dialysis, but avoid salt substitutes and potassium supplements; check labs
Raw/undercooked food, unpasteurised dairy, raw salads, oysters, runny eggs	Not an interaction — infection risk (Listeria, Salmonella, Toxoplasma)	Especially the first 6 months and during high-dose periods
Large amounts of green tea / coffee	Limited evidence; high-dose EGCG extract capsules may affect CYP3A4 and liver	Brewed tea is fine; avoid concentrated extracts
Liquorice (herbal formulas, sweets, tea)	Potentiates steroids → low potassium, high blood pressure, oedema	Avoid large amounts on long-term steroids

1-3 🟠 Herbs and supplements

The thing patients most often "forget to mention." Rule of thumb: anything marketed to "boost immunity" is working against your anti-rejection drugs.

Item	Risk	Evidence
Schisandra (Wuzhi capsule)	Tacrolimus level ~2× higher (CYP3A4/P-gp inhibition)	Healthy-volunteer PK study; used deliberately in China to "spare" drug — dangerous without monitoring
Berberine (Coptis, Phellodendron)	Cyclosporine level rises	Trial in kidney transplant recipients
High-dose curcumin/turmeric capsules	Case report: acute tacrolimus nephrotoxicity (level ~8 → >29 ng/mL)	Case report; culinary turmeric is fine
Cannabidiol (CBD) oil	Tacrolimus ~3× higher	Case report (Am J Transplant 2019)
Red yeast rice	Contains natural lovastatin; with cyclosporine → rhabdomyolysis	Same as statin interaction
Echinacea, astragalus, reishi, agaricus, cat's claw, cordyceps	Immunostimulant — theoretically antagonises immunosuppression; some CYP effects	Low-grade evidence, but transplant centres uniformly advise avoid
Ginseng	CYP3A4 and glucose effects; case reports of lower tacrolimus	Avoid
Chamomile (large amounts)	Case report of raised cyclosporine	Occasional cup OK
Probiotics (esp. Saccharomyces boulardii)	No level change, but fungaemia cases in heavily immunosuppressed patients	Avoid live products in year 1, in hospital or with a central line
Fish oil, vitamin D, calcium, iron, magnesium	No effect on CNI levels; but calcium, iron, magnesium and aluminium antacids block mycophenolate absorption	Separate from CellCept/Myfortic by ≥2 hours
High-dose vitamin C / E	No clear interaction; megadose vitamin C raises oxalate stone risk	Stay within recommended intake

One line: herbal remedies, "kidney tonics", wellness teas — ask your doctor or pharmacist first. If you see a traditional-medicine practitioner, show them your anti-rejection prescription.

2. Medicines

2-1 🔴 Raise tacrolimus/cyclosporine/sirolimus levels (CYP3A4/P-gp inhibitors)

Class	Drugs	Severity	What to do
COVID-19 oral antivirals	Paxlovid (nirmatrelvir/ritonavir)	★★★ Extreme: ritonavir raises tacrolimus tens of times; multiple acute kidney failure reports	Tell the prescriber you are a transplant recipient. Most centres hold tacrolimus during Paxlovid and resume 2–3 days after by level, or use molnupiravir/remdesivir instead
Azole antifungals	Ketoconazole, itraconazole, voriconazole, posaconazole, fluconazole (dose-dependent)	★★★	Pre-emptive tacrolimus reduction by 1/3–2/3 with frequent levels
Macrolide antibiotics	Clarithromycin, erythromycin	★★★	Common in H. pylori regimens and bronchitis; azithromycin has minimal effect — ask to switch
Calcium-channel blockers	Diltiazem, verapamil, nicardipine (amlodipine minor)	★★	Some centres co-prescribe diltiazem deliberately; the key is never stop or start it on your own
HIV / hepatitis C drugs	Ritonavir, cobicistat, some DAAs (e.g. glecaprevir/pibrentasvir with cyclosporine)	★★★	Joint ID–transplant management
CMV prophylaxis	Letermovir (Prevymis)	★★	Raises cyclosporine and tacrolimus
Antiarrhythmics	Amiodarone, dronedarone	★★	Long half-life — effect persists for weeks
Others	Metoclopramide (↑absorption), nefazodone, fluvoxamine, imatinib, ticagrelor	★–★★	Check a level when starting or stopping

2-2 🔴 Lower levels (CYP3A4 inducers) → rejection risk

Drug	Notes
Rifampin, rifabutin	The classic tuberculosis problem — tacrolimus may fall >50%; dose must rise 2–5× with close monitoring
Phenytoin, carbamazepine, phenobarbital, oxcarbazepine	Older antiepileptics; levetiracetam and lamotrigine do not interact — ask neurology about alternatives
Efavirenz, nevirapine	HIV drugs
Modafinil, bosentan, enzalutamide, apalutamide	Less common but monitor
St John's wort	See food section

2-3 🔴 Additive kidney toxicity (levels unchanged, but both hurt the kidney)

Drug	Notes
NSAIDs: ibuprofen, diclofenac, naproxen, mefenamic acid, celecoxib, etoricoxib	Use acetaminophen/paracetamol for pain. Dental, orthopaedic and over-the-counter products often contain NSAIDs — always say "I have a kidney transplant." Avoid large-area long-term topical NSAID patches too
Aminoglycosides (gentamicin, amikacin), vancomycin, colistin, amphotericin B	Hospital antibiotics; dose adjustment and monitoring
Iodinated contrast (CT, angiography)	Tell the transplant team before the scan; hydration and review of other nephrotoxins
High-dose IV acyclovir/valacyclovir	Crystal nephropathy; usual oral doses are relatively safe

2-4 🟡 Additive hyperkalaemia

Tacrolimus and cyclosporine already raise potassium. Check potassium regularly when combined with ACE inhibitors/ARBs, spironolactone, eplerenone, trimethoprim (co-trimoxazole/Bactrim — routine Pneumocystis prophylaxis after transplant), potassium supplements, salt substitutes, long-term heparin.

2-5 🔴 Specific combinations to remember

Combination	Consequence	Action
Azathioprine + allopurinol or febuxostat	Xanthine oxidase blocked → AZA metabolites accumulate → severe bone-marrow suppression	Tell your doctor if you have gout; if unavoidable, AZA reduced to 1/4–1/3 with frequent blood counts — most centres switch to mycophenolate
Cyclosporine + simvastatin/lovastatin/high-dose atorvastatin	Statin levels rise several-fold → rhabdomyolysis	Use pravastatin, fluvastatin or low-dose rosuvastatin; tacrolimus interacts less but still monitor
Cyclosporine + colchicine	Myoneuropathy	Tell your doctor during gout flares
Cyclosporine + digoxin	Digoxin toxicity	Monitor
Mycophenolate + Al/Mg antacids, iron, calcium, sevelamer, cholestyramine	MPA absorption falls 20–40%	Separate by ≥2 hours
Mycophenolate (CellCept) + proton-pump inhibitors (omeprazole, pantoprazole…)	CellCept needs acid to dissolve — exposure −~25%; Myfortic unaffected	Tell your doctor if on long-term PPI
Mycophenolate + acyclovir/valacyclovir/ganciclovir/valganciclovir	Compete for tubular secretion — both rise	More marked with reduced kidney function; common during CMV prophylaxis — monitor blood counts
Mycophenolate + oral contraceptives	Contraceptive efficacy may fall; mycophenolate is highly teratogenic	Two methods of contraception; switch drugs ≥6 weeks before planned pregnancy
Sirolimus + cyclosporine	Sirolimus level rises	Separate doses by 4 hours
Sirolimus/everolimus + ACE inhibitors	Higher angioedema risk	Watch for face, lip, tongue swelling
Tacrolimus + other QT-prolonging drugs (some antipsychotics, high-dose ondansetron, fluoroquinolones)	Arrhythmia	Tell your doctor if you have heart disease

2-6 🔴 Vaccines: live attenuated vaccines are contraindicated

Contraindicated (live)	Allowed (inactivated/subunit)
MMR, varicella, live zoster (Zostavax), yellow fever, oral typhoid, BCG, nasal-spray influenza, oral polio, live smallpox/mpox	Influenza (injection), COVID-19, pneumococcal (PCV20/PPSV23), hepatitis B, recombinant zoster (Shingrix), HPV, tetanus, RSV, hepatitis A, meningococcal

If a travel destination requires yellow fever vaccination, obtain a medical exemption letter from your transplant clinic.
Household members may receive live vaccines; wear gloves and wash hands when changing nappies for 4 weeks after an infant's rotavirus vaccine.

2b. Deep dive: how much do levels actually change? (public databases and literature)

New in v1.1. Figures below come from prescribing information (FDA labels / EMA SmPCs), the clinical pharmacokinetic studies cited in FDA drug-interaction guidance, and peer-reviewed literature. AUC = area under the concentration–time curve (total exposure); Cmax = peak concentration; "×" = ratio with vs without the interacting agent. Numbers vary with study design and population — they illustrate magnitude and must never be used to self-adjust doses.

Free, verifiable public databases

Database	Provider	What to look up	Short link
DailyMed	US National Library of Medicine	Full US labels (Section 7 Drug Interactions; Section 12.3 Pharmacokinetics gives actual fold-changes)	/go/dailymed
Drugs@FDA	US FDA	Approval packages incl. Clinical Pharmacology Reviews with raw PK data	/go/fda
FDA Table of Substrates, Inhibitors and Inducers	US FDA	Official strong/moderate/weak CYP3A4 and P-gp classification	/go/fda-ddi
EMA EPAR / SmPC	European Medicines Agency	European labels, Section 4.5	/go/ema
Flockhart Cytochrome P450 Drug Interaction Table	Indiana University School of Medicine	Quick substrate/inhibitor/inducer lookup per CYP	/go/flockhart
Liverpool Drug Interactions (HIV/HEP/COVID)	University of Liverpool	Traffic-light checker for antivirals (incl. Paxlovid) vs immunosuppressants	/go/liverpool
PharmGKB	Stanford University	CYP3A5 genotype–tacrolimus dosing evidence	/go/pharmgkb
CPIC guidelines	Clinical Pharmacogenetics Implementation Consortium	CYP3A5–tacrolimus dosing recommendation (2015)	/go/cpic
DrugBank	University of Alberta	Interaction summaries and mechanisms (free tier)	/go/drugbank
Taiwan TFDA licence search	Taiwan FDA	Approved products and Chinese labels	/go/tfda

Tacrolimus: quantified interactions

Co-administered agent	Change in tacrolimus exposure	Source
Ritonavir (in Paxlovid)	Healthy volunteers: tacrolimus AUC ↑ ~57-fold, half-life 32 h → 232 h after a single 100 mg ritonavir dose; clinical cases >100 ng/mL	Badri et al. 2015; Paxlovid FDA label §7; Lange et al. 2022
Ketoconazole 200 mg/day	Oral bioavailability 14% → 30% (~2×); most centres cut dose 50–75%	Floren et al. 1997; Prograf FDA label §12.3
Voriconazole	Healthy volunteers: AUC ↑ 3.2×, Cmax ↑ 2.2×; label advises reducing tacrolimus to one-third	Vfend FDA label §7
Posaconazole	AUC ↑ 4.6×, Cmax ↑ 2.2×; label advises ~two-thirds reduction	Noxafil FDA label §7
Itraconazole	Case series: 2–3× rise, ~50% dose reduction	Prograf label §7; Capone et al. 1996
Fluconazole 200 mg/day	Kidney recipients: ~1.4–2× rise (dose-dependent; 100 mg less)	Mañez et al. 1994
Clarithromycin	Case series: 2–3× rise within 24–48 h	Wolter et al. 1994; Prograf label §7
Erythromycin	Cases: 2–4× rise	Shaeffer et al. 1994
Azithromycin	No significant change (not CYP3A4-dependent)	Page et al. 2011
Diltiazem 180 mg/day	Kidney recipients: tacrolimus dose requirement ↓ 25–50% (C/D ratio ↑ 1.5–2×)	Hebert et al. 1999; Jones et al. 1997
Verapamil	~2× rise	Prograf label §7
Amlodipine	Mostly no significant effect; minor rises in a few reports	Prograf label §7 (listed as weak)
Letermovir 480 mg/day	Healthy volunteers: AUC ↑ 2.4×, Cmax ↑ 1.6×	Prevymis FDA label §7
Amiodarone	Cases: 2–3× rise, persisting weeks after stopping	Nalli et al. 2011
Nirmatrelvir alone	Weak CYP3A4 inhibitor in vitro; clinical interaction driven by ritonavir	Paxlovid label §12.3
Rifampin 600 mg/day	Healthy volunteers: oral tacrolimus AUC ↓ 68%, clearance ↑ 47%; clinically 2–5× dose increases	Hebert et al. 1999; Prograf label §7
Phenytoin	Cases: >50% fall; phenytoin levels may also rise	Thompson et al. 1996
Carbamazepine	Falls requiring dose increase; paediatric reports of 2–3× doses	Prograf label §7
St John's wort 600 mg/day (0.3% hypericin)	Kidney recipients: tacrolimus AUC ↓ 58%, Cmax ↓ 65%; doses had to be raised back after stopping	Hebert et al. 2004; Mai et al. 2003
Grapefruit juice (250 mL/day for days)	Liver recipients: ~2–5× rise (high inter-individual variability)	Liu et al. 2009; Peynaud et al. 2007
Pomelo	Case: level 10 → >25 ng/mL	Egashira et al. 2003
Schisandra extract (Wuzhi capsule)	Healthy volunteers: AUC ↑ 2.6×, Cmax ↑ 2.2×; in kidney recipients AUC ↑ 1.5–2×	Xin et al. 2007; Qin et al. 2013
High-dose curcumin	Case: level 8.4 → 29.9 ng/mL, acute kidney injury	Nayeri et al. 2017
CBD oil (2000–2900 mg/day)	Case: ~3× rise in dose-normalised level	Leino et al. 2019
High-fat meal	Healthy volunteers: tacrolimus AUC ↓ 27–37%, Cmax ↓ 50–77% vs fasting	Prograf FDA label §12.3
Alcohol + Envarsus XR	In-vitro dissolution: markedly faster release in 40% ethanol within 2 h; labelled warning	Envarsus XR FDA label §2, §7

Cyclosporine: quantified interactions

Agent	Change in cyclosporine exposure	Source
Ketoconazole 200 mg/day	Dose requirement ↓ 70–85% (historically used deliberately to spare drug)	First et al. 1993; Neoral label §7
Diltiazem	Dose requirement ↓ ~30–50%	Neoral label §7
Clarithromycin	~1.5–2× rise	Neoral label §7
Rifampin	70–80% fall; 2–5× dose increases	Neoral label §7
St John's wort	Kidney/heart recipients: 30–60% fall; multiple acute rejection reports (incl. 2 heart-transplant rejections)	Ruschitzka et al. 2000; Breidenbach et al. 2000
Grapefruit juice 200 mL	Kidney recipients: AUC ↑ ~40–60%	Ducharme et al. 1995
Berberine 300 mg tid	Kidney recipients: AUC ↑ ~35%, C/D ratio ↑ 88%	Wu et al. 2005
Simvastatin 80 mg + cyclosporine	Simvastatin AUC ↑ ~2.5–8×, rhabdomyolysis; label limits simvastatin to ≤10 mg or contraindicates	Zocor FDA label §7; Neuvonen et al. 2006
Atorvastatin + cyclosporine	Atorvastatin AUC ↑ 8.7×; avoid or ≤10 mg	Lipitor FDA label §7
Rosuvastatin + cyclosporine	Rosuvastatin AUC ↑ 7×; limit 5 mg	Crestor FDA label §7
Pravastatin + cyclosporine	AUC ↑ 5–10× yet few myopathy reports; still a preferred choice (start ≤20 mg)	Pravachol label §7
Colchicine + cyclosporine	Colchicine AUC ↑ 3.2×; multiple myoneuropathy cases	Colcrys FDA label §7

Sirolimus / Everolimus

Agent	Change	Source
Ketoconazole	Sirolimus AUC ↑ 10.9×, Cmax ↑ 4.4× — labelled contraindicated	Rapamune FDA label §7
Voriconazole	Sirolimus AUC ↑ 11× — contraindicated	Vfend label §7
Diltiazem	Sirolimus AUC ↑ 60%, Cmax ↑ 43%	Rapamune label §7
Verapamil	Sirolimus AUC ↑ 2.2×; verapamil AUC itself ↑ 1.5×	Rapamune label §7
Erythromycin	Sirolimus AUC ↑ 4.2×	Rapamune label §7
Rifampin	Sirolimus AUC ↓ 82%	Rapamune label §7
Cyclosporine simultaneous vs 4 h apart	Simultaneous: sirolimus AUC ↑ 230%; 4 h apart: ↑ 80%	Rapamune label §7
High-fat meal	Oral solution AUC ↑ 35%; tablets ↑ 23–35%	Rapamune label §12.3
Everolimus + ketoconazole	Everolimus AUC ↑ 15×	Zortress FDA label §7

Mycophenolate

Agent	Change in MPA (active metabolite)	Source
Mg/Al antacids	MMF: MPA AUC ↓ 17%, Cmax ↓ 33%	CellCept FDA label §7
Sevelamer 2400 mg	MPA AUC ↓ 25%, Cmax ↓ 30%	CellCept label §7; Pieper et al. 2004
Cholestyramine 4 g tid	MPA AUC ↓ 40%	CellCept label §7
Pantoprazole 40 mg bid	MMF: MPA AUC ↓ 27%, Cmax ↓ 57%; Myfortic (enteric-coated) unaffected	Kofler et al. 2009; Rupprecht et al. 2009
Rifampin	Heart–lung recipient: MPA AUC ↓ 70% (UGT induction and intestinal efflux)	Kuypers et al. 2005
Acyclovir / Ganciclovir	Both AUCs rise slightly (tubular competition); more marked with reduced kidney function	CellCept label §7
Cyclosporine (vs tacrolimus)	MPA AUC is ~30–40% lower with cyclosporine than with tacrolimus (CsA blocks enterohepatic recirculation) — the main reason MPA levels shift when switching CNIs	van Gelder et al. 2001
Oral contraceptives	Levonorgestrel AUC ↓ 15%; pregnancy risk is mainly teratogenicity rather than contraceptive failure	CellCept label §7, §8.1

Azathioprine

Agent	Change	Source
Allopurinol	6-MP/6-TGN levels ↑ 3–5×; AZA must be cut to 25–33%, severe leukopenia still reported	Imuran FDA label §7; Kennedy et al. 1996
Febuxostat	Also a xanthine-oxidase inhibitor; labelled contraindicated with AZA	Uloric FDA label §4
Warfarin	AZA reduces warfarin effect (INR falls); INR rebounds when AZA is stopped	Imuran label §7
ACE inhibitors	Case reports of worsened leukopenia/anaemia	Imuran label §7

Pharmacogenomics: why the same dose gives such different levels

CYP3A5 genotype: carriers of at least one CYP3A5*1 (expresser) allele (~30–40% of East Asians, ~70% of people of African ancestry, ~10–20% of Europeans) metabolise tacrolimus faster and need roughly 1.5–2× the dose to reach the same level. CPIC 2015 recommends a 1.5–2× starting dose for expressers (not exceeding 0.3 mg/kg/day) with continued monitoring.
CYP3A4*22: reduced activity; carriers need lower doses (~5–7% of Europeans, rare in Asians).
ABCB1 (P-gp) polymorphisms: small and inconsistent effect on tacrolimus levels — not recommended as a dosing basis.
In practice: some centres offer CYP3A5 testing; useful for reaching target quickly early after transplant, but it does not replace level monitoring.

Three reminders when reading these numbers

Fold-changes are averages: the same drug may be 1.5× in one person and 5× in another — which is why "re-check the level 3–7 days after starting or stopping any interacting drug" matters more than memorising figures.
Rebound after stopping is just as dangerous: when an inhibitor stops (end of Paxlovid, stopping diltiazem), tacrolimus levels fall back within days — if the dose was lowered, rejection risk follows; when an inducer stops (rifampin, St John's wort), levels climb back toward toxicity.
Labels are the most reliable and conservative source: most figures above can be found directly in Sections 7 and 12.3 of the corresponding DailyMed label; where a label and an online article disagree, trust the label.

3. Practical habits

Carry an "anti-rejection drug card": drug names, doses, latest trough level, transplant centre phone. Show it at the dentist, ER, pharmacy and any practitioner.
Three questions: "Will this affect my tacrolimus/cyclosporine level?" "Is it harmful to the kidney or does it raise potassium?" "Should I get an extra level checked?"
Re-check the level 5–7 days after any new drug — CYP3A4 effects usually stabilise in 3–5 days.
Be consistent: same time daily, same relationship to food, no brand switching without a level (Prograf ↔ generics included).
Lab day: draw the trough before the morning dose, then take it. A post-dose level is meaningless.
Keep an up-to-date medication list (app or national health record) and show it at every clinic visit.
In Taiwan, at every clinic, dental office or pharmacy, ask the front desk / nurse / pharmacist to read your NHI IC-card orders and the NHI cloud medication record (雲端藥歷). It lists every prescription you have received across institutions — the most direct way to catch duplicate or interacting drugs — but only if someone actually opens it. Abroad, carry a printed medication list instead.

Version history

Version	Date	Content
v1.0	2026-10-13	First edition: 5 drug classes, food/herb/drug interactions, vaccines, practical habits, references
v1.1	2026-10-13	Added "2b. Deep dive": 10 public databases, 60+ quantified interactions for tacrolimus/cyclosporine/sirolimus/mycophenolate/azathioprine (AUC/Cmax fold-changes with label sections), CYP3A5 pharmacogenomics, rebound-after-stopping reminders; references expanded to 39

(Planned next update: interactions with newer oral antivirals and emerging agents such as belatacept/tegoprubart.)

References

Astellas Pharma. Prograf / Advagraf / Envarsus XR Prescribing Information (alcohol and extended-release warnings).
Novartis. Sandimmun Neoral (cyclosporine) Prescribing Information.
Roche. CellCept Prescribing Information; Novartis. Myfortic Prescribing Information.
Pfizer. Rapamune (sirolimus) Prescribing Information.
KDIGO Transplant Work Group. KDIGO Clinical Practice Guideline for the Care of Kidney Transplant Recipients. Am J Transplant. 2009;9(Suppl 3):S1-S155.
Bailey DG, Dresser G, Arnold JM. Grapefruit–medication interactions. CMAJ. 2013;185(4):309-316.
Egashira K, et al. Pomelo-induced increase in the blood level of tacrolimus in a renal transplant patient. Transplantation. 2003;75(7):1057.
Neto MM, et al. Intoxication by star fruit in 32 uraemic patients. Nephrol Dial Transplant. 2003;18(1):120-125.
Nowack R. CYP450- and transporter-mediated herb–drug interactions in renal transplant patients. Nephrology (Carlton). 2008;13(4):337-347.
Xin HW, et al. Effects of Schisandra sphenanthera extract on the pharmacokinetics of tacrolimus. Br J Clin Pharmacol. 2007;64(4):469-475.
Wu X, et al. Effects of berberine on the blood concentration of cyclosporin A in renal transplanted recipients. Eur J Clin Pharmacol. 2005;61(8):567-572.
Nayeri A, et al. Acute calcineurin inhibitor nephrotoxicity secondary to turmeric intake. Transplant Proc. 2017;49(1):198-200.
Leino AD, et al. Clinically significant drug-drug interaction between cannabidiol and tacrolimus. Am J Transplant. 2019;19(10):2944-2948.
Lange NW, et al. Nirmatrelvir/ritonavir use: managing drug-drug interactions with transplant immunosuppressants. Am J Transplant. 2022;22(7):1925-1926.
Salerno DM, et al. Early clinical experience with nirmatrelvir/ritonavir in solid organ transplant recipients. Am J Transplant. 2022;22(8):2083-2088.
Kennedy DT, et al. Azathioprine and allopurinol: the price of an avoidable interaction. Ann Pharmacother. 1996;30(9):951-954.
Neuvonen PJ, Niemi M, Backman JT. Drug interactions with lipid-lowering drugs. Clin Pharmacol Ther. 2006;80(6):565-581.
Bullingham R, et al. Effects of food and antacid on the pharmacokinetics of mycophenolate mofetil. Br J Clin Pharmacol. 1996;41(6):513-516.
Kofler S, et al. Proton pump inhibitor co-medication reduces mycophenolate acid drug exposure. J Heart Lung Transplant. 2009;28(6):605-611.
Perazella MA. Trimethoprim-induced hyperkalaemia. Drug Saf. 2000;22(3):227-236.
Danziger-Isakov L, Kumar D; AST ID Community of Practice. Vaccination of solid organ transplant candidates and recipients. Clin Transplant. 2019;33(9):e13563.
Badri P, et al. Pharmacokinetics and dose recommendations for cyclosporine and tacrolimus when coadministered with ABT-450, ombitasvir, and dasabuvir. Am J Transplant. 2015;15(5):1313-1322.
Floren LC, et al. Tacrolimus oral bioavailability doubles with coadministration of ketoconazole. Clin Pharmacol Ther. 1997;62(1):41-49.
Hebert MF, et al. Effects of rifampin on tacrolimus pharmacokinetics in healthy volunteers. J Clin Pharmacol. 1999;39(1):91-96.
Hebert MF, et al. Effects of St. John's wort (Hypericum perforatum) on tacrolimus pharmacokinetics in healthy volunteers. J Clin Pharmacol. 2004;44(1):89-94.
Mai I, et al. Impact of St John's wort treatment on the pharmacokinetics of tacrolimus and mycophenolic acid in renal transplant patients. Nephrol Dial Transplant. 2003;18(4):819-822.
Ruschitzka F, et al. Acute heart transplant rejection due to Saint John's wort. Lancet. 2000;355(9203):548-549.
Ducharme MP, et al. Disposition of intravenous and oral cyclosporine after administration with grapefruit juice. Clin Pharmacol Ther. 1995;57(5):485-491.
Liu C, et al. Co-administration of grapefruit juice increases bioavailability of tacrolimus in liver transplant patients: a prospective study. Eur J Clin Pharmacol. 2009;65(9):881-885.
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