TACROLIMUS — tacrolimus capsule
Biocon Pharma Inc.
WARNING — MALIGNANCIES AND SERIOUS INFECTIONS
1 INDICATIONS AND USAGE
1.1 Prophylaxis of Organ Rejection in Kidney, Liver and Heart Transplant
Tacrolimus capsules are indicated for the prophylaxis of organ rejection, in adult patients receiving allogeneic kidney transplant [see Clinical Studies (14.1)], liver transplants [see Clinical Studies (14.2)] and heart transplant [see Clinical Studies (14.3) ], and pediatric patients receiving allogeneic liver transplants [see Clinical Studies (14.2) ] in combination with other immunosuppressants.
Additional pediatric use information is approved for Astellas Pharma US, Inc.’s Prograf (tacrolimus) products. However, due to Astellas Pharma US, Inc.’s marketing exclusivity rights, this drug product is not labeled with that information.
2 DOSAGE AND ADMINISTRATION
2.1 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)].
Patients receiving tacrolimus injection should be under continuous observation for at least the first 30 minutes following the start of the infusion and at frequent intervals thereafter. If signs or symptoms of anaphylaxis occur, the infusion should be stopped. An aqueous solution of epinephrine should be available at the bedside as well as a source of oxygen.
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 capsules should not be used simultaneously with cyclosporine. Tacrolimus capsules or cyclosporine should be discontinued at least 24 hours before initiating the other. In the presence of elevated tacrolimus capsules 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)].
2.2 Dosing for Adult Kidney, Liver, or Heart Transplant Patients — Capsules and Injection
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 and heart 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 capsules dosage recommendations for adult patients with kidney, liver, or heart 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 Dosing Recommendations and Whole Blood Trough Concentration Range in Adults
|Patient Population||Tacrolimus Capsules * Initial Oral Dosing||Whole Blood Trough Concentration Range|
|With Azathioprine||0.2 mg/kg/day, divided in two doses, administered every 12 hours||Month 1 to 3: 7 to 20 ng/mL Month 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 hours||Month 1 to 12: 4 to 11 ng/mL|
|With corticosteroids only||0.10 to 0.15 mg/kg/day, divided in two doses, administered every 12 hours||Month 1 to 12: 5 to 20 ng/mL|
|With azathioprine or MMF||0.075 mg/kg/day, divided in two doses, administered every 12 hours||Month 1 to 3: 10 to 20 ng/mL Month ≥ 4: 5 to 15 ng/mL|
Dosing should be titrated based on clinical assessments of rejection and tolerability. Lower tacrolimus capsules dosages 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)].
Table 2. Comparative Dose and Trough Concentrations Based on Race
|Time After Transplant||Caucasian||African-American|
|N = 114||N = 56|
|Dose (mg/kg)||Trough Concentrations (ng/mL)||Dose (mg/kg)||Trough Concentrations (ng/mL)|
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 and liver transplant and 0.01 mg/kg/day in heart 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)].
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