Tacrolimus 

Jul 31, 2022

Dosage form: capsule
Drug class:  Calcineurin inhibitors

WARNING: MALIGNANCIES and SERIOUS INFECTIONS

Increased risk for developing serious infections and malignancies with Tacrolimus or other immunosuppressants that may lead to hospitalization or death. ( 5.1 ,  5.2 )

Indications and Usage for Tacrolimus

Prophylaxis of Organ Rejection in Kidney, Liver, Heart, or Lung Transplant

Tacrolimus capsules are indicated for the prophylaxis of organ rejection, in adult and pediatric patients receiving allogeneic kidney transplant [see Clinical Studies ( 14.1) ], liver transplant [see Clinical Studies ( 14.2 )], heart transplant [see Clinical Studies ( 14.3 )], or lung transplant [see Clinical Studies ( 14.4 )] in combination with other immunosuppressants.

Tacrolimus Dosage and Administration

Important Administration Instructions

Tacrolimus capsules should not be used without supervision by a physician with experience in immunosuppressive therapy.

Tacrolimus capsules are not interchangeable or substitutable for other Tacrolimus extended-release products. This is because rate of absorption following the administration of an extended-release Tacrolimus product is not equivalent to that of an immediate-release Tacrolimus drug product. Under- or overexposure to Tacrolimus may result in graft rejection or other serious adverse reactions. Changes between Tacrolimus immediate-release and extended-release dosage forms must occur under physician supervision [see Warnings and Precautions ( 5.3 )].

Intravenous Formulation – Administration Precautions due to Risk of Anaphylaxis

Intravenous use is recommended for patients who cannot tolerate oral formulations, and conversion from intravenous to oral Tacrolimus is recommended as soon as oral therapy can be tolerated to minimize the risk of anaphylactic reactions that occurred with injectables containing castor oil derivatives [see Warnings and Precautions ( 5.9 )].

Oral Formulations (Capsules)

If patients are able to initiate oral therapy, the recommended starting doses should be initiated. Tacrolimus capsules may be taken with or without food. However, since the presence of food affects the bioavailability of Tacrolimus, if taken with food, it should be taken consistently the same way each time [see Clinical Pharmacology ( 12.3 )].

General Administration Instructions

Patients should not eat grapefruit or drink grapefruit juice in combination with Tacrolimus capsules [see Drug Interactions ( 7.2 )].

Tacrolimus should not be used simultaneously with cyclosporine. Tacrolimus or cyclosporine should be discontinued at least 24 hours before initiating the other. In the presence of elevated Tacrolimus or cyclosporine concentrations, dosing with the other drug usually should be further delayed.

Therapeutic drug monitoring (TDM) is recommended for all patients receiving Tacrolimus capsules [see Dosage and Administration ( 2.6 )].

Dosage Recommendations for Adult Kidney, Liver, Heart, or Lung Transplant Patients – Capsules and Injection

Capsules

If patients are able to tolerate oral therapy, the recommended oral starting doses should be initiated. The initial dose of Tacrolimus capsules should be administered no sooner than 6 hours after transplantation in the liver, heart, or lung transplant patients. In kidney transplant patients, the initial dose of Tacrolimus capsules may be administered within 24 hours of transplantation, but should be delayed until renal function has recovered.

The initial oral Tacrolimus capsule dosage recommendations for adult patients with kidney, liver, heart, or lung transplants and whole blood trough concentration range are shown in Table 1. Perform therapeutic drug monitoring (TDM) to ensure that patients are within the ranges listed in Table 1.

Table 1 Summary of Initial Oral Tacrolimus Capsules Dosage Recommendations and Whole Blood Trough Concentration Range in Adults

Patient PopulationTacrolimus Capsules *  Initial Oral DosageWhole Blood Trough Concentration Range
Kidney Transplant
With Azathioprine0.2 mg/kg/day, divided in two doses, administered every 12 hoursMonth 1 to 3: 7 to 20 ng/mLMonth 4 to 12: 5 to 15 ng/mL
With MMF/IL-2
receptor antagonist †
0.1 mg/kg/day, divided in two doses, administered every 12 hoursMonth 1 to 12: 4 to 11 ng/mL
Liver Transplant
With corticosteroids only0.10 to 0.15 mg/kg/day, divided in two doses, administered every 12 hoursMonth 1 to 12: 5 to 20 ng/mL
Heart Transplant
With azathioprine or MMF0.075 mg/kg/day, divided in two doses, administered every 12 hoursMonth 1 to 3: 10 to 20 ng/mLMonth ≥4: 5 to 15 ng/mL
Lung Transplant
With azathioprine or MMF0.075 mg/kg/day ‡ , divided in two doses, administered every 12 hoursMonth 1 to 3: 10 to 20 ng/mLMonth 4 to 12: 8 to 12 ng/mL
* African-American patients may require higher doses compared to Caucasians (see Table 2) † In a second smaller trial, the initial dose of Tacrolimus was 0.15 to 0.2 mg/kg/day and observed Tacrolimus concentrations were 6 to 16 ng/mL during month 1 to 3 and 5 to 12 ng/mL during month 4 to 12 [see Clinical Studies ( 14.1 )]. ‡ Patients with cystic fibrosis may require higher doses due to lower bioavailability [see Clinical Pharmacology (12.3)].

Dosage should be titrated based on clinical assessments of rejection and tolerability. Tacrolimus capsules dosages lower than the recommended initial dosage may be sufficient as maintenance therapy. Adjunct therapy with adrenal corticosteroids is recommended early post-transplant.

The data in kidney transplant patients indicate that the African-American patients required a higher dose to attain comparable trough concentrations compared to Caucasian patients (Table 2) [see Use in Specific Populations ( 8.8 ) and Clinical Pharmacology ( 12.3 )].

Time After TransplantCaucasianN=114African-AmericanN=56
Dose(mg/kg)Trough Concentrations(ng/mL)Dose(mg/kg)Trough Concentrations (ng/mL)
Day 70.18120.2310.9
Month 10.1712.80.2612.9
Month 60.1411.80.2411.5
Month 120.1310.10.1911

In lung transplantation, cystic fibrosis patients may have a reduced bioavailability of orally administered Tacrolimus resulting in the need for higher doses to achieve target Tacrolimus trough concentrations. Monitor Tacrolimus trough concentrations and adjust the dose accordingly.

Intravenous Injection

Tacrolimus injection should be used only as a continuous intravenous infusion and should be discontinued as soon as the patient can tolerate oral administration. The first dose of Tacrolimus capsules should be given 8 to 12 hours after discontinuing the intravenous infusion.

The recommended starting dose of Tacrolimus injection is 0.03 to 0.05 mg/kg/day in kidney or liver transplant, 0.01 mg/kg/day in heart transplant, and 0.01 to 0.03 mg/kg/day in lung transplant, given as a continuous intravenous infusion. Adult patients should receive doses at the lower end of the dosing range. Concomitant adrenal corticosteroid therapy is recommended early post-transplantation.

The whole blood trough concentration range described in Table 1 pertains to oral administration of Tacrolimus only; while monitoring Tacrolimus concentrations in patients receiving Tacrolimus injection as a continuous intravenous infusion may have some utility, the observed concentrations will not represent comparable exposures to those estimated by the trough concentrations observed in patients on oral therapy.

Anaphylactic reactions have occurred with injectables containing castor oil derivatives, such as Tacrolimus injection. Therefore, monitoring for signs and symptoms of anaphylaxis is recommended [see Warnings and Precautions ( 5.9 )].

Dosage Recommendations for Pediatric Kidney, Liver, Heart, or Lung Transplant Patients

Oral formulations (capsules)

Pediatric patients, in general, need higher Tacrolimus doses compared to adults: the higher dose requirements may decrease as the child grows older. Recommendations for the initial oral dosage for pediatric transplant patients and whole blood trough concentration range are shown in Table 3. Perform TDM to ensure that patients are within the ranges listed in Table 3.

Patient PopulationInitial Tacrolimus Capsule DosingWhole Blood Trough Concentration Range
Pediatric kidney transplant patients * 0.3 mg/kg/day capsules, divided in two doses, administered every 12 hoursMonth 1 to 12: 5 to 20 ng/mL
Pediatric liver transplant patients † 0.15 to 0.2 mg/kg/day capsules, divided in two doses, administered every 12 hoursMonth 1 to 12: 5 to 20 ng/mL
Pediatric heart transplant patients * 0.3 mg/kg/day ‡  capsules, divided in two doses, administered every 12 hoursMonth 1 to 12: 5 to 20 ng/mL
Pediatric lung transplant patients0.3 mg/kg/day ‡ §  capsules, divided in two doses, administered every 12 hoursWeek 1 to 2: 10 to 20 ng/mL Week 2 to Month 12: 10 to 15 ng/mL
* See Clinical Pharmacology ( 12.3 ), Pharmacokinetics in Pediatric Patients † See Clinical Studies ( 14.2 ), Liver Transplantation ‡ Dose at 0.1 mg/kg/day if antibody induction treatment is administered. § Patients with cystic fibrosis may require higher doses due to lower bioavailability [see Clinical Pharmacology ( 12.3 )].

In lung transplantation, cystic fibrosis patients may have a reduced bioavailability of orally administered Tacrolimus resulting in the need for higher doses to achieve target Tacrolimus trough concentrations. Monitor Tacrolimus trough concentrations and adjust the dose accordingly.

For conversion of pediatric patients from Tacrolimus granules to Tacrolimus capsules or from Tacrolimus capsules to Tacrolimus granules, the total daily dose should remain the same. Following conversion from one formulation to another formulation of Tacrolimus, therapeutic drug monitoring is recommended [see Dosage and Administration ( 2.6 )].

Intravenous Injection

If a patient is unable to receive an oral formulation, the patient may be started on Tacrolimus injection. For pediatric liver transplant patients, the intravenous dose is 0.03 to 0.05 mg/kg/day.

Dosage Adjustment in Patients with Renal Impairment

Due to its potential for nephrotoxicity, consider dosing Tacrolimus capsules at the lower end of the therapeutic dosing range in patients who have received a liver, heart, or lung transplant, and have pre-existing renal impairment. Further reductions in dose below the targeted range may be required.

In kidney transplant patients with post-operative oliguria, the initial dose of Tacrolimus capsules should be administered no sooner than 6 hours and within 24 hours of transplantation, but may be delayed until renal function shows evidence of recovery [see Dosage and Administration ( 2.2 ), Warnings and Precautions ( 5.5 ), Use in Specific Populations ( 8.6 ), and Clinical Pharmacology ( 12.3 )].

Dosage Adjustment in Patients with Hepatic Impairment

Due to the reduced clearance and prolonged half-life, patients with severe hepatic impairment (Child-Pugh ≥10) may require lower doses of Tacrolimus capsules. Close monitoring of blood concentrations is warranted.

The use of Tacrolimus capsules in liver transplant recipients experiencing post-transplant hepatic impairment may be associated with increased risk of developing renal insufficiency related to high whole blood concentrations of Tacrolimus. These patients should be monitored closely, and dosage adjustments should be considered. Some evidence suggests that lower doses should be used in these patients [see Dosage and Administration ( 2.2 ), Warnings and Precautions ( 5.5 ), Use in Specific Populations ( 8.7 ), and Clinical Pharmacology ( 12.3 )].

Therapeutic Drug Monitoring

Monitoring of Tacrolimus blood concentrations in conjunction with other laboratory and clinical parameters is considered an essential aid to patient management for the evaluation of rejection, toxicity, dose adjustments, and compliance. Whole blood trough concentration range can be found in Table 1.

Factors influencing frequency of monitoring include but are not limited to hepatic or renal dysfunction, the addition or discontinuation of potentially interacting drugs and the post-transplant time. Blood concentration monitoring is not a replacement for renal and liver function monitoring and tissue biopsies. Data from clinical trials show that Tacrolimus whole blood concentrations were most variable during the first week post-transplantation.

The relative risks of toxicity and efficacy failure are related to Tacrolimus whole blood trough concentrations. Therefore, monitoring of whole blood trough concentrations is recommended to assist in the clinical evaluation of toxicity and efficacy failure.

Methods commonly used for the assay of Tacrolimus include high-performance liquid chromatography with tandem mass spectrometric detection (HPLC/MS/MS) and immunoassays. Immunoassays may react with metabolites as well as parent compound. Therefore, assay results obtained with immunoassays may have a positive bias relative to results of HPLC/MS. The bias may depend upon the specific assay and laboratory. Comparison of the concentrations in published literature to patient concentrations using the current assays must be made with detailed knowledge of the assay methods and biological matrices employed. Whole blood is the matrix of choice and specimens should be collected into tubes containing ethylene diamine tetraacetic acid (EDTA) anti-coagulant. Heparin anti-coagulation is not recommended because of the tendency to form clots on storage. Samples which are not analyzed immediately should be stored at room temperature or in a refrigerator and assayed within 7 days; see assay instructions for specifics. If samples are to be kept longer, they should be deep frozen at -20° C. One study showed drug recovery >90% for samples stored at -20° C for 6 months, with reduced recovery observed after 6 months.

Dosage Forms and Strengths

Tacrolimus capsules, USP are available in 0.5 mg and 1 mg strengths.

Tacrolimus capsules, USP containing white to off white powder equivalent to 0.5 mg of anhydrous Tacrolimus, are hard gelatin capsules with white opaque body and ivory cap. The body is imprinted ‘643’ and cap is imprinted ‘ ’ in black ink.

Tacrolimus capsules, USP containing white to off white powder equivalent to 1 mg of anhydrous Tacrolimus, are hard gelatin capsules with white opaque body and brown cap. The body is imprinted ‘644’ and cap is imprinted ‘ ’ in black ink.

Contraindications

Tacrolimus capsules are contraindicated in patients with a hypersensitivity to Tacrolimus. Hypersensitivity symptoms reported include dyspnea, rash, pruritus, and acute respiratory distress syndrome [see Adverse Reactions( 6 )].

Warnings and Precautions

Lymphoma and Other Malignancies

Patients receiving immunosuppressants, including Tacrolimus, are at increased risk of developing lymphomas and other malignancies, particularly of the skin. The risk appears to be related to the intensity and duration of immunosuppression rather than to the use of any specific agent.

As usual for patients with increased risk for skin cancer, examine patients for skin changes; exposure to sunlight and UV light should be limited by wearing protective clothing and using a broad-spectrum sunscreen with a high protection factor.

Post-transplant lymphoproliferative disorder (PTLD) has been reported in immunosuppressed organ transplant recipients. The majority of PTLD events appear related to Epstein-Barr Virus (EBV) infection. The risk of PTLD appears greatest in those individuals who are EBV seronegative, a population which includes many young children. Monitor EBV serology during treatment.

Serious Infections

Patients receiving immunosuppressants, including Tacrolimus, are at increased risk of developing bacterial, viral, fungal, and protozoal infections, including opportunistic infections. These infections may lead to serious, including fatal, outcomes. Serious viral infections reported include:•Polyomavirus-associated nephropathy (PVAN), mostly due to BK virus infection•JC virus-associated progressive multifocal leukoencephalopathy (PML)•Cytomegalovirus infections: CMV seronegative transplant patients who receive an organ from a CMV seropositive donor disease are at higher risk of developing CMV viremia and CMV disease.

Monitor for the development of infection and adjust the immunosuppressive regimen to balance the risk of rejection with the risk of infection [see Adverse Reactions ( 6.1 ,  6.2 )].

Not Interchangeable with Extended-Release Tacrolimus Products – Medication Errors

Medication errors, including substitution and dispensing errors, between Tacrolimus immediate-release products and Tacrolimus extended-release products were reported outside the U.S. This led to serious adverse reactions, including graft rejection, or other adverse reactions due to under- or overexposure to Tacrolimus. Tacrolimus is not interchangeable or substitutable for Tacrolimus extended-release products. Changes between Tacrolimus immediate-release and extended-release dosage forms must occur under physician supervision. Instruct patients and caregivers to recognize the appearance of Tacrolimus dosage forms [see Dosage Forms and Strengths ( 3 )] and to confirm with the healthcare provider if a different product is dispensed.

New Onset Diabetes After Transplant

Tacrolimus was shown to cause new onset diabetes mellitus in clinical trials of kidney, liver, heart, or lung transplantation. New onset diabetes after transplantation may be reversible in some patients. African-American and Hispanic kidney transplant patients are at an increased risk. Blood glucose concentrations should be monitored closely in patients using Tacrolimus [see Adverse Reactions( 6.1 )].

Nephrotoxicity

Tacrolimus, like other calcineurin inhibitors, can cause acute or chronic nephrotoxicity. Nephrotoxicity was reported in clinical trials [see Adverse Reactions ( 6.1 )]. Consider dosage reduction in patients with elevated serum creatinine and Tacrolimus whole blood trough concentrations greater than the recommended range. The risk for nephrotoxicity may increase when Tacrolimus is concomitantly administered with CYP3A inhibitors (by increasing Tacrolimus whole blood concentrations) or drugs associated with nephrotoxicity (e.g., aminoglycosides, ganciclovir, amphotericin B, cisplatin, nucleotide reverse transcriptase inhibitors, protease inhibitors) [see Drug Interactions ( 7.2 )]. Monitor renal function and consider dosage reduction if nephrotoxicity occurs.

Neurotoxicity

Tacrolimus may cause a spectrum of neurotoxicities. The most severe neurotoxicities include posterior reversible encephalopathy syndrome (PRES), delirium, seizure and coma; others include tremors, paresthesias, headache, mental status changes, and changes in motor and sensory functions [see Adverse Reactions ( 6.1 ,  6.2 )]. As symptoms may be associated with Tacrolimus whole blood trough concentrations at or above the recommended range, monitor for neurologic symptoms and consider dosage reduction or discontinuation of Tacrolimus if neurotoxicity occurs.

Hyperkalemia

Hyperkalemia has been reported with Tacrolimus use. Serum potassium levels should be monitored. Careful consideration should be given prior to use of other agents also associated with hyperkalemia (e.g., potassium-sparing diuretics, ACE inhibitors, angiotensin receptor blockers) during Tacrolimus therapy [see Adverse Reactions ( 6.1 )]. Monitor serum potassium levels periodically during treatment.

Hypertension

Hypertension is a common adverse effect of Tacrolimus therapy and may require antihypertensive therapy [see Adverse Reactions ( 6.1 )]. The control of blood pressure can be accomplished with any of the common antihypertensive agents, though careful consideration should be given prior to use of antihypertensive agents associated with hyperkalemia (e.g., potassium-sparing diuretics, ACE inhibitors, angiotensin receptor blockers) [see Warnings and Precautions ( 5.7 )]. Calcium-channel blocking agents may increase Tacrolimus blood concentrations and therefore require dosage reduction of Tacrolimus [see Drug Interactions ( 7.2 )].

Anaphylactic Reactions with Tacrolimus Injection

Anaphylactic reactions have occurred with injectables containing castor oil derivatives, including Tacrolimus, in a small percentage of patients (0.6%). The exact cause of these reactions is not known. Tacrolimus injection should be reserved for patients who are unable to take Tacrolimus capsules orally. Monitor patients for anaphylaxis when using the intravenous route of administration [see Dosage and Administration ( 2.1 )].

Not Recommended for Use with Sirolimus

Tacrolimus is not recommended for use with sirolimus:•The use of sirolimus with Tacrolimus in studies of de novo liver transplant patients was associated with an excess mortality, graft loss, and hepatic artery thrombosis (HAT), and is not recommended.•The use of sirolimus (2 mg per day) with Tacrolimus in heart transplant patients in a U.S. trial was associated with increased risk of renal function impairment, wound healing complications, and insulin-dependent post–transplant diabetes mellitus, and is not recommended [see Clinical Studies ( 14.3 )].

Interactions with CYP3A4 Inhibitors and Inducers

When co-administering Tacrolimus with strong CYP3A4 inhibitors (e.g., telaprevir, boceprevir, ritonavir, ketoconazole, itraconazole, voriconazole, clarithromycin) and strong inducers (e.g., rifampin, rifabutin), adjustments in the dosing regimen of Tacrolimus and subsequent frequent monitoring of Tacrolimus whole blood trough concentrations and Tacrolimus-associated adverse reactions are recommended. A rapid, sharp rise in Tacrolimus levels has been reported after co-administration with a strong CYP3A4 inhibitor, clarithromycin, despite an initial reduction of Tacrolimus dose. Early and frequent monitoring of Tacrolimus whole blood trough levels is recommended [see Drug Interactions ( 7.2 )].

QT Prolongation

Tacrolimus may prolong the QT/QTc interval and may cause Torsade de Pointes. Avoid Tacrolimus in patients with congenital long QT syndrome. In patients with congestive heart failure, bradyarrhythmias, those taking certain antiarrhythmic medications or other medicinal products that lead to QT prolongation, and those with electrolyte disturbances such as hypokalemia, hypocalcemia, or hypomagnesemia, consider obtaining electrocardiograms and monitoring electrolytes (magnesium, potassium, calcium) periodically during treatment.

When co-administering Tacrolimus with other substrates and/or inhibitors of CYP3A4 that also have the potential to prolong the QT interval, a reduction in Tacrolimus dose, frequent monitoring of Tacrolimus whole blood concentrations, and monitoring for QT prolongation is recommended. Use of Tacrolimus with amiodarone has been reported to result in increased Tacrolimus whole blood concentrations with or without concurrent QT prolongation [see Drug Interactions ( 7.2 )].

Myocardial Hypertrophy

Myocardial hypertrophy has been reported in infants, children, and adults, particularly those with high Tacrolimus trough concentrations, and is generally manifested by echocardiographically demonstrated concentric increases in left ventricular posterior wall and interventricular septum thickness. This condition appears reversible in most cases following dose reduction or discontinuance of therapy. In patients who develop renal failure or clinical manifestations of ventricular dysfunction while receiving Tacrolimus therapy, echocardiographic evaluation should be considered. If myocardial hypertrophy is diagnosed, dosage reduction or discontinuation of Tacrolimus should be considered [see Adverse Reactions ( 6.2 )].

Immunizations

Whenever possible, administer the complete complement of vaccines before transplantation and treatment with Tacrolimus.

The use of live vaccines should be avoided during treatment with Tacrolimus; examples include (not limited to) the following: intranasal influenza, measles, mumps, rubella, oral polio, BCG, yellow fever, varicella, and TY21a typhoid vaccines. Inactivated vaccines noted to be safe for administration after transplantation may not be sufficiently immunogenic during treatment with Tacrolimus.

Pure Red Cell Aplasia

Cases of pure red cell aplasia (PRCA) have been reported in patients treated with Tacrolimus. A mechanism for Tacrolimus-induced PRCA has not been elucidated. All patients reported risk factors for PRCA such as parvovirus B19 infection, underlying disease, or concomitant medications associated with PRCA. If PRCA is diagnosed, discontinuation of Tacrolimus should be considered [see Adverse Reactions ( 6.2 )].

Adverse Reactions

The following serious and otherwise important adverse drug reactions are discussed in greater detail in other sections of labeling:•Lymphoma and Other Malignancies [see Warnings and Precautions ( 5.1 )]•Serious Infections [see Warnings and Precautions ( 5.2 )]•New Onset Diabetes After Transplant [see Warnings and Precautions ( 5.4 )]•Nephrotoxicity [see Warnings and Precautions ( 5.5 )]•Neurotoxicity [see Warnings and Precautions ( 5.6 )]•Hyperkalemia [see Warnings and Precautions ( 5.7 )]•Hypertension [see Warnings and Precautions ( 5.8 )]•Anaphylactic Reactions with Tacrolimus Injection [see Warnings and Precautions ( 5.9 )]•Myocardial Hypertrophy [see Warnings and Precautions ( 5.13 )]•Pure Red Cell Aplasia [see Warnings and Precautions ( 5.15 )]

Clinical Studies Experience

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. In addition, the clinical trials were not designed to establish comparative differences across study arms with regards to the adverse reactions discussed below.

Kidney Transplantation

The incidence of adverse reactions was determined in three randomized kidney transplant trials. One of the trials used azathioprine (AZA) and corticosteroids and two of the trials used mycophenolate mofetil (MMF) and corticosteroids concomitantly for maintenance immunosuppression.

Tacrolimus-based immunosuppression in conjunction with azathioprine and corticosteroids following kidney transplantation was assessed in a trial where 205 patients received Tacrolimus-based immunosuppression and 207 patients received cyclosporine-based immunosuppression. The trial population had a mean age of 43 years (mean ± SD was 43±13 years on Tacrolimus and 44±12 years on cyclosporine arm), the distribution was 61% male, and the composition was White (58%), African-American (25%), Hispanic (12%), and Other (5%). The 12-month post-transplant information from this trial is presented below.

The most common adverse reactions (≥30%) observed in Tacrolimus-treated kidney transplant patients are: infection, tremor, hypertension, abnormal renal function, constipation, diarrhea, headache, abdominal pain, insomnia, nausea, hypomagnesemia, urinary tract infection, hypophosphatemia, peripheral edema, asthenia, pain, hyperlipidemia, hyperkalemia, and anemia. Based on reported adverse reaction terms related to decreased renal function, nephrotoxicity was reported in approximately 52% of kidney transplantation patients.

Adverse reactions that occurred in ≥15% of kidney transplant patients treated with Tacrolimus in conjunction with azathioprine are presented below:

Tacrolimus/AZA(N=205)Cyclosporine/AZA
(N=207)
Nervous System
Tremor54%34%
Headache44%38%
Insomnia32%30%
Paresthesia23%16%
Dizziness19%16%
Gastrointestinal
Diarrhea44%41%
Nausea38%36%
Constipation35%43%
Vomiting29%23%
Dyspepsia28%20%
Cardiovascular
Hypertension50%52%
Chest Pain19%13%
Urogenital
Creatinine Increased45%42%
Urinary Tract Infection34%35%
Metabolic and Nutritional
Hypophosphatemia49%53%
Hypomagnesemia34%17%
Hyperlipemia31%38%
Hyperkalemia31%32%
Diabetes Mellitus24%9%
Hypokalemia22%25%
Hyperglycemia22%16%
Edema18%19%
Hemic and Lymphatic
Anemia30%24%
Leukopenia15%17%
Miscellaneous
Infection45%49%
Peripheral Edema36%48%
Asthenia34%30%
Abdominal Pain33%31%
Pain32%30%
Fever29%29%
Back Pain24%20%
Respiratory System
Dyspnea22%18%
Cough Increased18%15%
Musculoskeletal
Arthralgia25%24%
Skin
Rash17%12%
Pruritus15%7%

Two trials were conducted for Tacrolimus-based immunosuppression in conjunction with MMF and corticosteroids. In the non-US trial (Study 1), the incidence of adverse reactions was based on 1,195 kidney transplant patients that received Tacrolimus (Group C, n=403), or one of two cyclosporine (CsA) regimens (Group A, n=384 and Group B, n=408) in combination with MMF and corticosteroids; all patients, except those in one of the two cyclosporine groups, also received induction with daclizumab. The trial population had a mean age of 46 years (range 17 to 76); the distribution was 65% male, and the composition was 93% Caucasian. The 12-month post-transplant information from this trial is presented below.

Adverse reactions that occurred in ≥10% of kidney transplant patients treated with Tacrolimus in conjunction with MMF in Study 1 [Note: This trial was conducted entirely outside of the United States. Such trials often report a lower incidence of adverse reactions in comparison to U.S. trials] are presented below:

Tacrolimus (Group C)Cyclosporine (Group A)Cyclosporine (Group B)
(N=403)(N=384)(N=408)
Diarrhea25%16%13%
Urinary Tract Infection24%28%24%
Anemia17%19%17%
Hypertension13%14%12%
Leukopenia13%10%10%
Edema Peripheral11%12%13%
Hyperlipidemia10%15%13%
Key: Group A = CsA/MMF/CS, B = CsA/MMF/CS/Daclizumab, C = Tac/MMF/CS/Daclizumab
CsA = Cyclosporine, CS = Corticosteroids, Tac = Tacrolimus, MMF = mycophenolate mofetil

In the U.S. trial (Study 2) with Tacrolimus-based immunosuppression in conjunction with MMF and corticosteroids, 424 kidney transplant patients received Tacrolimus (n=212) or cyclosporine (n=212) in combination with MMF 1 gram twice daily, basiliximab induction, and corticosteroids. The trial population had a mean age of 48 years (range 17 to 77); the distribution was 63% male, and the composition was White (74%), African-American (20%), Asian (3%), and Other (3%). The 12-month post-transplant information from this trial is presented below.

Adverse reactions that occurred in ≥15% of kidney transplant patients treated with Tacrolimus in conjunction with MMF in Study 2 are presented below:

Tacrolimus /MMFCyclosporine/MMF
(N=212)(N=212)
Gastrointestinal Disorders
Diarrhea44%26%
Nausea39%47%
Constipation36%41%
Vomiting26%25%
Dyspepsia18%15%
Injury, Poisoning, and Procedural Complications
Post-Procedural Pain29%27%
Incision Site Complication28%23%
Graft Dysfunction24%18%
Metabolism and Nutrition Disorders
Hypomagnesemia28%22%
Hypophosphatemia28%21%
Hyperkalemia26%19%
Hyperglycemia21%15%
Hyperlipidemia18%25%
Hypokalemia16%18%
Nervous System Disorders
Tremor34%20%
Headache24%25%
Blood and Lymphatic System Disorders
Anemia30%28%
Leukopenia16%12%
Miscellaneous
Edema Peripheral35%46%
Hypertension32%35%
Insomnia30%21%
Urinary Tract Infection26%22%
Blood Creatinine Increased23%23%

Less frequently observed adverse reactions in kidney transplantation patients are described under the subsection “Less Frequently Reported Adverse Reactions (> 3% and <15%) in Liver, Kidney, and Heart Transplant Studies.”

Liver Transplantation

There were two randomized comparative liver transplant trials. In the U.S. trial, 263 adult and pediatric patients received Tacrolimus and steroids and 266 patients received cyclosporine-based immunosuppressive regimen (CsA/AZA). The trial population had a mean age of 44 years (range 0.4 to 70); the distribution was 52% male, and the composition was White (78%), African-American (5%), Asian (2%), Hispanic (13%), and Other (2%). In the European trial, 270 patients received Tacrolimus and steroids and 275 patients received CsA/AZA. The trial population had a mean age of 46 years (range 15 to 68); the distribution was 59% male, and the composition was White (95.4%), Black (1%), Asian (2%), and Other (2%).

The proportion of patients reporting more than one adverse event was >99% in both the Tacrolimus group and the CsA/AZA group. Precautions must be taken when comparing the incidence of adverse reactions in the U.S. trial to that in the European trial. The 12-month post-transplant information from the U.S. trial and from the European trial is presented below. The two trials also included different patient populations and patients were treated with immunosuppressive regimens of differing intensities. Adverse reactions reported in ≥15% in Tacrolimus patients (combined trial results) are presented below for the two controlled trials in liver transplantation.

The most common adverse reactions (≥40%) observed in Tacrolimus-treated liver transplant patients are: tremor, headache, diarrhea, hypertension, nausea, abnormal renal function, abdominal pain, insomnia, paresthesia, anemia, pain, fever, asthenia, hyperkalemia, hypomagnesemia, and hyperglycemia. These all occur with oral administration of Tacrolimus and some may respond to a reduction in dosing (e.g., tremor, headache, paresthesia, hypertension). Diarrhea was sometimes associated with other gastrointestinal complaints such as nausea and vomiting. Based on reported adverse reaction terms related to decreased renal function, nephrotoxicity was reported in approximately 40% and 36% of liver transplantation patients receiving Tacrolimus in the U.S. and European randomized trials.

Table 7 Liver Transplantation: Adverse Reactions Occurring in ≥15% of Patients Treated with Tacrolimus

U.S. TRIALEUROPEAN TRIAL
Tacrolimus (N=250)Cyclosporine/AZA (N=250)Tacrolimus (N=264)Cyclosporine/AZA (N=265)
Nervous System
Headache64%60%37%26%
Insomnia64%68%32%23%
Tremor56%46%48%32%
Paresthesia40%30%17%17%
Gastrointestinal
Diarrhea72%47%37%27%
Nausea46%37%32%27%
LFT Abnormal36%30%6%5%
Anorexia34%24%7%5%
Vomiting27%15%14%11%
Constipation24%27%23%21%
Cardiovascular
Hypertension47%56%38%43%
Urogenital
Kidney Function Abnormal40%27%36%23%
Creatinine Increased39%25%24%19%
BUN Increased30%22%12%9%
Oliguria18%15%19%12%
Urinary Tract Infection16%18%21%19%
Metabolic and Nutritional
Hypomagnesemia48%45%16%9%
Hyperglycemia47%38%33%22%
Hyperkalemia45%26%13%9%
Hypokalemia29%34%13%16%
Hemic and Lymphatic
Anemia47%38%5%1%
Leukocytosis32%26%8%8%
Thrombocytopenia24%20%14%19%
Miscellaneous
Pain63%57%24%22%
Abdominal Pain59%54%29%22%
Asthenia52%48%11%7%
Fever48%56%19%22%
Back Pain30%29%17%17%
Ascites27%22%7%8%
Peripheral Edema26%26%12%14%
Respiratory System
Pleural Effusion30%32%36%35%
Dyspnea29%23%5%4%
Atelectasis28%30%5%4%
Skin and Appendages
Pruritus36%20%15%7%
Rash24%19%10%4%

Less frequently observed adverse reactions in liver transplantation patients are described under the subsection “Less Frequently Reported Adverse Reactions (>3% and <15%) in Liver, Kidney, and Heart Transplant Studies.”

Heart Transplantation

The incidence of adverse reactions was determined based on two trials in primary orthotopic heart transplantation. In a trial conducted in Europe, 314 patients received a regimen of antibody induction, corticosteroids, and azathioprine (AZA) in combination with Tacrolimus (n=157) or cyclosporine (n=157) for 18 months. The trial population had a mean age of 51 years (range 18 to 65); the distribution was 82% male, and the composition was White (96%), Black (3%), and Other (1%).

The most common adverse reactions (≥15%) observed in Tacrolimus-treated heart transplant patients are: abnormal renal function, hypertension, diabetes mellitus, CMV infection, tremor, hyperglycemia, leukopenia, infection, anemia, bronchitis, pericardial effusion, urinary tract infection, and hyperlipemia. Based on reported adverse reaction terms related to decreased renal function, nephrotoxicity was reported in approximately 59% of heart transplantation patients in the European trial.

Adverse reactions in heart transplant patients in the European trial are presented below:

Table 9 Heart Transplantation: Adverse Reactions Occurring in ≥15% of Patients Treated with Tacrolimus in Conjunction with Azathioprine (AZA)

Tacrolimus/AZACyclosporine/AZA
(N=157)(N=157)
Cardiovascular System
Hypertension62%69%
Pericardial Effusion15%14%
Body as a Whole
CMV Infection32%30%
Infection24%21%
Metabolic and Nutritional Disorders
Diabetes Mellitus26%16%
Hyperglycemia23%17%
Hyperlipemia18%27%
Hemic and Lymphatic System
Anemia50%36%
Leukopenia48%39%
Urogenital System
Kidney Function Abnormal56%57%
Urinary Tract Infection16%12%
Respiratory System
Bronchitis17%18%
Nervous System
Tremor15%6%

In the European trial, the cyclosporine trough concentrations were above the pre-defined target range (i.e., 100 to 200 ng/mL) at Day 122 and beyond in 32% to 68% of the patients in the cyclosporine treatment arm, whereas the Tacrolimus trough concentrations were within the pre-defined target range (i.e., 5 to 15 ng/mL) in 74% to 86% of the patients in the Tacrolimus treatment arm.

In a U.S. trial, the incidence of adverse reactions was based on 331 heart transplant patients that received corticosteroids and Tacrolimus in combination with sirolimus (n=109), Tacrolimus in combination with MMF (n=107) or cyclosporine modified in combination with MMF (n=115) for 1 year. The trial population had a mean age of 53 years (range 18 to 75); the distribution was 78% male, and the composition was White (83%), African-American (13%) and Other (4%).

Only selected targeted treatment-emergent adverse reactions were collected in the U.S. heart transplantation trial. Those reactions that were reported at a rate of 15% or greater in patients treated with Tacrolimus and MMF include the following: any target adverse reactions (99%), hypertension (89%), hyperglycemia requiring antihyperglycemic therapy (70%), hypertriglyceridemia (65%), anemia (hemoglobin <10 g/dL) (65%), fasting blood glucose >140 mg/dL (on two separate occasions) (61%), hypercholesterolemia (57%), hyperlipidemia (34%), WBCs <3000 cells/mcL (34%), serious bacterial infections (30%), magnesium <1.2 mEq/L (24%), platelet count <75,000 cells/mcL (19%), and other opportunistic infections (15%).

Other targeted treatment-emergent adverse reactions in Tacrolimus-treated patients occurred at a rate of less than 15%, and include the following: Cushingoid features, impaired wound healing, hyperkalemia, Candida infection, and CMV infection/syndrome. Other less frequently observed adverse reactions in heart transplantation patients are described under the subsection “Less Frequently Reported Adverse Reactions (>3% and <15%) in Liver, Kidney and Heart Transplant Studies.”

New Onset Diabetes After Transplant

Kidney Transplantation

New Onset Diabetes After Transplant (NODAT) is defined as a composite of fasting plasma glucose ≥126 mg/dL, HbA1C ≥6%, insulin use ≥30 days, or oral hypoglycemic use. In a trial in kidney transplant patients (Study 2), NODAT was observed in 75% in the Tacrolimus-treated and 61% in the NEORAL-treated patients without pre-transplant history of diabetes mellitus (Table 10) [see Clinical Studies ( 14.1 )].

ParameterTreatment Group
Tacrolimus/MMF(N=212)NEORAL/MMF(N=212)
NODAT112/150 (75%)93/152 (61%)
Fasting Plasma Glucose ≥126 mg/dL96/150 (64%)80/152 (53%)
HbA1C ≥6%59/150 (39%)28/152 (18%)
Insulin Use ≥30 days9/150 (6%)4/152 (3%)
Oral Hypoglycemic Use15/150 (10%)5/152 (3%)

In early trials of Tacrolimus, Post-Transplant Diabetes Mellitus (PTDM) was evaluated with a more limited criterion of “use of insulin for 30 or more consecutive days with <5-day gap” in patients without a prior history of insulin-dependent diabetes mellitus or non-insulin dependent diabetes mellitus. Data are presented in Tables 11 to 14. PTDM was reported in 20% of Tacrolimus/Azathioprine (AZA)-treated kidney transplant patients without pre-transplant history of diabetes mellitus in a Phase 3 trial (Table 11). The median time to onset of PTDM was 68 days. Insulin dependence was reversible in 15% of these PTDM patients at one year and in 50% at 2 years post-transplant. African-American and Hispanic kidney transplant patients were at an increased risk of development of PTDM (Table 12).

Status of PTDM * Tacrolimus/AZACsA/AZA
Patients without pre-transplant history of diabetes mellitus151151
New onset PTDM * , 1st Year30/151 (20%)6/151 (4%)
Still insulin-dependent at one year in those without prior history of diabetes25/151 (17%)5/151 (3%)
New onset PTDM *  post 1 year10
Patients with PTDM *  at 2 years16/151 (11%)5/151 (3%)
* Use of insulin for 30 or more consecutive days, with <5-day gap, without a prior history of insulin-dependent diabetes mellitus or non-insulin dependent diabetes mellitus.

Patient RacePatients Who Developed PTDM *
TacrolimusCyclosporine
African-American15/41 (37%)3 (8%)
Hispanic5/17 (29%)1 (6%)
Caucasian10/82 (12%)1 (1%)
Other0/11 (0%)1 (10%)
Total30/151 (20%)6 (4%)
* Use of insulin for 30 or more consecutive days, with <5-day gap, without a prior history of insulin-dependent diabetes mellitus or non-insulin dependent diabetes mellitus.

Liver Transplantation

Insulin-dependent PTDM was reported in 18% and 11% of Tacrolimus-treated liver transplant patients and was reversible in 45% and 31% of these patients at 1 year post-transplant, in the U.S. and European randomized trials, respectively (Table 13). Hyperglycemia was associated with the use of Tacrolimus in 47% and 33% of liver transplant recipients in the U.S. and European randomized trials, respectively, and may require treatment [see Adverse Reactions ( 6.1 )].

Status of PTDM * US TrialEuropean Trial
TacrolimusCyclosporineTacrolimusCyclosporine
Patients at risk † 239236239249
New Onset PTDM * 42 (18%)30 (13%)26 (11%)12 (5%)
Patients still on insulin at 1 year23 (10%)19 (8%)18 (8%)6 (2%)
* Use of insulin for 30 or more consecutive days, with <5 day gap, without a prior history of insulin-dependent diabetes mellitus or non-insulin dependent diabetes mellitus. † Patients without pre-transplant history of diabetes mellitus.

Heart Transplantation

Insulin-dependent PTDM was reported in 13% and 22% of Tacrolimus-treated heart transplant patients receiving mycophenolate mofetil (MMF) or azathioprine (AZA) and was reversible in 30% and 17% of these patients at one year post-transplant, in the U.S. and European randomized trials, respectively (Table 14). Hyperglycemia, defined as two fasting plasma glucose levels ≥126 mg/dL, was reported with the use of Tacrolimus plus MMF or AZA in 32% and 35% of heart transplant recipients in the U.S. and European randomized trials, respectively, and may require treatment [see Adverse Reactions ( 6.1 )].

Table 14 Incidence of Post-Transplant Diabetes Mellitus and Insulin Use at 1 Year in Heart Transplant Recipients

Status of PTDM * US TrialEuropean Trial
Tacrolimus/MMFCyclosporine/MMFTacrolimus/AZACyclosporine/AZA
Patients at risk † 7583132138
New Onset PTDM * 10 (13%)6 (7%)29 (22%)5 (4%)
Patients still on insulin at 1 year ‡ 7 (9%)1 (1%)24 (18%)4 (3%)
* Use of insulin for 30 or more consecutive days without a prior history of insulin-dependent diabetes mellitus or non-insulin dependent diabetes mellitus. † Patients without pre-transplant history of diabetes mellitus. ‡ 7 to 12 months for the U.S. trial.

Less Frequently Reported Adverse Reactions (>3% and <15%) in Liver, Kidney, and Heart Transplant Studies

The following adverse reactions were reported in either liver, kidney, and/or heart transplant recipients who were treated with Tacrolimus in clinical trials.•Nervous SystemAbnormal dreams, agitation, amnesia, anxiety, confusion, convulsion, crying, depression, elevated mood, emotional lability, encephalopathy, hemorrhagic stroke, hallucinations, hypertonia, incoordination, monoparesis, myoclonus, nerve compression, nervousness, neuralgia, neuropathy, paralysis flaccid, psychomotor skills impaired, psychosis, quadriparesis, somnolence, thinking abnormal, vertigo, writing impaired•Special SensesAbnormal vision, amblyopia, ear pain, otitis media, tinnitus•GastrointestinalCholangitis, cholestatic jaundice, duodenitis, dysphagia, esophagitis, flatulence, gastritis, gastroesophagitis, gastrointestinal hemorrhage, GGT increase, GI disorder, GI perforation, hepatitis, hepatitis granulomatous, ileus, increased appetite, jaundice, liver damage, esophagitis ulcerative, oral moniliasis, pancreatic pseudocyst, stomatitis•CardiovascularAbnormal ECG, angina pectoris, arrhythmia, atrial fibrillation, atrial flutter, bradycardia, cardiac fibrillation, cardiopulmonary failure, congestive heart failure, deep thrombophlebitis, echocardiogram abnormal, electrocardiogram QRS complex abnormal, electrocardiogram ST segment abnormal, heart failure, heart rate decreased, hemorrhage, hypotension, phlebitis, postural hypotension, syncope, tachycardia, thrombosis, vasodilatation•UrogenitalAcute kidney failure, albuminuria, BK nephropathy, bladder spasm, cystitis, dysuria, hematuria, hydronephrosis, kidney failure, kidney tubular necrosis, nocturia, pyuria, toxic nephropathy, urge incontinence, urinary frequency, urinary incontinence, urinary retention, vaginitis•Metabolic/NutritionalAcidosis, alkaline phosphatase increased, alkalosis, ALT (SGPT) increased, AST (SGOT) increased, bicarbonate decreased, bilirubinemia, dehydration, GGT increased, gout, healing abnormal, hypercalcemia, hypercholesterolemia, hyperphosphatemia, hyperuricemia, hypervolemia, hypocalcemia, hypoglycemia, hyponatremia, hypoproteinemia, lactic dehydrogenase increased, weight gain•EndocrineCushing’s syndrome•Hemic/LymphaticCoagulation disorder, ecchymosis, hematocrit increased, hypochromic anemia, leukocytosis, polycythemia, prothrombin decreased, serum iron decreased•MiscellaneousAbdomen enlarged, abscess, accidental injury, allergic reaction, cellulitis, chills, fall, flu syndrome, generalized edema, hernia, mobility decreased, peritonitis, photosensitivity reaction, sepsis, temperature intolerance, ulcer•MusculoskeletalArthralgia, cramps, generalized spasm, leg cramps, myalgia, myasthenia, osteoporosis•RespiratoryAsthma, emphysema, hiccups, lung function decreased, pharyngitis, pneumonia, pneumothorax, pulmonary edema, rhinitis, sinusitis, voice alteration•SkinAcne, alopecia, exfoliative dermatitis, fungal dermatitis, herpes simplex, herpes zoster, hirsutism, neoplasm skin benign, skin discoloration, skin ulcer, sweating

Lung Transplantation

Adverse reactions in lung transplant patients were similar to those in kidney, liver, or heart transplant patients treated with Tacrolimus [see Adverse Reactions ( 6.2 )].

Postmarketing Experience

The following adverse reactions have been reported from worldwide marketing experience with Tacrolimus. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. Decisions to include these reactions in labeling are typically based on one or more of the following factors: (1) seriousness of the reaction, (2) frequency of the reporting, or (3) strength of causal connection to the drug.

Other reactions include:•CardiovascularAtrial fibrillation, atrial flutter, cardiac arrhythmia, cardiac arrest, electrocardiogram T wave abnormal, flushing, myocardial infarction, myocardial ischemia, pericardial effusion, QT prolongation, Torsade de Pointes, venous thrombosis deep limb, ventricular extrasystoles, ventricular fibrillation, myocardial hypertrophy•GastrointestinalBile duct stenosis, colitis, enterocolitis, gastroenteritis, gastroesophageal reflux disease, hepatic cytolysis, hepatic necrosis, hepatotoxicity, impaired gastric emptying, liver fatty, mouth ulceration, pancreatitis hemorrhagic, pancreatitis necrotizing, stomach ulcer, veno-occlusive liver disease•Hemic/LymphaticAgranulocytosis, disseminated intravascular coagulation, hemolytic anemia, neutropenia, febrile neutropenia, pancytopenia, thrombocytopenic purpura, thrombotic thrombocytopenic purpura, pure red cell aplasia•InfectionsCases of progressive multifocal leukoencephalopathy (PML), sometimes fatal; polyoma virus-associated nephropathy (PVAN) including graft loss•Metabolic/NutritionalGlycosuria, increased amylase including pancreatitis, weight decreased•MiscellaneousFeeling hot and cold, feeling jittery, hot flushes, multi-organ failure, primary graft dysfunction•Musculoskeletal and Connective Tissue DisordersPain in extremity including Calcineurin-Inhibitor Induced Pain Syndrome (CIPS)•Nervous SystemCarpal tunnel syndrome, cerebral infarction, hemiparesis, leukoencephalopathy, mental disorder, mutism, posterior reversible encephalopathy syndrome (PRES), progressive multifocal leukoencephalopathy (PML), quadriplegia, speech disorder, syncope•RespiratoryAcute respiratory distress syndrome, interstitial lung disease, lung infiltration, respiratory distress, respiratory failure•SkinStevens-Johnson syndrome, toxic epidermal necrolysis•Special SensesBlindness, optic neuropathy, blindness cortical, hearing loss including deafness, photophobia•UrogenitalAcute renal failure, cystitis hemorrhagic, hemolytic-uremic syndrome

Postmarketing Adverse Reactions in Lung Transplantation

Based on U.S. Scientific Registry of Transplant Recipients (SRTR) data, published clinical trials, and postmarketing reports, the safety profile for lung transplant patients treated with Tacrolimus is consistent with the safety profile in kidney, liver, and heart transplant patients treated with Tacrolimus. The primary adverse reactions described include renal dysfunction, infection, diabetes, gastrointestinal disturbances (e.g., diarrhea), hypertension, and neurological events (e.g., tremor). As expected, lung transplant patients have a higher incidence of pulmonary complications (e.g., pneumonia, bronchiolitis obliterans syndrome) than other solid organ transplant patients, which is in part due to the underlying disease and to the nature of the transplanted organ.

Drug Interactions

Mycophenolic Acid

When Tacrolimus is prescribed with a given dose of a mycophenolic acid (MPA) product, exposure to MPA is higher with Tacrolimus co-administration than with cyclosporine co-administration with MPA, because cyclosporine interrupts the enterohepatic recirculation of MPA while Tacrolimus does not. Monitor for MPA-associated adverse reactions and reduce the dose of concomitantly administered mycophenolic acid products as needed.

Effects of Other Drugs on Tacrolimus

Table 15 displays the effects of other drugs on Tacrolimus.

Table 15 Effects of Other Drugs/Substances on Tacrolimus *
Drug/Substance Class or NameDrug Interaction EffectRecommendations
Grapefruit or grapefruit juice † May increase Tacrolimus whole blood trough concentrations and increase the risk of serious adverse reactions (e.g., neurotoxicity, QT prolongation) [see Warnings and Precautions ( 5.6 ,  5.11 , 5.12 )].Avoid grapefruit or grapefruit juice.
Strong CYP3A Inducers ‡ :Antimycobacterials (e.g., rifampin, rifabutin), anticonvulsants (e.g., phenytoin, carbamazepine and phenobarbital), St John’s WortMay decrease Tacrolimus whole blood trough concentrations and increase the risk of rejection [see Warnings and Precautions ( 5.11 )].Increase Tacrolimus dose and monitor Tacrolimus whole blood trough concentrations [see Dosage and Administration ( 2.2 ,  2.6 ) and Clinical Pharmacology ( 12.3 )].
Strong CYP3A Inhibitors ‡ :Protease inhibitors (e.g, nelfinavir, telaprevir, boceprevir, ritonavir), azole antifungals (e.g., voriconazole, posaconazole, itraconazole, ketoconazole), antibiotics (e.g., clarithromycin, troleandomycin, chloramphenicol), nefazodone, letermovir, Schisandra sphenanthera extractsMay increase Tacrolimus whole blood trough concentrations and increase the risk of serious adverse reactions (e.g., neurotoxicity, QT prolongation). A rapid, sharp rise in Tacrolimus levels may occur early, despite an immediate reduction of Tacrolimus dose [see Warnings and Precautions ( 5.6 ,  5.11 ,  5.12 )].Reduce Tacrolimus dose (for voriconazole and posaconazole, give one-third of the original dose) and adjust dose based on Tacrolimus whole blood trough concentrations [see Dosage and Administration ( 2.2 ,  2.6 ) and Clinical Pharmacology ( 12.3 )]. Early and frequent monitoring of Tacrolimus whole blood trough levels should start within 1-3 days and continue monitoring as necessary [see Warnings and Precautions ( 5.11 )].
Mild or Moderate CYP3A Inhibitors: Clotrimazole, antibiotics (e.g., erythromycin, fluconazole), calcium channel blockers (e.g., verapamil, diltiazem, nifedipine, nicardipine), amiodarone, danazol, ethinyl estradiol, cimetidine, lansoprazole and omeprazoleMay increase Tacrolimus whole blood trough concentrations and increase the risk of serious adverse reactions (e.g., neurotoxicity, QT prolongation) [see Warnings and Precautions ( 5.6 ,  5.11 ,  5.12 )].Monitor Tacrolimus whole blood trough concentrations and reduce Tacrolimus dose if needed [see Dosage and Administration ( 2.2 ,  2.6 ) and Clinical Pharmacology ( 12.3 )].
Other drugs, such as:Magnesium and aluminum hydroxide antacidsMetoclopramideMay increase Tacrolimus whole blood trough concentrations and increase the risk of serious adverse reactions (e.g., neurotoxicity, QT prolongation) [see Warnings and Precautions ( 5.6 ,  5.11 , 5.12 )].Monitor Tacrolimus whole blood trough concentrations and reduce Tacrolimus dose if needed [see Dosage and Administration ( 2.2 ,  2.6 ) and Clinical Pharmacology ( 12.3 )].
Mild or Moderate CYP3A InducersMethylprednisolone, prednisoneMay decrease Tacrolimus concentrations.Monitor Tacrolimus whole blood trough concentrations and adjust Tacrolimus dose if needed [see Dosage and Administration ( 2.2 ,  2.6 )].
* Tacrolimus dosage adjustment recommendation based on observed effect of coadministered drug on Tacrolimus exposures [see Clinical Pharmacology ( 12.3 )], literature reports of altered Tacrolimus exposures, or the other drug’s known CYP3A inhibitor/inducer status. † High dose or double strength grapefruit juice is a strong CYP3A inhibitor; low dose or single strength grapefruit juice is a moderate CYP3A inhibitor. ‡ Strong CYP3A inhibitor/inducer, based on reported effect on exposures to Tacrolimus along with supporting in vitro CYP3A inhibitor/inducer data, or based on drug-drug interaction studies with midazolam (sensitive CYP3A probe substrate).

Direct Acting Antiviral (DAA) Therapy

The pharmacokinetics of Tacrolimus may be impacted by changes in liver function during DAA therapy, related to clearance of HCV virus. Close monitoring and potential dose adjustment of Tacrolimus is warranted to ensure continued efficacy and safety [see Dosage and Administration ( 2.2 ,  2.6 )].

USE IN SPECIFIC POPULATIONS

Pregnancy

Pregnancy Exposure Registry

There is a pregnancy registry that monitors pregnancy outcomes in women exposed to Tacrolimus during pregnancy. The Transplantation Pregnancy Registry International (TPRI) is a voluntary pregnancy exposure registry that monitors outcomes of pregnancy in female transplant recipients and those fathered by male transplant recipients exposed to immunosuppressants including Tacrolimus. Healthcare providers are encouraged to advise their patients to register by contacting the Transplantation Pregnancy Registry International at 1-877-955-6877 or https://www.transplantpregnancyregistry.org/.

Risk Summary

Tacrolimus can cause fetal harm when administered to a pregnant woman. Data from postmarketing surveillance and TPRI suggest that infants exposed to Tacrolimus in utero are at a risk of prematurity, birth defects/congenital anomalies, low birth weight, and fetal distress [see Human Data]. Advise pregnant women of the potential risk to the fetus.

Administration of oral Tacrolimus to pregnant rabbits and rats throughout the period of organogenesis was associated with maternal toxicity/lethality, and an increased incidence of abortion, malformation and embryofetal death at clinically relevant doses (0.5 to 6.9 times the recommended clinical dose range [0.2 to 0.075 mg/kg/day], on a mg/m2 basis). Administration of oral Tacrolimus to pregnant rats after organogenesis and throughout lactation produced maternal toxicity, effects on parturition, reduced pup viability and reduced pup weight at clinically relevant doses (0.8 to 6.9 times the recommended clinical dose range, on a mg/m2 basis). Administration of oral Tacrolimus to rats prior to mating, and throughout gestation and lactation produced maternal toxicity/lethality, marked effects on parturition, embryofetal loss, malformations, and reduced pup viability at clinically relevant doses (0.8 to 6.9 times the recommended clinical dose range, on a mg/m2 basis). Interventricular septal defects, hydronephrosis, craniofacial malformations and skeletal effects were observed in offspring that died [see Animal Data].

The background risk of major birth defects and miscarriage in the indicated population is unknown. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2 to 4% and 15 to 20%, respectively.

Clinical Considerations

Disease-Associated Maternal and/or Embryo-Fetal Risk

Risks during pregnancy are increased in organ transplant recipients.

The risk of premature delivery following transplantation is increased. Pre-existing hypertension and diabetes confer additional risk to the pregnancy of an organ transplant recipient. Pre-gestational and gestational diabetes are associated with birth defects/congenital anomalies, hypertension, low birth weight and fetal death.

Cholestasis of pregnancy (COP) was reported in 7% of liver or liver-kidney (LK) transplant recipients, compared with approximately 1% of pregnancies in the general population. However, COP symptoms resolved postpartum and no long‑term effects on the offspring were reported.

Maternal Adverse Reactions

Tacrolimus may increase hyperglycemia in pregnant women with diabetes (including gestational diabetes). Monitor maternal blood glucose levels regularly [see Warnings and Precautions ( 5.4 )].

Tacrolimus may exacerbate hypertension in pregnant women and increase pre-eclampsia. Monitor and control blood pressure [see Warnings and Precautions ( 5.7 ,  5.8 )].

Fetal/Neonatal Adverse Reactions

Renal dysfunction, transient neonatal hyperkalemia and low birth weight have been reported at the time of delivery in infants of mothers taking Tacrolimus.

Labor or Delivery

There is an increased risk for premature delivery (<37 weeks) following transplantation and maternal exposure to Tacrolimus.

Data

Human Data

There are no adequate and well controlled studies on the effects of Tacrolimus in human pregnancy.

Safety data from the TPRI and postmarketing surveillance suggest infants exposed to Tacrolimus in utero have an increased risk for miscarriage, pre-term delivery (<37 weeks), low birth weight (<2500 g), birth defects/congenital anomalies and fetal distress.

TPRI reported 450 and 241 total pregnancies in kidney and liver transplant recipients exposed to Tacrolimus, respectively. The TPRI pregnancy outcomes are summarized in Table 16. In the table below, the number of recipients exposed to Tacrolimus concomitantly with mycophenolic acid (MPA) products during the preconception and first trimester periods is high (27% and 29% for renal and liver transplant recipients, respectively). Because MPA products may also cause birth defects, the birth defect rate may be confounded and this should be taken into consideration when reviewing the data, particularly for birth defects. Birth defects observed include cardiac malformations, craniofacial malformations, renal/urogenital disorders, skeletal abnormalities, neurological abnormalities and multiple malformations.

Table 16 TPRI Reported Pregnancy Outcomes in Transplant Recipients with Exposure to Tacrolimus

KidneyLiver
Pregnancy Outcomes * 462253
Miscarriage24.5%25%
Live births331180
Pre-term delivery (< 37 weeks)49%42%
Low birth weight (< 2500 g)42%30%
Birth defects8% † 5%
* Includes multiple births and terminations. † Birth defect rate confounded by concomitant MPA products exposure in over half of offspring with birth defects.

Additional information reported by TPRI in pregnant transplant patients receiving Tacrolimus included diabetes during pregnancy in 9% of kidney recipients and 13% of liver recipients and hypertension during pregnancy in 53% of kidney recipients and 16.2% of liver recipients.

Animal Data

Administration of oral Tacrolimus to pregnant rabbits throughout organogenesis produced maternal toxicity and abortion at 0.32 mg/kg (0.5 to 1.4 times the recommended clinical dose range [0.2 to 0.075 mg/kg/day], on a mg/m2 basis). At 1 mg/kg (1.6 to 4.3 times the recommended clinical dose range), embryofetal lethality and fetal malformations (ventricular hypoplasia, interventricular septal defect, bulbous aortic arch, stenosis of ductus arteriosus, omphalocele, gallbladder agenesis, skeletal anomalies) were observed. Administration of 3.2 mg/kg oral Tacrolimus (2.6 to 6.9 times the recommended clinical dose range) to pregnant rats throughout organogenesis produced maternal toxicity/lethality, embryofetal lethality and decreased fetal body weight in the offspring of C-sectioned dams; and decreased pup viability and interventricular septal defect in offspring of dams that delivered.

In a peri-/postnatal development study, oral administration of Tacrolimus to pregnant rats during late gestation (after organogenesis) and throughout lactation produced maternal toxicity, effects on parturition, and reduced pup viability at 3.2 mg/kg (2.6 to 6.9 times the recommended clinical dose range); among these pups that died early, an increased incidence of kidney hydronephrosis was observed. Reduced pup weight was observed at 1.0 mg/kg (0.8 to 2.2 times the recommended clinical dose range).

Administration of oral Tacrolimus to rats prior to mating, and throughout gestation and lactation, produced maternal toxicity/lethality, embryofetal loss and reduced pup viability at 3.2 mg/kg (2.6 to 6.9 times the recommended clinical dose range). Interventricular septal defects, hydronephrosis, craniofacial malformations and skeletal effects were observed in offspring that died. Effects on parturition (incomplete delivery of nonviable pups) were observed at 1 mg/kg (0.8 to 2.2 times the recommended clinical dose range) [see Nonclinical Toxicology ( 13.1 )].

Lactation

Risk Summary

Controlled lactation studies have not been conducted in humans; however, Tacrolimus has been reported to be present in human milk. The effects of Tacrolimus on the breastfed infant, or on milk production have not been assessed. Tacrolimus is excreted in rat milk and in peri-/postnatal rat studies; exposure to Tacrolimus during the postnatal period was associated with developmental toxicity in the offspring at clinically relevant doses [see Use in Specific Populations ( 8.1 ) and Nonclinical Toxicology ( 13.1 )].

The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for Tacrolimus and any potential adverse effects on the breastfed child from Tacrolimus or from the underlying maternal condition.

Females and Males of Reproductive Potential

Contraception

Tacrolimus can cause fetal harm when administered to pregnant women. Advise female and male patients of reproductive potential to speak to their healthcare provider on family planning options including appropriate contraception prior to starting treatment with Tacrolimus [see Use in Specific Populations ( 8.1 ) and Nonclinical Toxicology ( 13.1 )].

Infertility

Based on findings in animals, male and female fertility may be compromised by treatment with Tacrolimus [see Nonclinical Toxicology ( 13.1 )].

Pediatric Use

Safety and effectiveness have been established in pediatric liver, kidney, heart, and lung transplant patients.

Kidney and Heart Transplantation

Use of Tacrolimus capsules in pediatric kidney and heart transplant patients is supported by adequate and well-controlled studies and pharmacokinetic data in adult kidney and heart transplant patients with additional pharmacokinetic data in pediatric kidney and heart transplant patients and safety data in pediatric liver transplant patients [see Dosage and Administration ( 2.3 ) and Clinical Pharmacology ( 12.3 )].

Lung Transplantation

The use of Tacrolimus capsules in pediatric lung transplantation is supported by the experience in the U.S. Scientific Registry of Transplant Recipients (SRTR) including 450 pediatric patients receiving Tacrolimus immediate-release products in combination with mycophenolate mofetil and 72 pediatric patients receiving Tacrolimus immediate-release products in combination with azathioprine between 1999-2017.

Geriatric Use

Clinical trials of Tacrolimus did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. Other reported clinical experience has not identified differences in responses between the elderly and younger patients. In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy.

Renal Impairment

The pharmacokinetics of Tacrolimus in patients with renal impairment was similar to that in healthy volunteers with normal renal function. However, consideration should be given to dosing Tacrolimus at the lower end of the therapeutic dosing range in patients who have received a liver or heart transplant and have pre-existing renal impairment. Further reductions in dose below the targeted range may be required [see Dosage and Administration ( 2.4 ) and Clinical Pharmacology ( 12.3 )].

Hepatic Impairment

The mean clearance of Tacrolimus was substantially lower in patients with severe hepatic impairment (mean Child-Pugh score: >10) compared to healthy volunteers with normal hepatic function. Close monitoring of Tacrolimus trough concentrations is warranted in patients with hepatic impairment [see Clinical Pharmacology ( 12.3 )].

The use of Tacrolimus in liver transplant recipients experiencing post-transplant hepatic impairment may be associated with increased risk of developing renal insufficiency related to high whole blood trough concentrations of Tacrolimus. These patients should be monitored closely and dosage adjustments should be considered. Some evidence suggests that lower doses should be used in these patients [see Dosage and Administration ( 2.5 ) and Clinical Pharmacology ( 12.3 )].

Race or Ethnicity

African-American patients may need to be titrated to higher dosages to attain comparable trough concentrations compared to Caucasian patients [see Dosage and Administration ( 2.2 ) and Clinical Pharmacology ( 12.3 )].

African-American and Hispanic patients are at increased risk for new onset diabetes after transplant. Monitor blood glucose concentrations and treat appropriately [see Warnings and Precautions ( 5.4 )].

Overdosage

Limited overdosage experience is available. Acute overdosages of up to 30 times the intended dose have been reported. Almost all cases have been asymptomatic and all patients recovered with no sequelae. Acute overdosage was sometimes followed by adverse reactions consistent with those reported with the use of Tacrolimus [see Adverse Reactions ( 6.1 ,  6.2 )], including tremors, abnormal renal function, hypertension, and peripheral edema; in one case of acute overdosage, transient urticaria and lethargy were observed. Based on the poor aqueous solubility and extensive erythrocyte and plasma protein binding, it is anticipated that Tacrolimus is not dialyzable to any significant extent; there is no experience with charcoal hemoperfusion. The oral use of activated charcoal has been reported in treating acute overdoses, but experience has not been sufficient to warrant recommending its use. General supportive measures and treatment of specific symptoms should be followed in all cases of overdosage.

Tacrolimus Description

Tacrolimus, previously known as FK506, is the active ingredient in Tacrolimus capsules. Tacrolimus is a calcineurin-inhibitor immunosuppressant produced by Streptomyces tsukubaensis. Chemically, Tacrolimus is designated as
[3S-[3R*[E(1S*,3S*,4S*)],4S*,5R*,8S*,9E,12R* ,14R*, 15S*,16R*,18S*,19S*,26aR*]]-5,6,8,11,12,13,14,15,16,17,18,19,24,25,26,26a-hexadecahydro-5,19-dihydroxy-3-[2-(4-hydroxy-3-methoxycyclohexyl)-1-methylethenyl]-14,16-dimethoxy-4,10,12,18-tetramethyl-8-(2-propenyl)-15,19-epoxy-3H-pyrido[2,1-c][1,4]oxaazacyclotricosine-1,7,20,21(4H,23H)-tetrone, monohydrate.

The chemical structure of Tacrolimus is:

Tacrolimus has a molecular formula of C44H69NO12•H2O and a formula weight of 822.03. Tacrolimus appears as white crystals or crystalline powder. It is practically insoluble in water, freely soluble in ethanol, and very soluble in methanol and chloroform.

Tacrolimus capsules, USP are available for oral administration containing the equivalent of 0.5 mg or 1 mg of anhydrous Tacrolimus. In addition, each capsule contains the following inactive ingredients: croscarmellose sodium, hypromellose, lactose monohydrate, and magnesium stearate.

The Tacrolimus capsule shell for 0.5 mg strength consists of gelatin, titanium dioxide and yellow iron oxide.

The Tacrolimus capsule shell for 1 mg strength consists of black iron oxide, gelatin, red iron oxide, titanium dioxide, and yellow iron oxide.

Tacrolimus capsules, USP 0.5 mg and 1 mg are printed with edible black ink. The black ink is comprised of ammonia, black iron oxide, butyl alcohol, potassium hydroxide, propylene glycol, and shellac.

USP Dissolution test 2 and Organic Impurities procedure 2 used.

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