Tacrolimus (Page 2 of 10)

2.3 Dosing for Pediatric Kidney, Liver, and Heart 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 dosing 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.

Table 3 Summary of Initial Tacrolimus Capsule Dosing Recommendations and Whole Blood Trough Concentration Range in Children
*
See Clinical Pharmacology (12.3), Pharmacokinetics in Pediatric Patients
See Clinical Studies (14.2), Liver Transplantation
0.1 mg/kg/day if cell depleting induction treatment is administered.

Patient Population

Initial Tacrolimus Capsule Dosing

Whole Blood Trough Concentration Range

Pediatric kidney transplant patients *

0.3 mg/kg/day capsules, divided in two doses, administered every 12 hours

Month 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 hours

Month 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 hours

Month 1 to 12: 5 to 20 ng/mL

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)]. 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.

2.4 Dosage Adjustment in Patients with Renal Impairment

Due to its potential for nephrotoxicity, consideration should be given to dosing tacrolimus capsules 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.

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)] .

2.5 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)].

2.6 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 the 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.

3 DOSAGE FORMS AND STRENGTHS

Tacrolimus capsules, USP are available in 0.5 mg, 1 mg, and 5 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.

Tacrolimus capsules, USP containing white to off white powder equivalent to 5 mg of anhydrous tacrolimus, are hard gelatin capsules with white opaque body and orange cap. The body is imprinted ‘645’ and cap is imprinted ‘ ’ in black ink.

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