Tacrolimus (Page 11 of 14)

Drug Interactions

Frequent monitoring of whole blood concentrations and appropriate dosage adjustments of tacrolimus are recommended when concomitant use of the following drugs with tacrolimus is initiated or discontinued [see Drug Interactions (7)].

Telaprevir: In a single dose study in 9 healthy volunteers, coadministration of tacrolimus (0.5 mg single dose) with telaprevir (750 mg three times daily for 13 days) increased the tacrolimus dose normalized Cmax by 9.3-fold and AUC by 70-fold compared to tacrolimus alone [see Drug Interactions (7.3)].

Boceprevir: In a single dose study in 12 subjects, coadministration of tacrolimus (0.5 mg single dose) with boceprevir (800 mg three times daily for 11 days) increased tacrolimus Cmax by 9.9-fold and AUC by 17-fold compared to tacrolimus alone [see Drug Interactions (7.3)].

Nelfinavir: Based on a clinical study of 5 liver transplant recipients, co-administration of tacrolimus with nelfinavir increased blood concentrations of tacrolimus significantly and, as a result, a reduction in the tacrolimus dose by an average of 16-fold was needed to maintain mean trough tacrolimus blood concentrations of 9.7 ng/mL. It is recommended to avoid concomitant use of tacrolimus and nelfinavir unless the benefits outweigh the risks [see Drug Interactions (7.3)].

Rifampin: In a study of 6 normal volunteers, a significant decrease in tacrolimus oral bioavailability (14±6% vs. 7±3%) was observed with concomitant rifampin administration (600 mg). In addition, there was a significant increase in tacrolimus clearance (0.036±0.008 L/hr/kg vs. 0.053±0.010 L/hr/kg) with concomitant rifampin administration [see Drug Interactions (7.7)].

Magnesium-aluminum-hydroxide: In a single-dose crossover study in healthy volunteers, co-administration of tacrolimus and magnesium-aluminum-hydroxide resulted in a 21% increase in the mean tacrolimus AUC and a 10% decrease in the mean tacrolimus Cmax relative to tacrolimus administration alone [see Drug Interactions (7.10)].

Ketoconazole: In a study of 6 normal volunteers, a significant increase in tacrolimus oral bioavailability (14±5% vs. 30±8%) was observed with concomitant ketoconazole administration (200 mg). The apparent oral clearance of tacrolimus during ketoconazole administration was significantly decreased compared to tacrolimus alone (0.430±0.129 L/hr/kg vs. 0.148±0.043 L/hr/kg). Overall, IV clearance of tacrolimus was not significantly changed by ketoconazole coadministration, although it was highly variable between patients [see Drug Interactions (7.4)].

Voriconazole (see complete prescribing information for VFEND®): Repeat oral dose administration of voriconazole (400 mg every 12 hours for one day, then 200 mg every 12 hours for 6 days) increased tacrolimus (0.1 mg/kg single dose) Cmax and AUCτ in healthy subjects by an average of 2-fold (90% CI: 1.9, 2.5) and 3-fold (90% CI: 2.7, 3.8), respectively [see Drug Interactions(7.4)]

Posaconazole (see complete prescribing information for Noxafil®): Repeat oral administration of posaconazole (400 mg twice daily for 7 days) increased tacrolimus (0.05 mg/kg single dose) Cmax and AUC in healthy subjects by an average of 2-fold (90% CI: 2.01, 2.42) and 4.5-fold (90% CI 4.03, 5.19), respectively [ s ee Drug Interactions (7.4)].

Caspofungin (see complete prescribing information for CANCIDAS®): Caspofungin reduced the blood AUC0-12 of tacrolimus by approximately 20%, peak blood concentration (Cmax ) by 16%, and 12-hour blood concentration (C12hr) by 26% in healthy adult subjects when tacrolimus (2 doses of 0.1 mg/kg 12 hours apart) was administered on the 10th day of CANCIDAS® 70 mg daily, as compared to results from a control period in which tacrolimus was administered alone [see Drug Interactions (7.4)].

13 NONCLINICAL TOXICOLOGY

13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility

Carcinogenicity studies were conducted in male and female rats and mice. In the 80-week mouse oral study and in the 104-week rat oral study, no relationship of tumor incidence to tacrolimus dosage was found. The highest dose used in the mouse was 3 mg/kg/day (0.9 to 2.2 times the AUC at clinical doses of 0.075 to 0.2 mg/kg/day) and in the rat was 5 mg/kg/day (0.265 to 0.65 times the AUC at clinical doses of 0.075 to 0.2 mg/kg/day) [see Boxed Warning and Warnings and Precautions(5.2)].

A 104-week dermal carcinogenicity study was performed in mice with tacrolimus ointment (0.03% to 3%), equivalent to tacrolimus doses of 1.1 to 118 mg/kg/day or 3.3 to 354 mg/m2 /day. In the study, the incidence of skin tumors was minimal and the topical application of tacrolimus was not associated with skin tumor formation under ambient room lighting. However, a statistically significant elevation in the incidence of pleomorphic lymphoma in high dose male (25/50) and female animals (27/50) and in the incidence of undifferentiated lymphoma in high dose female animals (13/50) was noted in the mouse dermal carcinogenicity study. Lymphomas were noted in the mouse dermal carcinogenicity study at a daily dose of 3.5 mg/kg (0.1% tacrolimus ointment). No drug-related tumors were noted in the mouse dermal carcinogenicity study at a daily dose of 1.1 mg/kg (0.03% tacrolimus ointment). The relevance of topical administration of tacrolimus in the setting of systemic tacrolimus use is unknown.

The implications of these carcinogenicity studies to the human condition are limited; doses of tacrolimus were administered that likely induced immunosuppression in these animals impairing their immune system’s ability to inhibit unrelated carcinogenesis.

No evidence of genotoxicity was seen in bacterial (Salmonella and E. coli) or mammalian (Chinese hamster lung-derived cells) in vitro assays of mutagenicity, the in vitro CHO/HGPRT assay of mutagenicity, or in vivo clastogenicity assays performed in mice; tacrolimus did not cause unscheduled DNA synthesis in rodent hepatocytes.

Tacrolimus given orally at 1.0 mg/kg (0.8 to 2.2 times the clinical dose range of 0.075 to 0.2 mg/kg/day based on body surface area) to male and female rats, prior to and during mating, as well as to dams during gestation and lactation, was associated with embryolethality and adverse effects on female reproduction. Effects on female reproductive function (parturition) and embryolethal effects were indicated by a higher rate of pre-implantation loss and increased numbers of undelivered and nonviable pups. When given at 3.2 mg/kg (2.6 to 6.9 times the clinical dose range based on body surface area), tacrolimus was associated with maternal and paternal toxicity as well as reproductive toxicity including marked adverse effects on estrus cycles, parturition, pup viability, and pup malformations.

14 CLINICAL STUDIES

14.1 Kidney Transplantation

Tacrolimus/azathioprine (AZA)

Tacrolimus-based immunosuppression in conjunction with azathioprine and corticosteroids following kidney transplantation was assessed in a randomized, multicenter, non-blinded, prospective trial. There were 412 kidney transplant patients enrolled at 19 clinical sites in the United States. Study therapy was initiated when renal function was stable as indicated by a serum creatinine ≤ 4 mg/dL (median of 4 days after transplantation, range 1 to 14 days). Patients less than 6 years of age were excluded.

There were 205 patients randomized to tacrolimus-based immunosuppression and 207 patients were randomized to cyclosporine-based immunosuppression. All patients received prophylactic induction therapy consisting of an antilymphocyte antibody preparation, corticosteroids and azathioprine. Overall 1 year patient and graft survival was 96.1% and 89.6%, respectively.

Data from this trial of tacrolimus in conjunction with azathioprine indicate that during the first three months of that trial, 80% of the patients maintained trough concentrations between 7 — 20 ng/mL, and then between 5 — 15 ng/mL, through 1 year.

Tacrolimus/mycophenolate mofetil (MMF)

Tacrolimus-based immunosuppression in conjunction with MMF, corticosteroids, and induction has been studied. In a randomized, open-label, multi-center trial (Study 1), 1589 kidney transplant patients received tacrolimus (Group C, n=401), sirolimus (Group D, n=399), or one of two cyclosporine (CsA) regimens (Group A, n=390 and Group B, n=399) in combination with MMF and corticosteroids; all patients, except those in one of the two cyclosporine groups, also received induction with daclizumab. The trial was conducted outside the United States; the trial population was 93% Caucasian. In this trial, mortality at 12 months in patients receiving tacrolimus/MMF was similar (3%) compared to patients receiving cyclosporine/MMF (3% and 2%) or sirolimus/MMF (3%). Patients in the tacrolimus group exhibited higher estimated creatinine clearance rates (eCLcr ) using the Cockcroft-Gault formula (Table 16) and experienced fewer efficacy failures, defined as biopsy proven acute rejection (BPAR), graft loss, death, and/or lost to follow-up (Table 17) in comparison to each of the other three groups. Patients randomized to tacrolimus/MMF were more likely to develop diarrhea and diabetes after the transplantation and experienced similar rates of infections compared to patients randomized to either cyclosporine/MMF regimen [see Adverse Reactions (6.1)].

*
All death/graft loss (n=41, 27, 23 and 42 in Groups A, B, C and D, respectively) and patients whose last recorded creatinine values were prior to month 3 visit (n=10, 9, 7 and 9 in Groups A, B, C and D,respectively) were inputed with Glomerular Filtration rate (GFR) of 10 mL/min; a subject’s last observed creatinine value from month 3 on was used for the remainder of subjects with missing creatinine at month 12 (n=11, 12, 15 and 19 for Groups A, B, C and D). Weight was also imputed in the calculation of estimated GFR, if missing.
Adjusted for multiple (6) pairwise comparisons using Bonferroni corrections.
Group eCLcr [mL/min] at Month 12*
N MEAN SD MEDIAN Treatment Difference with Group C (99.2% Cl )
(A) CsA/MMF/CS 390 56.5 25.8 56.9 -8.6 (-13.7, -3.7)
(B) CsA/MMF/CS/Daclizumab 399 58.9 25.6 60.9 -6.2 (-11.2, -1.2)
(C) Tac/MMF/CS/Daclizumab 401 65.1 27.4 66.2 -
(D) Siro/MMF/CS/Daclizumab 399 56.2 27.4 57.3 -8.9 (-14.1, -3.9)
Total 1589 59.2 26.8 60.5
Key: CsA = Cyclosporine, CS = Corticosteroids, Siro = Sirolimus

Key: Group A=CsA/MMF/CS, B=CsA/MMF/CS/Daclizumab, C=Tac/MMF/CS/Daclizumab, and D=Siro/MMF/CS/Daclizumab

*
Adjusted for multiple (6) pairwise comparisons using Bonferroni corrections.
Group A N=390 Group B N=399 Group C N=401 Group D N=399
Overall Failure 141 (36.2%) 126 (31.6%) 82 (20.4%) 185 (46.4%)
Components of efficacy failure
BPAR 113 (29.0%) 106 (26.6%) 60 (15%) 152 (38.1%)
Graft loss excluding death 28 (7.2%) 20 (5.0%) 12 (3.0%) 30 (7.5%)
Mortality 13 (3.3%) 7 (1.8%) 11 (2.7%) 12 (3%)
Lost to follow-up 5 (1.3%) 7 (1.8%) 5 (1.3%) 6 (1.5%)
Treatment Difference of efficacy failure compared to Group C (99.2% CI *) 15.8% (7.1%, 24.3%) 11.2% (2.7%, 19.5%) - 26.0% (17.2%, 34.7%)

The protocol-specified target tacrolimus trough concentrations (Ctrough ,Tac ) were 3 — 7 ng/mL; however, the observed median Ctroughs ,Tac approximated 7 ng/mL throughout the 12 month trial (Table 18). Approximately 80% of patients maintained tacrolimus whole blood concentrations between 4 to 11 ng/mL through 1 year post-transplant.

*
10 to 90 Percentile: range of Ctrough , Tac that excludes lowest 10% and highest 10% of Ctrough,Tac
Time Median (P10-P90*) tacrolimus whole blood trough concentrations (ng/mL)
Day 30 (N=366) 6.9 (4.4 to 11.3)
Day 90 (N=351) 6.8 (4.1 to 10.7)
Day 180 (N=355) 6.5 (4.0 to 9.6)
Day 365 (N=346) 6.5 (3.8 to 10.0)

The protocol-specified target cyclosporine trough concentrations (Ctrough ,CsA ) for Group B were 50 to 100 ng/mL; however, the observed median Ctroughs ,CsA approximated 100 ng/mL throughout the 12 month trial. The protocol-specified target Ctroughs ,CsA for Group A were 150 to 300 ng/mL for the first 3 months and 100 to 200 ng/mL from month 4 to month 12; the observed median Ctroughs , CsA approximated 225 ng/mL for the first 3 months and 140 ng/mL from month 4 to month 12.

While patients in all groups started MMF at 1 gram twice daily, the MMF dose was reduced to less than 2 g per day in 63% of patients in the tacrolimus treatment arm by month 12 (Table 19); approximately 50% of these MMF dose reductions were due to adverse reactions. By comparison, the MMF dose was reduced to less than 2 g per day in 49% and 45% of patients in the two cyclosporine arms (Group A and Group B, respectively), by month 12 and approximately 40% of MMF dose reductions were due to adverse reactions.

Key: Time-averaged MMF dose = (total MMF dose)/(duration of treatment)

*
Percentage of patients for each time-averaged MMF dose range during various treatment periods. Administration of 2 g per day of time-averaged MMF dose means that MMF dose was not reduced in those patients during the treatment periods.
Time-averaged MMF dose (grams per day) *
Time period (Days) Less than 2.0 2.0 Greater than 2.0
0 — 30 (N=364) 37% 60% 2%
0 — 90 (N=373) 47% 51% 2%
0 — 180 (N=377) 56% 42% 2%
0 — 365 (N=380) 63% 36% 1%

In a second randomized, open-label, multi-center trial (Study 2), 424 kidney transplant patients received tacrolimus (N=212) or cyclosporine (N=212) in combination with MMF 1 gram twice daily, basiliximab induction, and corticosteroids. In this trial, the rate for the combined endpoint of BPAR, graft failure, death, and/or lost to follow-up at 12 months in the tacrolimus/MMF group was similar to the rate in the cyclosporine/MMF group. There was, however, an imbalance in mortality at 12 months in those patients receiving tacrolimus /MMF (4%) compared to those receiving cyclosporine/MMF (2%), including cases attributed to over immunosuppression (Table 20).

*
95% confidence interval calculated using Fisher’s Exact Test
Tacrolimus/MMF (N=212) Cyclosporine/MMF (N=212)
Overall Failure 32 (15.1%) 36 (17.0%)
Components of efficacy failure
BPAR 16 (7.5%) 29 (13.7%)
Graft loss excluding death 6 (2.8%) 4 (1.9%)
Mortality 9 (4.2%) 5 (2.4%)
Lost to follow-up 4 (1.9%) 1 (0.5%)
Treatment Difference of efficacy failure compared to tacrolimus/MMF group (95% Cl *) 1.9% (-5.2%, 9%)

The protocol-specified target tacrolimus whole blood trough concentrations (Ctrough,Tac ) in Study 2 were 7 — 16 ng/mL for the first three months and 5 — 15 ng/mL thereafter. The observed median Ctroughs,Tac approximated 10 ng/mL during the first three months and 8 ng/mL from month 4 to month 12 (Table 21). Approximately 80% of patients maintained tacrolimus whole trough blood concentrations between 6 to 16 ng/mL during months 1 through 3 and, then, between 5 to 12 ng/mL from month 4 through 1 year.

*
10 to 90 Percentile:range of Ctrough , Tac that excludes lowest 10% and highest 10% of Ctrough , Tac
Time Median (P10 to P90*) tacrolimus whole blood trough concentrations (ng/mL)
Day 30 (N=174) 10.5 (6.3 — 16.8)
Day 60 (N=179) 9.2 (5.9 — 15.3)
Day 120 (N=176) 8.3 (4.6 — 13.3)
Day 180 (N=171) 7.8 (5.5 — 13.2)
Day 365 (N=178) 7.1 (4.2 — 12.4)

The protocol-specified target cyclosporine whole blood concentrations (Ctrough,CsA ) were 125 to 400 ng/mL for the first three months, and 100 to 300 ng/mL thereafter. The observed median Ctroughs, CsA approximated 280 ng/mL during the first three months and 190 ng/mL from month 4 to month 12.

Patients in both groups started MMF at 1gram twice daily. The MMF dose was reduced to less than 2 grams per day by month 12 in 62% of patients in the tacrolimus/MMF group (Table 22) and in 47% of patients in the cyclosporine/MMF group. Approximately 63% and 55% of these MMF dose reductions were because of adverse reactions in the tacrolimus/MMF group and the cyclosporine/MMF group, respectively [see Adverse Reactions (6.1)].

*
Percentage of patients for each time-averaged MMF dose range during various treatment periods. Two grams per day of time- averaged MMF dose means that MMF dose was not reduced in those patients during the treatment periods.
Time period (Days) Time-averaged MMF dose (g/day)*
Less than 2.0 2.0 Greater than 2.0
0-30 (N=212) 25% 69% 6%
0-90 (N=212) 41% 53% 6%
0-180 (N=212) 52% 41% 7%
0-365 (N=212) 62% 34% 4%
Key: Time-averaged MMF dose=(total MMF dose)/(duration of treatment)

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