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Kocur A, Kunicki PK, Pawiński T. Generic Medicinal Products in Immunosuppressive Therapy-Should It be a Challenge for Therapeutic Drug Monitoring? Ther Drug Monit 2023; 45:173-190. [PMID: 36920502 DOI: 10.1097/ftd.0000000000001041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 07/29/2022] [Indexed: 03/16/2023]
Abstract
ABSTRACT Immunosuppressants have a narrow therapeutic index (NTIDs). Indisputably cyclosporine, tacrolimus, everolimus, and sirolimus have NTIDs, and only in the case of mycophenolic acid, a scientific discussion has not been yet concluded. Their specificities highlight the implications for generics introduced into the drug market, more precisely, with bioequivalence testing. In the European Union, the European Medicines Agency (EMA) released the "Guideline on the Investigation of Bioequivalence." The bioequivalence (BE) of the generic (tested, T) versus original (reference, R) product should be confirmed by obtaining a 90% confidence interval (CI) for the T:R ratio of each of the 2 decisive pharmacokinetic parameters, namely, the area under the curve (AUC) between 90.00% and 111.11%. A similar approach (90.00%-112.00%) for AUC was adopted by the Canadian Agency for Drugs and Technologies in Health (CADTH) for NTIDs; however, the US Food and Drug Administration is still based on classic acceptance criteria: 90% CI between 80.00% and 125.00% but with special requirements of BE testing. A discussion about long-expected global consensus was performed in this study based on the literature concerning BE testing in the case of NTIDs. The narrow acceptance criteria reduce the potential mean difference in bioavailability between generic and original products by a few percent. To identify this problem, special attention has been paid to switching drugs (generic-generic, original-generic) and therapeutic drug monitoring after conversion (TDM). There is no global consensus on the acceptance criteria for the BE of generic drugs; therefore, consensus and harmonization are strictly necessary. This study presents a review of the generic drug market and its classification by manufacturers, drug agencies, and dates of marketing authorization. Guidelines for TDM optimization (during switching/conversion) have been proposed. Physicians and clinical pharmacists should pay special attention to switching immunosuppressive drugs between original versus generic formulations, and generic versus generic formulations. Patients and their families should be educated on the risks associated with uncontrolled conversion.
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Affiliation(s)
- Arkadiusz Kocur
- Department of Drug Chemistry, Faculty of Pharmacy, Medical University of Warsaw, Warsaw, Poland
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Job KM, Roberts JK, Enioutina EY, IIIamola SM, Kumar SS, Rashid J, Ward RM, Fukuda T, Sherbotie J, Sherwin CM. Treatment optimization of maintenance immunosuppressive agents in pediatric renal transplant recipients. Expert Opin Drug Metab Toxicol 2021; 17:747-765. [PMID: 34121566 PMCID: PMC10726690 DOI: 10.1080/17425255.2021.1943356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 06/11/2021] [Indexed: 10/21/2022]
Abstract
Introduction: Graft survival in pediatric kidney transplant patients has increased significantly within the last three decades, correlating with the discovery and utilization of new immunosuppressants as well as improvements in patient care. Despite these developments in graft survival for patients, there is still improvement needed, particularly in long-term care in pediatric patients receiving grafts from deceased donor patients. Maintenance immunosuppressive therapies have narrow therapeutic indices and are associated with high inter-individual and intra-individual variability.Areas covered: In this review, we examine the impact of pharmacokinetic variability on renal transplantation and its association with age, genetic polymorphisms, drug-drug interactions, drug-disease interactions, renal insufficiency, route of administration, and branded versus generic drug formulation. Pharmacodynamics are outlined in terms of the mechanism of action for each immunosuppressant, potential adverse effects, and the utility of pharmacodynamic biomarkers.Expert opinion: Acquiring abetter quantitative understanding of immunosuppressant pharmacokinetics and pharmacodynamic components should help clinicians implement treatment regimens to maintain the balance between therapeutic efficacy and drug-related toxicity.
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Affiliation(s)
- Kathleen M Job
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Jessica K Roberts
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Elena Y Enioutina
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Sílvia M IIIamola
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, USA
| | - Shaun S Kumar
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Jahidur Rashid
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Robert M Ward
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
- Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Tsuyoshi Fukuda
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Joseph Sherbotie
- Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Catherine M Sherwin
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, USA
- Department of Pediatrics, Boonshoft School of Medicine, Dayton Children’s Hospital, Wright State University, Dayton, OH, USA
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT, USA
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Abstract
Tacrolimus was discovered in 1984 and entered clinical use shortly thereafter, contributing to successful solid organ transplantation across the globe. In this review, we cover development of tacrolimus, its evolving clinical utility, and issues affecting its current usage. Since earliest use of this class of immunosuppressant, concerns for calcineurin-inhibitor toxicity have led to efforts to minimize or eliminate these agents in clinical regimens but with limited success. Current understanding of the role of tacrolimus focuses more on its efficacy in preventing graft rejection and graft loss. As we enter the fourth decade of tacrolimus use, newer studies utilizing novel combinations (as with the mammalian target of rapamycin inhibitor, everolimus, and T-cell costimulation blockade with belatacept) offer potential for enhanced benefits.
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Affiliation(s)
- Song C Ong
- Department of Medicine, Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL
| | - Robert S Gaston
- Department of Medicine, Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL
- CTI Clinical Trial and Consulting, Inc., Covington, KT
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Kahn J, Pregartner G, Schemmer P. Immunosuppression with generic tacrolimus in liver and kidney transplantation-systematic review and meta-analysis on biopsy-proven acute rejection and bioequivalence. Transpl Int 2020; 33:356-372. [PMID: 31971288 PMCID: PMC7154701 DOI: 10.1111/tri.13581] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 02/26/2019] [Accepted: 01/17/2020] [Indexed: 12/26/2022]
Abstract
While rejection prevention with innovator tacrolimus (Tac) is one of the key factors for long-lasting graft function, the use of generic Tac is still under debate. Thus, we performed a systematic review and meta-analysis to provide an overview on the current body of evidence for the effect of generic Tac in adult liver (LT) and kidney transplantation (KT) with focus on both biopsy-proven acute rejection (BPAR) and bioequivalence. A systematic literature search for trials comparing generic versus innovator Tac was conducted accordingly. Seventeen studies (5 LT, 11 KT, 1 LT/KT) including 1412 patients were identified. About 92.9% (13/14; 5/5 LT, 8/9 KT) of studies reported the same or lower BPAR with generics (pooled RR: 0.84, 95% CI: 0.65-1.09); however, de novo studies showed a significantly lower risk with generic Tac (RR: 0.75, 95% CI: 0.63-0.90), whereas conversion studies showed increased risk (RR: 1.93, 95% CI: 1.00-3.70). Bioequivalence was demonstrated primarily in studies on conversion. The current evidence is mostly based on observational data and studies showing some risk of bias. In conclusion, whereas overall there was no significant difference in terms of BPAR, there is some evidence suggesting lower BPAR risk with generic Tac for de novo use.
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Affiliation(s)
- Judith Kahn
- General, Visceral, and Transplant SurgeryDepartment of SurgeryMedical University of GrazGrazAustria
- Transplant Center GrazMedical University of GrazGrazAustria
| | - Gudrun Pregartner
- Institute for Medical Informatics, Statistics and DocumentationMedical University of GrazGrazAustria
| | - Peter Schemmer
- General, Visceral, and Transplant SurgeryDepartment of SurgeryMedical University of GrazGrazAustria
- Transplant Center GrazMedical University of GrazGrazAustria
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Bentata Y. Mycophenolates: The latest modern and potent immunosuppressive drugs in adult kidney transplantation: What we should know about them? Artif Organs 2020; 44:561-576. [DOI: 10.1111/aor.13623] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 11/25/2019] [Accepted: 12/20/2019] [Indexed: 12/18/2022]
Affiliation(s)
- Yassamine Bentata
- Nephrology and Kidney Transplantation Unit University Hospital Mohammed VI University Mohammed First Oujda Morocco
- Laboratory of Epidemiology Clinical Research and Public Health Medical School University Mohammed First Oujda Morocco
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Liu Q, Smith AR, Park JM, Oguntimein M, Dutcher S, Bello G, Helmuth M, Turenne M, Balkrishnan R, Fava M, Beil CA, Saulles A, Goel S, Sharma P, Leichtman A, Zee J. The adoption of generic immunosuppressant medications in kidney, liver, and heart transplantation among recipients in Colorado or nationally with Medicare part D. Am J Transplant 2018; 18:1764-1773. [PMID: 29603899 PMCID: PMC6537862 DOI: 10.1111/ajt.14722] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 02/20/2018] [Accepted: 02/26/2018] [Indexed: 01/25/2023]
Abstract
The transplant community is divided regarding whether substitution with generic immunosuppressants is appropriate for organ transplant recipients. We estimated the rate of uptake over time of generic immunosuppressants using US Medicare Part D Prescription Drug Event (PDE) and Colorado pharmacy claims (including both Part D and non-Part D) data from 2008 to 2013. Data from 26 070 kidney, 15 548 liver, and 6685 heart recipients from Part D, and 1138 kidney and 389 liver recipients from Colorado were analyzed. The proportions of patients with PDEs or claims for generic and brand-name tacrolimus or mycophenolate mofetil were calculated over time by transplanted organ and drug. Among Part D kidney, liver, and heart beneficiaries, the proportion dispensed generic tacrolimus reached 50%-56% at 1 year after first generic approval and 78%-81% by December 2013. The proportion dispensed generic mycophenolate mofetil reached 70%-73% at 1 year after generic market entry and 88%-90% by December 2013. There was wide interstate variability in generic uptake, with faster uptake in Colorado compared with most other states. Overall, generic substitution for tacrolimus and mycophenolate mofetil for organ transplant recipients increased rapidly following first availability, and utilization of generic immunosuppressants exceeded that of brand-name products within a year of market entry.
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Affiliation(s)
- Qian Liu
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | | | - Jeong M. Park
- University of Michigan, College of Pharmacy, Ann Arbor, MI, USA
| | | | - Sarah Dutcher
- Food and Drug Administration, Silver Spring, MD, USA
| | - Ghalib Bello
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA,Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Marc Turenne
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | | | - Melissa Fava
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | | | - Adam Saulles
- University of Michigan, College of Pharmacy, Ann Arbor, MI, USA
| | - Sangeeta Goel
- University of Michigan, College of Pharmacy, Ann Arbor, MI, USA
| | - Pratima Sharma
- Department of Internal Medicine, University of Michigan, Division of Gastroenterology, Ann Arbor, MI, USA
| | - Alan Leichtman
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | - Jarcy Zee
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
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Rottembourg J, Rostoker G. [The use of generics in transplantation: Towards rational and safe solutions!]. Presse Med 2018; 47:199-210. [PMID: 29555162 DOI: 10.1016/j.lpm.2017.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2017] [Revised: 11/27/2017] [Accepted: 12/13/2017] [Indexed: 10/17/2022] Open
Abstract
Generic immunosuppressive drugs are available in Europe Canada and the United States. Between countries, there are large differences in penetration of generic drugs in general, and for immunosuppressive drugs in particular. The registration for generic immunosuppressive drugs are slightly different, but the criteria for registration of narrow therapeutic index drugs and bioequivalence studies, performed only in healthy volunteers, will remain in the medical landscape. About 50 studies compare the clinical efficacy and bioequivalence of the generic immunosuppressive drugs in patients with solid organ transplants. To allow for safe substitution, a number of criteria need to be fulfilled. Consensus statements were made by most transplant organizations. Authorities and payers should refrain from forcing pharmacists to dispense generic drugs in patients on maintenance immunosuppressive treatment. Generic substitution could be safe if realized by the treating physician, for a well-informed patient. Substitution must be followed by control visits to check if the patient is taking the medication correctly and if the drug exposure, through a close monitoring, remains stable. Substitution from one generic to another generic should be avoided, in all cases.
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Affiliation(s)
- Jacques Rottembourg
- Groupe hospitalier Pitié-Salpêtrière, service de néphrologie, 83, boulevard de l'Hôpital, 75013 Paris, France.
| | - Guy Rostoker
- Hôpital privé Claude-Galien, Ramsay-Générale de Santé, service de néphrologie et de dialyse, 91480 Quincy-sous-Sénart, France
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Choi HJ, Kim DG, Kwak BJ, Han JH, Hong TH, You YK. Comparison of the long-term efficacy and safety of generic tacrolimus, Tacrobell, with Prograf in liver transplant recipients. DRUG DESIGN DEVELOPMENT AND THERAPY 2018; 12:295-301. [PMID: 29483770 PMCID: PMC5815471 DOI: 10.2147/dddt.s149906] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Introduction The purpose of this study was to compare the safety and efficacy of generic tacrolimus (Tacrobell [TCB]) and a reference tacrolimus (Prograf [PGF]) in liver transplant recipients. Patients and methods We retrospectively analyzed 167 patients who used TCB or PGF between January 2009 and March 2016 for >1 year (TCB group, n=86; PGF group, n=81). To assess the efficacy and safety of TCB, we evaluated the relationship between drug dose and trough level, survival, rejection, infection, kidney function, and side effects. Results There was no difference in the preoperative demographics between the two groups. Moreover, there was no difference in the drug dose and trough level between the groups at 1 week after surgery. Coefficient of variation (CV) values were obtained at the drug trough level for each patient and no differences in CV values were identified within 1 year (p=0.587) and up to 5 years (p=0.824) in both groups. Rehospitalization (p=0.1) and total rejection (p=0.915) did not differ between the two groups, but the rejection severity, recorded as the rejection activity index value, was worse in the PGF group (p=0.039). No difference was found in the infection rate (p=0.818), and with regard to nephrotoxicity, there was no difference in the rate of patients with chronic kidney disease stage 3 and above during the follow-up period. No differences were found between the two groups in terms of drug side effects and adverse events. Conclusion The generic tacrolimus, TCB, is a comparable alternative to the original tacrolimus, PGF, as a main immunosuppressive drug for liver transplantation.
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Affiliation(s)
- Ho Joong Choi
- Department of Surgery, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Dong Goo Kim
- Department of Surgery, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Bong Jun Kwak
- Department of Surgery, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jae Hyun Han
- Department of Surgery, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Tae Ho Hong
- Department of Surgery, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Young Kyoung You
- Department of Surgery, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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Alloway RR, Vinks AA, Fukuda T, Mizuno T, King EC, Zou Y, Jiang W, Woodle ES, Tremblay S, Klawitter J, Klawitter J, Christians U. Bioequivalence between innovator and generic tacrolimus in liver and kidney transplant recipients: A randomized, crossover clinical trial. PLoS Med 2017; 14:e1002428. [PMID: 29135993 PMCID: PMC5685573 DOI: 10.1371/journal.pmed.1002428] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 10/06/2017] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Although the generic drug approval process has a long-term successful track record, concerns remain for approval of narrow therapeutic index generic immunosuppressants, such as tacrolimus, in transplant recipients. Several professional transplant societies and publications have generated skepticism of the generic approval process. Three major areas of concern are that the pharmacokinetic properties of generic products and the innovator (that is, "brand") product in healthy volunteers may not reflect those in transplant recipients, bioequivalence between generic and innovator may not ensure bioequivalence between generics, and high-risk patients may have specific bioequivalence concerns. Such concerns have been fueled by anecdotal observations and retrospective and uncontrolled published studies, while well-designed, controlled prospective studies testing the validity of the regulatory bioequivalence testing approach for narrow therapeutic index immunosuppressants in transplant recipients have been lacking. Thus, the present study prospectively assesses bioequivalence between innovator tacrolimus and 2 generics in individuals with a kidney or liver transplant. METHODS AND FINDINGS From December 2013 through October 2014, a prospective, replicate dosing, partially blinded, randomized, 3-treatment, 6-period crossover bioequivalence study was conducted at the University of Cincinnati in individuals with a kidney (n = 35) or liver transplant (n = 36). Abbreviated New Drug Applications (ANDA) data that included manufacturing and healthy individual pharmacokinetic data for all generics were evaluated to select the 2 most disparate generics from innovator, and these were named Generic Hi and Generic Lo. During the 8-week study period, pharmacokinetic studies assessed the bioequivalence of Generic Hi and Generic Lo with the Innovator tacrolimus and with each other. Bioequivalence of the major tacrolimus metabolite was also assessed. All products fell within the US Food and Drug Administration (FDA) average bioequivalence (ABE) acceptance criteria of a 90% confidence interval contained within the confidence limits of 80.00% and 125.00%. Within-subject variability was similar for the area under the curve (AUC) (range 12.11-15.81) and the concentration maximum (Cmax) (range 17.96-24.72) for all products. The within-subject variability was utilized to calculate the scaled average bioequivalence (SCABE) 90% confidence interval. The calculated SCABE 90% confidence interval was 84.65%-118.13% and 80.00%-125.00% for AUC and Cmax, respectively. The more stringent SCABE acceptance criteria were met for all product comparisons for AUC and Cmax in both individuals with a kidney transplant and those with a liver transplant. European Medicines Agency (EMA) acceptance criteria for narrow therapeutic index drugs were also met, with the only exception being in the case of Brand versus Generic Lo, in which the upper limits of the 90% confidence intervals were 111.30% (kidney) and 112.12% (liver). These were only slightly above the upper EMA acceptance criteria limit for an AUC of 111.11%. SCABE criteria were also met for the major tacrolimus metabolite 13-O-desmethyl tacrolimus for AUC, but it failed the EMA criterion. No acute rejections, no differences in renal function in all individuals, and no differences in liver function were observed in individuals with a liver transplant using the Tukey honest significant difference (HSD) test for multiple comparisons. Fifty-two percent and 65% of all individuals with a kidney or liver transplant, respectively, reported an adverse event. The Exact McNemar test for paired categorical data with adjustments for multiple comparisons was used to compare adverse event rates among the products. No statistically significant differences among any pairs of products were found for any adverse event code or for adverse events overall. Limitations of this study include that the observations were made under strictly controlled conditions that did not allow for the impact of nonadherence or feeding on the possible pharmacokinetic differences. Generic Hi and Lo were selected based upon bioequivalence data in healthy volunteers because no pharmacokinetic data in recipients were available for all products. The safety data should be interpreted in light of the small number of participants and the short observation periods. Lastly, only the 1 mg tacrolimus strength was utilized in this study. CONCLUSIONS Using an innovative, controlled bioequivalence study design, we observed equivalence between tacrolimus innovator and 2 generic products as well as between 2 generic products in individuals after kidney or liver transplantation following current FDA bioequivalence metrics. These results support the position that bioequivalence for the narrow therapeutic index drug tacrolimus translates from healthy volunteers to individuals receiving a kidney or liver transplant and provides evidence that generic products that are bioequivalent with the innovator product are also bioequivalent to each other. TRIAL REGISTRATION ClinicalTrials.gov NCT01889758.
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Affiliation(s)
- Rita R. Alloway
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States of America
- * E-mail:
| | - Alexander A. Vinks
- Division of Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, United States of America
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States of America
| | - Tsuyoshi Fukuda
- Division of Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, United States of America
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States of America
| | - Tomoyuki Mizuno
- Division of Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, United States of America
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States of America
| | - Eileen C. King
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States of America
- Division of Biostatistics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, United States of America
| | - Yuanshu Zou
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States of America
- Division of Biostatistics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, United States of America
| | - Wenlei Jiang
- Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, U.S. Food & Drug Administration, Silver Spring, Maryland, United States of America
| | - E. Steve Woodle
- Division of Transplantation, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States of America
| | - Simon Tremblay
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States of America
| | - Jelena Klawitter
- iC42 Clinical Research and Development, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States of America
| | - Jost Klawitter
- iC42 Clinical Research and Development, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States of America
| | - Uwe Christians
- iC42 Clinical Research and Development, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States of America
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Naicker D, Reed PW, Ronaldson J, Kara T, Wong W, Prestidge C. Nationwide conversion to generic tacrolimus in pediatric kidney transplant recipients. Pediatr Nephrol 2017; 32:2125-2131. [PMID: 28660366 DOI: 10.1007/s00467-017-3707-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2016] [Revised: 05/13/2017] [Accepted: 05/15/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Bioequivalence between Tacrolimus Prograf® and generic tacrolimus formulations has been demonstrated in adult populations, however clinical experience and safety data regarding generic tacrolimus in pediatric transplant recipients is limited. This study aimed to evaluate conversion from Tacrolimus Prograf® to Sandoz® in pediatric renal transplant recipients nationwide. The primary outcome was a change in mean trough tacrolimus concentration. Additionally, changes in tacrolimus intra-patient coefficient of variation (CoV), allograft function, requirement for dose adjustments, and episodes of biopsy-proven rejection were evaluated. METHODS Retrospective cohort study in 37 pediatric renal transplant recipients who switched to Tacrolimus Sandoz®. Each patient had three pre-conversion tacrolimus trough and creatinine concentrations within the 4 months prior and three post-conversion concentrations on day 3, 10, and the next subsequent level. Mean pre- and post-conversion tacrolimus trough concentrations and glomerular filtration rate (eGFR) were calculated. Tacrolimus concentration, CoV, and creatinine differences were compared by paired t test. RESULTS Thirty-seven patients (41% females, age 3-18 years) were included. Average intra-patient difference in trough tacrolimus concentration was 0.05μg/l (95% CI -0.37 to 0.47). Average intra-patient difference in eGFR was -1.20 ml/min/1.732 (95% CI -3.53 to 1.13). Three patients had acute rejection during 12 months post-conversion compared to none during 12 months pre-conversion. CONCLUSIONS Pediatric renal transplant recipients can be converted from Tacrolimus Prograf® to Sandoz® with negligible change in trough concentration, dose adjustments, or immediate allograft function. Of concern was the number of acute rejection episodes, however non-adherence contributed to at least one episode and this difference was determined clinically and statistically not significant.
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Affiliation(s)
- Derisha Naicker
- Department of Pediatric Nephrology, Starship Children's Hospital, Park Road, Private Bag 92024, Auckland, 1142, New Zealand.
| | - Peter W Reed
- Children's Research Centre, Starship Children's Hospital, Auckland, New Zealand
| | - Jane Ronaldson
- Department of Pediatric Nephrology, Starship Children's Hospital, Park Road, Private Bag 92024, Auckland, 1142, New Zealand
| | - Tonya Kara
- Department of Pediatric Nephrology, Starship Children's Hospital, Park Road, Private Bag 92024, Auckland, 1142, New Zealand
| | - William Wong
- Department of Pediatric Nephrology, Starship Children's Hospital, Park Road, Private Bag 92024, Auckland, 1142, New Zealand
| | - Chanel Prestidge
- Department of Pediatric Nephrology, Starship Children's Hospital, Park Road, Private Bag 92024, Auckland, 1142, New Zealand
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Reimers A, Olsson P, Nilsson J, Hoff E, Reis M, Strandberg M, Lundgren A, Källén K. Impact of generic substitution on levetiracetam serum concentration—A prospective study in an outpatient setting. Epilepsy Res 2017; 134:54-61. [DOI: 10.1016/j.eplepsyres.2017.04.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Revised: 03/22/2017] [Accepted: 04/22/2017] [Indexed: 10/19/2022]
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12
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Mounting Clinical Evidence With Tacrolimus Generic Products. Transplantation 2017; 101:2663-2664. [PMID: 28749820 DOI: 10.1097/tp.0000000000001892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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13
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Son SY, Jang HR, Lee JE, Yoo H, Kim K, Park JB, Kim SJ, Oh HY, Huh W. Comparison of the long-term efficacy and safety of generic Tacrobell with original tacrolimus (Prograf) in kidney transplant recipients. DRUG DESIGN DEVELOPMENT AND THERAPY 2017; 11:203-210. [PMID: 28138224 PMCID: PMC5238812 DOI: 10.2147/dddt.s118154] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
This study aimed to evaluate the long-term efficacy and safety of a generic tacrolimus (Tacrobell [TCB]) compared to the original tacrolimus (Prograf [PGF]) in kidney transplant recipients. In this retrospective observational study, we analyzed the data from 444 patients who took TCB as a first-line immunosuppressive drug and 245 patients who took PGF. The 5-year graft survival rate was 92% for patients in the PGF group and 97% for patients in the TCB group, respectively. Cox proportional hazards for a one-sided, noninferiority model showed noninferiority (upper confidence interval [CI] limit of the hazard ratio [HR]<1.2) for TCB compared to PGF (HR: 0.58; 95% CI: 0–1.14). The 5-year patient survival rate was 96% for patients in the PGF group and 97% for patients in the TCB group. Cox proportional hazards for a one-sided, noninferiority model showed noninferiority (upper confidence interval limit of the HR<2.0) for TCB compared to PGF (HR: 0.83; 95% CI: 0–1.95). The 5-year acute rejection-free graft survival rate was not significantly different between the groups (TCB 67%, PGF 68.8%; P=0.6286). The incidence of adverse events including adverse cardiovascular or cerebrovascular events, malignancies, new-onset diabetes after transplantation, and infection events did not differ significantly between the two groups. We conclude that TCB is a comparable alternative to the original tacrolimus as a first-line immunosuppressive drug. Producers of generics should support further study of their products after approval to assure physicians of their efficacy and safety.
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Affiliation(s)
- Seung Yeon Son
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Hye Ryoun Jang
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Jung Eun Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Heejin Yoo
- Statistics and Data Center, Research Institute for Future Medicine, Samsung Medical Center
| | - Kyunga Kim
- Statistics and Data Center, Research Institute for Future Medicine, Samsung Medical Center; Department of Digital Health, SAIHST
| | - Jae Berm Park
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sung Joo Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Ha Young Oh
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Wooseong Huh
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine
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Lim MA, Kohli J, Bloom RD. Immunosuppression for kidney transplantation: Where are we now and where are we going? Transplant Rev (Orlando) 2016; 31:10-17. [PMID: 28340885 DOI: 10.1016/j.trre.2016.10.006] [Citation(s) in RCA: 86] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2016] [Accepted: 10/05/2016] [Indexed: 01/15/2023]
Abstract
Advances in immunosuppression have propelled kidney transplantation from a scientific curiosity to the optimal treatment for patients with end stage kidney disease. Declining rates of acute rejection have led to improvements in short term kidney transplant survival, culminating in incrementally better long term patient and allograft outcomes. Contextualized around established immune-suppressing drug targets, this review summarizes the history of the clinical science and highlights the pivotal trials that have led to present-day treatment standards at the level of both individual agents and multidrug regimens for kidney recipients. Finally, recently approved and emerging therapies are discussed, with an emphasis on challenges faced by clinicians managing this increasingly complex patient population.
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Affiliation(s)
- Mary Ann Lim
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jatinder Kohli
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Roy D Bloom
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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Is There Evidence to Support Brand to Generic Interchange of the Mycophenolic Acid Products? J Pharm Pract 2016; 30:9-16. [DOI: 10.1177/0897190015585758] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The uptake of generic immunosuppressants lags comparatively to other drug classes, despite that the Food and Drug Administration (FDA) uses identical bioequivalence standards for all drugs. Transplant societies acknowledge the cost savings associated with generic immunosuppressants and support their use following heart, lung, kidney, or bone marrow transplantation. Seven studies of the pharmacokinetics or clinical efficacy of generic mycophenolate mofetil compared to the innovator product are published; all studies and products were ex-United States. Three studies did not demonstrate any pharmacokinetic differences between generic and innovator products in healthy subjects, achieving FDA bioequivalence requirements. Two studies in renal allograft recipients demonstrated no difference in area under the curves between generic and innovator products, and in one, the maximum concentration (Cmax) fell outside the FDA regulatory range. Two studies revealed no difference in acute organ rejection or graft function in renal allograft recipients. Patient surveys indicate that cost is a barrier to immunosuppressant adherence. Generics present a viable method to reduce costs to payers, patients, and health care systems. Adherence to immunosuppressants is crucial to prevent graft failure. An affordable regimen potentially confers greater adherence. Concerns regarding the presumed inferiority of generic immunosuppressants should be assuaged by regulatory requirements for bioequivalency testing, transplant society position statements, and pharmacokinetic and clinical studies.
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Hauch A, John M, Smith A, Dortonne I, Patel U, Kandil E, Killackey M, Paramesh A, Lee B, Zhang R, Buell JF. Generics: Are all immunosuppression agents created equally? Surgery 2015. [PMID: 26206317 DOI: 10.1016/j.surg.2015.05.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Ting TY, Jiang W, Lionberger R, Wong J, Jones JW, Kane MA, Krumholz A, Temple R, Polli JE. Generic lamotrigine versus brand-name Lamictal bioequivalence in patients with epilepsy: A field test of the FDA bioequivalence standard. Epilepsia 2015. [PMID: 26201987 DOI: 10.1111/epi.13095] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To test the current U.S. Food and Drug Administration (FDA) bioequivalence standard in a comparison of generic and brand-name drug pharmacokinetic (PK) performance in "generic-brittle" patients with epilepsy under clinical use conditions. METHODS This randomized, double-blind, multiple-dose, steady-state, fully replicated bioequivalence study compared generic lamotrigine to brand-name Lamictal in "generic-brittle" patients with epilepsy (n = 34) who were already taking lamotrigine. Patients were repeatedly switched between masked Lamictal and generic lamotrigine. Intensive PK blood sampling at the end of each 2-week treatment period yielded two 12-h PK profiles for brand-name and generic forms for each patient. Steady-state area under the curve (AUC), peak plasma concentration (Cmax ), and minimum plasma concentration (Cmin ) data were subjected to conventional average bioequivalence (ABE) analysis, reference-scaled ABE analysis, and within-subject variability (WSV) comparisons. In addition, generic-versus-brand comparisons in individual patients were performed. Secondary clinical outcomes included seizure frequency and adverse events. RESULTS Generic demonstrated bioequivalence to brand. The 90% confidence intervals of the mean for steady-state AUC, Cmax , and Cmin for generic-versus-brand were 97.2-101.6%, 98.8-104.5%, and 93.4-101.0%, respectively. The WSV of generic and brand were also similar. Individual patient PK ratios for generic-versus-brand were similar but not identical, in part because brand-versus-brand profiles were not identical, even though subjects were rechallenged with the same product. Few subjects had seizure exacerbations or tolerability issues with product switching. One subject, however, reported 267 focal motor seizures, primarily on generic, although his brand and generic PK profiles were practically identical. SIGNIFICANCE Some neurologists question whether bioequivalence in healthy volunteers ensures therapeutic equivalence of brand and generic antiepileptic drugs in patients with epilepsy, who may be at increased risk for problems with brand-to-generic switching. Bioequivalence results in "generic-brittle" patients with epilepsy under clinical conditions support the soundness of the FDA bioequivalence standards. Adverse events on generic were not related to the small, allowable PK differences between generic and brand.
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Affiliation(s)
- Tricia Y Ting
- Department of Neurology, University of Maryland, Baltimore, Maryland, U.S.A
| | - Wenlei Jiang
- Food and Drug Administration, White Oak, Maryland, U.S.A
| | | | - Jessica Wong
- Department of Pharmaceutical Sciences, University of Maryland, Baltimore, Maryland, U.S.A
| | - Jace W Jones
- Department of Pharmaceutical Sciences, University of Maryland, Baltimore, Maryland, U.S.A
| | - Maureen A Kane
- Department of Pharmaceutical Sciences, University of Maryland, Baltimore, Maryland, U.S.A
| | - Allan Krumholz
- Department of Neurology, University of Maryland, Baltimore, Maryland, U.S.A
| | - Robert Temple
- Food and Drug Administration, White Oak, Maryland, U.S.A
| | - James E Polli
- Department of Pharmaceutical Sciences, University of Maryland, Baltimore, Maryland, U.S.A
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Molnar AO, Fergusson D, Tsampalieros AK, Bennett A, Fergusson N, Ramsay T, Knoll GA. Generic immunosuppression in solid organ transplantation: systematic review and meta-analysis. BMJ 2015; 350:h3163. [PMID: 26101226 PMCID: PMC4476317 DOI: 10.1136/bmj.h3163] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To compare the clinical efficacy and bioequivalence of generic immunosuppressive drugs in patients with solid organ transplants. DESIGN Systematic review and meta-analysis of all studies comparing generic with innovator immunosuppressive drugs. DATA SOURCES Medline and Embase from 1980 to September 2014. REVIEW METHODS A literature search was performed for all studies comparing a generic to an innovator immunosuppressive drug in solid organ transplantation. Two reviewers independently extracted data and assessed quality of studies. Meta-analyses of prespecified outcomes were performed when deemed appropriate. Outcomes included patient survival, allograft survival, acute rejection, adverse events and bioequivalence. RESULTS 1679 citations were screened, of which 50 studies met eligibility criteria (17 randomized trials, 15 non-randomized interventional studies, and 18 observational studies). Generics were compared with Neoral (cyclosporine) (32 studies), Prograf (tacrolimus) (12 studies), and Cellcept (mycophenolate mofetil) (six studies). Pooled analysis of randomized controlled trials in patients with kidney transplants that reported bioequivalence criteria showed that Neoral (two studies) and Prograf (three studies) were not bioequivalent with generic preparations according to criteria of the European Medicines Agency. The single Cellcept trial also did not meet bioequivalence. Acute rejection was rare but did not differ between groups. For Neoral, the pooled Peto odds ratio was 1.23 (95% confidence interval 0.64 to 2.36) for kidney randomized controlled trials and 0.66 (0.40 to 1.08) for observational studies. For kidney observational studies, the pooled Peto odds ratios were 0.98 (0.37 to 2.60) for Prograf and 0.49 (0.09 to 2.56) for Cellcept. Meta-analyses for non-renal solid organ transplants were not performed because of a lack of data.There were insufficient data reported on patient or graft survival. Pooling of results was limited by inconsistent study methods and reporting of outcomes. Many studies did not report standard criteria used to determine bioequivalence. While rates of acute rejection seemed similar and were relatively rare, few studies were designed to properly compare clinical outcomes. Most studies had short follow-up times and included stable patients without a history of rejection. CONCLUSIONS High quality data showing bioequivalence and clinical efficacy of generic immunosuppressive drugs in patients with transplants are lacking. Given the serious consequences of rejection and allograft failure, well designed studies on bioequivalence and safety of generic immunosuppression in transplant recipients are needed.
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Affiliation(s)
- Amber O Molnar
- Division of Nephrology, Kidney Research Centre, Department of Medicine, University of Ottawa, 501 Smyth Road, Ottawa, Canada, K1H 8L6 Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, Canada, K1H 8L6
| | - Dean Fergusson
- Division of Nephrology, Kidney Research Centre, Department of Medicine, University of Ottawa, 501 Smyth Road, Ottawa, Canada, K1H 8L6 Division of Nephrology, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, Canada, K1H 8L1
| | - Anne K Tsampalieros
- Division of Nephrology, Kidney Research Centre, Department of Medicine, University of Ottawa, 501 Smyth Road, Ottawa, Canada, K1H 8L6 Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, Canada, K1H 8L6
| | - Alexandria Bennett
- Division of Nephrology, Kidney Research Centre, Department of Medicine, University of Ottawa, 501 Smyth Road, Ottawa, Canada, K1H 8L6 Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, Canada, K1H 8L6
| | - Nicholas Fergusson
- Division of Nephrology, Kidney Research Centre, Department of Medicine, University of Ottawa, 501 Smyth Road, Ottawa, Canada, K1H 8L6 Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, Canada, K1H 8L6
| | - Timothy Ramsay
- Division of Nephrology, Kidney Research Centre, Department of Medicine, University of Ottawa, 501 Smyth Road, Ottawa, Canada, K1H 8L6
| | - Greg A Knoll
- Division of Nephrology, Kidney Research Centre, Department of Medicine, University of Ottawa, 501 Smyth Road, Ottawa, Canada, K1H 8L6
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Söderlund C, Rådegran G. Safety and efficacy of the switch to generic mycophenolate mofetil and tacrolimus in heart transplant patients. Clin Transplant 2015; 29:619-28. [PMID: 25981927 DOI: 10.1111/ctr.12564] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2015] [Indexed: 12/22/2022]
Abstract
BACKGROUND Generic immunosuppressants may offer economic advantages, but their use is still controversial. At our center, 55 heart transplant patients were switched from CellCept(®) to Myfenax Teva(®) (MT) (n = 51, 18% female, 8.1 ± 6.6 yr post-transplantation) and/or Prograf(®) to Tacrolimus Sandoz(®) (TS) (n = 17, 41% female, 6.6 ± 5.8 yr post-transplantation). METHODS We conducted an acute monitoring and a retrospective follow-up with regard to safety and efficacy. Acute cellular rejections (ACRs) on endomyocardial biopsies (EMBs) four wk after the MT switch were specifically compared to a matched retrospective control group. RESULTS Tacrolimus C0 levels (TS switch) as well as hemoglobin, leukocytes, and thrombocytes (MT switch) did not change (p = NS) during the three wk after each respective switch (8.7 ± 2.9 vs. 8.4 ± 1.9 μg/L, 129.1 ± 12.6 vs. 130.1 ± 12.8 g/L, 6.3 vs. 6.2 × 10(9) /L, and 217.4 ± 56.6 vs. 219.3 ± 61.8 × 10(9) /L, respectively). 0% of the EMBs in the MT switch vs. 3% of the EMBs in the control group showed ACR>grade 1R (p = NS). After six months, survival was 96% (MT switch) and 100% (TS switch), and the frequency of severe ACR was low. Safety parameters measured at the next annual follow-up were also stable following each switch. CONCLUSION Switching to MT and/or TS several years after heart transplantation appeared safe in the short-term perspective, showing no detectable changes in tacrolimus C0 levels, safety or efficacy, during an average follow-up of six months.
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Affiliation(s)
- Carl Söderlund
- The Haemodynamic Lab, The Section for Heart Failure and Valvular Disease, The Clinic for Heart and Lung Disease, Skåne University Hospital, Lund, Sweden.,Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
| | - Göran Rådegran
- The Haemodynamic Lab, The Section for Heart Failure and Valvular Disease, The Clinic for Heart and Lung Disease, Skåne University Hospital, Lund, Sweden.,Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
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El Hajj S, Kim M, Phillips K, Gabardi S. Generic immunosuppression in transplantation: current evidence and controversial issues. Expert Rev Clin Immunol 2015; 11:659-72. [DOI: 10.1586/1744666x.2015.1026895] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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23
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Kaló Z, Holtorf AP, Alfonso-Cristancho R, Shen J, Ágh T, Inotai A, Brixner D. Need for multicriteria evaluation of generic drug policies. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2015; 18:346-51. [PMID: 25773570 DOI: 10.1016/j.jval.2014.12.012] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Revised: 10/26/2014] [Accepted: 12/10/2014] [Indexed: 05/16/2023]
Abstract
Policymakers tend to focus on improving patented drug policies because they are under pressure from patients, physicians, and manufacturers to increase access to novel therapies. The success of pharmaceutical innovation over the last few decades has led to the availability of many off-patent drugs to treat disease areas with the greatest public health need. Therefore, the success of public health programs in improving the health status of the total population is highly dependent on the efficiency of generic drug policies. The objective of this article was to explore factors influencing the true efficiency of generic prescription drug policies in supporting public health initiatives in the developed world. Health care decision makers often assess the efficiency of generic drug policies by the level of price erosion and market share of generics. Drug quality, bioequivalence, in some cases drug formulations, supply reliability, medical adherence and persistence, health outcomes, and nondrug costs, however, are also attributes of success for generic drug policies. Further methodological research is needed to measure and improve the efficiency of generic drug policies. This also requires extension of the evidence base of the impact of generic drugs, partly based on real-world evidence. Multicriteria decision analysis may assist policymakers and researchers to evaluate the true value of generic drugs.
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Affiliation(s)
- Zoltán Kaló
- Faculty of Social Sciences, Department of Health Policy and Health Economics, Eötvös Loránd University (ELTE), Budapest, Hungary; Syreon Research Institute, Budapest, Hungary.
| | - Anke-Peggy Holtorf
- Health Outcomes Strategies, Basel, Switzerland; Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT, USA
| | | | - Jie Shen
- Abbott Products Operations AG, Allschwil, Switzerland
| | - Tamás Ágh
- Syreon Research Institute, Budapest, Hungary
| | | | - Diana Brixner
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT, USA
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Yu LX, Jiang W, Zhang X, Lionberger R, Makhlouf F, Schuirmann DJ, Muldowney L, Chen ML, Davit B, Conner D, Woodcock J. Novel bioequivalence approach for narrow therapeutic index drugs. Clin Pharmacol Ther 2014; 97:286-91. [PMID: 25669762 DOI: 10.1002/cpt.28] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Accepted: 10/02/2014] [Indexed: 11/07/2022]
Abstract
Narrow therapeutic index drugs are defined as those drugs where small differences in dose or blood concentration may lead to serious therapeutic failures and/or adverse drug reactions that are life-threatening or result in persistent or significant disability or incapacity. The US Food and Drug Administration proposes that the bioequivalence of narrow therapeutic index drugs be determined using a scaling approach with a four-way, fully replicated, crossover design study in healthy subjects that permits the simultaneous equivalence comparison of the mean and within-subject variability of the test and reference products. The proposed bioequivalence limits for narrow therapeutic index drugs of 90.00%-111.11% would be scaled based on the within-subject variability of the reference product. The proposed study design and data analysis should provide greater assurance of therapeutic equivalence of narrow therapeutic index drug products.
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Affiliation(s)
- L X Yu
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
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Madian AG, Panigrahi A, Perera MA, Pinto N. Case report: Inability to achieve a therapeutic dose of tacrolimus in a pediatric allogeneic stem cell transplant patient after generic substitution. BMC Pharmacol Toxicol 2014; 15:69. [PMID: 25472557 PMCID: PMC4287354 DOI: 10.1186/2050-6511-15-69] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Accepted: 11/18/2014] [Indexed: 11/24/2022] Open
Abstract
Background Tacrolimus is an immunosuppressive drug that is used to lower the activity of the patient’s immune system to prevent organ rejection. Unfortunately, there is limited data regarding the therapeutic equivalency of generic tacrolimus formulations especially in children. We report the case of a pediatric patient having an inability to achieve a therapeutic trough level for tacrolimus after conversion from brand name to the generic formulation. Case presentation A 17-month-old male patient diagnosed with T-cell acute lymphoblastic leukemia underwent allogeneic stem cell transplantation. The patient initially received intravenous (IV) tacrolimus for graft-versus-host disease (GVHD) prophylaxis and achieved therapeutic levels. The patient was then switched to an oral brand formulation of tacrolimus, and was able to maintain trough levels within the therapeutic range. After being discharged, the patient received the generic formulation of tacrolimus from an outside pharmacy and the care team was unable to reach therapeutic levels despite multiple dose escalations. Returning to brand name tacrolimus resulted in prompt achievement of therapeutic levels. Conclusions A likely etiology for the inability to achieve therapeutic trough levels in this patient is the change in formulation from brand formulation to generic version. Other factors including drug-drug interaction, preparation of the medication by a different pharmacy, drug-food interaction and genetic factors were also considered. Physicians and pharmacists must be aware of the inability to achieve targeted therapeutic concentrations of tacrolimus resulting from the conversion of brand name to the generic formulation until these generic formulations are tested in clinical trials in a pediatric population.
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Affiliation(s)
| | | | | | - Navin Pinto
- Committee of Clinical Pharmacology and Pharmacogenomics, The University of Chicago, Chicago, IL, USA.
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Jacobo-Cabral CO, García-Roca P, Reyes H, Lozada-Rojas L, Cruz-Antonio L, Medeiros M, Castañeda-Hernandez G. Limustin®, a non-innovator tacrolimus formulation, yields reduced drug exposure in pediatric renal transplant recipients. Pediatr Transplant 2014; 18:706-13. [PMID: 25156476 DOI: 10.1111/petr.12335] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/12/2014] [Indexed: 12/23/2022]
Abstract
The aim of this study was to evaluate the bioavailability of two oral tacrolimus formulations, the innovator Prograf(®) and a formulation commercialized in Mexico with the brand name Limustin(®), in children. Stable Mexican pediatric renal transplant recipients received the product authorized by their social security provider, being either Prograf(®) or Limustin(®). At steady state, blood samples were drawn and tacrolimus blood concentration against time curves was constructed. CYP3A5 genotype was also determined. There was no significant difference in dose or in trough concentrations between formulations. However, AUC and Cmax were significantly higher with Prograf(®). The lower tacrolimus bioavailability with Limustin(®) was observed in both expressers and non-expressers of the functional CYP3A5 protein. Dose-normalized AUC values in expressers were 12.7 ± 11.9 and 48.7 ± 20.4 ng·h/mL/mg for Limustin(®) and Prograf(®), whereas in non-expressers, dose-normalized AUC was 54.4 ± 49.1 and 110.4 ± 42.9 ng·h/mL/mg for Limustin(®) and Prograf(®), respectively (p < 0.05). Pharmaceutical quality analysis showed that Limustin(®) dissolution at 120 min was 31.1 ± 6.2% while Prograf(®) dissolution was 100 ± 4.8%. Furthermore, the mean percentage of labeled amount of Limustin(®) and Prograf(®) was 91.0 ± 3.1% and 100.0 ± 0.7%, respectively. Hence, Limustin(®) exhibits pharmaceutical characteristics dissimilar to the innovator that likely explain the reduced tacrolimus exposure in children. We consider Limustin(®) is not adequate for pediatric use.
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Affiliation(s)
- Carlos O Jacobo-Cabral
- Departamento de Farmacología, Centro de Investigación y de Estudios Avanzados del Instituto Politécnico Nacional, Mexico City, DF, Mexico
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Allard J, Fortin MC. Is it ethical to prescribe generic immunosuppressive drugs to renal transplant patients? Can J Kidney Health Dis 2014; 1:23. [PMID: 25780612 PMCID: PMC4349684 DOI: 10.1186/s40697-014-0023-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Accepted: 08/11/2014] [Indexed: 01/07/2023] Open
Abstract
PURPOSE OF THE REVIEW This review was conducted to determine the ethical acceptability of prescribing generic immunosuppressive drugs to renal transplant patients. SOURCES OF INFORMATION The literature search was conducted using Pubmed and Google Scholar. FINDINGS The use of generic immunosuppressive drugs (ISDs) in transplantation is a controversial topic. There is a consensus among transplant societies that clinical data is lacking and that caution should be exercised. The reluctance to use generic ISDs in organ transplantation is partly related to the fact that most are "critical dose drugs", and that either low dosing or overdosing could have serious adverse consequences for both patients and society (i.e., the loss of scarce organs). In this paper, we examine the various ethical issues involved such as distributive justice, physician duties, risks versus benefits, conflict of interest, informed consent, and logistical and economic issues. LIMITATIONS Our analysis was limited by the paucity of clinical data on generic ISDs and the absence of health economics studies to quantify the benefits of prescribing generic ISDs. IMPLICATIONS Our study led us to conclude that it would be ethical to prescribe generic ISDs provided certain conditions were met. These include regulatory safeguards to minimize the risks of substitution; education of patients; and further clinical and health economics studies to better inform clinicians, patients and society of the risks and costs related to drug substitution.
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Affiliation(s)
- Julie Allard
- Centre de recherche du Centre hospitalier de l′Université de Montréal (CRCHUM), 900 Saint-Denis Street, Montreal, Quebec H2X 0A9 Canada
| | - Marie-Chantal Fortin
- Centre de recherche du Centre hospitalier de l′Université de Montréal (CRCHUM), 900 Saint-Denis Street, Montreal, Quebec H2X 0A9 Canada ,Nephrology and Transplantation Division, Centre hospitalier de l’Université de Montréal (CHUM), 1560 Sherbrooke Street East, Montreal, Quebec H2L 4 M1 Canada ,Department of Social and Preventive Medicine, Bioethics Program, School of Public Health, Université de Montréal, Montreal, Canada
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González-Ramírez R, González-Bañuelos J, Villa MDLS, Jiménez B, García-Roca P, Cruz-Antonio L, Castañeda-Hernández G, Medeiros M. Bioavailability of a generic of the immunosuppressive agent mycophenolate mofetil in pediatric patients. Pediatr Transplant 2014; 18:568-74. [PMID: 24978101 DOI: 10.1111/petr.12311] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/30/2014] [Indexed: 12/18/2022]
Abstract
The use of generic immunosuppressive agents is controversial, especially for the treatment of pediatric patients, as information on the bioavailability of generic immunosuppressants in children is particularly scarce. The aim of the study was to compare the bioavailabilities of two products containing mycophenolate mofetil, the innovator and a generic, in children. Pediatric patients with end-stage renal disease on the waiting list for renal transplantation received a single oral dose of mycophenolate mofetil as either the innovator product (CellCept(®) , Roche) or the generic (Tevacept(®) , Teva Pharmaceuticals). A nine point pharmacokinetic profile was obtained. Mycophenolic acid concentration was quantitated in plasma by HPLC, plasma concentration-against-time curves were constructed, and bioavailability parameters were determined. Pharmaceutical quality analysis of both formulations, including drug content and dissolution profile, was also performed. There were no statistically significant differences between formulations in bioavailability parameters. Interindividual variability was very important, but individual values of AUC, an indicator of the extent of drug absorption, were within the same range for both formulations. The two formulations exhibited similar drug content and dissolution profiles, as well as comparable mycophenolic acid plasma levels in an end-stage renal failure population.
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Affiliation(s)
- Rodrigo González-Ramírez
- Departamento de Farmacología, Centro de Investigación y de Estudios Avanzados del Instituto Politécnico Nacional, Mexico City, Mexico
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Richards KR, Hager D, Muth B, Astor BC, Kaufman D, Djamali A. Tacrolimus Trough Level at Discharge Predicts Acute Rejection in Moderately Sensitized Renal Transplant Recipients. Transplantation 2014; 97:986-91. [DOI: 10.1097/tp.0000000000000149] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Heavner MS, Tichy EM, Yazdi M, Formica RN, Kulkarni S, Emre S. Clinical outcomes associated with conversion from brand-name to generic tacrolimus in hospitalized kidney transplant recipients. Am J Health Syst Pharm 2014; 70:1507-12. [PMID: 23943182 DOI: 10.2146/ajhp120783] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The safety of converting kidney transplant recipients on brand-name tacrolimus to generic tacrolimus during hospitalization was evaluated. METHODS A single-center observational study compared tacrolimus dosages and trough tacrolimus levels in kidney transplant recipients who had a kidney transplant more than 90 days before hospital admission. Patients in the "brand" group were maintained on brand-name tacrolimus throughout the entire study period. Patients in the generic group were maintained on brand-name tacrolimus before hospital admission, converted to the generic formulation during hospitalization, and returned to the brand-name product at discharge. Tacrolimus dosages were converted on a milligram-per-milligram basis and adjusted, if needed. Outcomes evaluated included the percentage of patients requiring a dosage change, absolute change in average tacrolimus trough level, and frequency of biopsy-proven acute rejection within six months of discharge. RESULTS A total of 100 patients were evaluated for inclusion in the brand group, with 42 meeting study criteria; 98 patients were evaluated in the generic group, with 36 qualifying for the study. There were no significant differences between the brand and generic groups with respect to dosage adjustments required or trough tacrolimus levels at any point in the transition of care. Mean trough concentrations were similar between groups during all periods of care. The only occurrence of new-onset acute rejection within six months after admission occurred in the brand group. CONCLUSION Substitution of a generic formulation of tacrolimus for the innovator product during hospitalization of kidney transplant recipients was safely implemented. Tacrolimus dosage adjustments were common throughout the transitions of care, regardless of the formulation used.
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Affiliation(s)
- Mojdeh S Heavner
- Department of Pharmacy, Yale-New Haven Hospital, New Haven, CT 06510, USA
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Taube D, Jones G, O'Beirne J, Wennberg L, Connor A, Rasmussen A, Backman L. Generic tacrolimus in solid organ transplantation. Clin Transplant 2014; 28:623-32. [PMID: 24750309 DOI: 10.1111/ctr.12336] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2014] [Indexed: 11/28/2022]
Affiliation(s)
- D. Taube
- Imperial College Academic Health Science Centre; London UK
| | - G. Jones
- UCL Centre for Nephrology; Royal Free Hospital; London UK
| | - J. O'Beirne
- Shelia Sherlock Liver Centre; UCL Institute of Liver and Digestive Health; Royal Free Hospital; London UK
| | - L. Wennberg
- Department of Transplantation Surgery; Karolinska University Hospital; Stockholm Sweden
| | - A. Connor
- South West Transplant Centre; Derriford Hospital; Plymouth UK
| | - A. Rasmussen
- Department of General Surgery and Transplantation; Rigshospitalet; Copenhagen Denmark
| | - L. Backman
- Transplantation Surgery; Uppsala University Hospital; Uppsala Sweden
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Poirier É, Desbiens C, Poirier B, Hogue JC, Lemieux J, Doyle C, Leblond AF, Côté I, Cantin G, Provencher L. Comparison of Serious Adverse Events Between the Original and a Generic Docetaxel in Breast Cancer Patients. Ann Pharmacother 2013; 48:447-55. [DOI: 10.1177/1060028013514941] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Generic formulations are not necessarily identical to the original in terms of efficacy and adverse events. Generic docetaxel has been available in Canada since 2011. Objective: To compare the occurrence of grade III to IV adverse events between original docetaxel and a generic formulation in breast cancer patients. Methods: A consecutive series of 400 patients were assessed retrospectively: 200 who received the original docetaxel and 200 who received a generic formulation. Patients who received both formulations or received their chemotherapy outside our center were excluded. The primary outcome was the occurrence of grade III to IV adverse events related to docetaxel (febrile neutropenia, hand and foot syndrome, intestinal perforation, thrombotic event, and death). Results: Three hundred-sixty-four patients were available for analysis (182/group). The use of a granulocyte colony-stimulating factor (G-CSF) was more frequent in the generic group (44.5% vs 28.8%), as well as treatment discontinuation (26.4% vs 14.8%). The occurrence of grade III to IV febrile neutropenia, hand and foot syndrome, intestinal perforation, thrombotic event, and docetaxel-related deaths were similar between the 2 formulations. However, grade IV febrile neutropenia was more frequent with the generic formulation (78.8% vs 56.3%). Limitations were the retrospective nature of the study and the variety of chemotherapy regimens. Conclusion: Adverse events occurrence was similar between the 2 formulations. However, febrile neutropenia was more serious with generic docetaxel, despite increased G-CSF use. Results suggest that the studied generic formulation may be safe, but more caution during treatments might be warranted, especially concerning febrile neutropenia events.
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Bloom RD, Trofe-Clark J, Wiland A, Alloway RR. A randomized, crossover pharmacokinetic study comparing generic tacrolimus vs. the reference formulation in subpopulations of kidney transplant patients. Clin Transplant 2013; 27:E685-93. [DOI: 10.1111/ctr.12256] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2013] [Indexed: 01/07/2023]
Affiliation(s)
- R. D. Bloom
- Renal Division; Perelman School of Medicine; University of Pennsylvania; Philadelphia PA
| | - J. Trofe-Clark
- Renal Division; Perelman School of Medicine; University of Pennsylvania; Philadelphia PA
- Department of Pharmacy; Hospital University of Pennsylvania; Philadelphia PA USA
| | - A. Wiland
- Novartis Pharmaceuticals Corporation; East Hanover NJ USA
| | - R. R. Alloway
- Section of Transplantation; University of Cincinnati; Cincinnati OH USA
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Min SI, Ha J, Kim YS, Ahn SH, Park T, Park DD, Kim SM, Min SK, Hong H, Ahn C, Kim SJ. Therapeutic equivalence and pharmacokinetics of generic tacrolimus formulation in de novo kidney transplant patients. Nephrol Dial Transplant 2013; 28:3110-9. [DOI: 10.1093/ndt/gft300] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Castillo G, Rossano-García A, Gutiérrez D, Diliz-Pérez HS, Córdova J. [Acute cellular rejection in a liver transplantation patient due to changing the brand of a generic immunosuppressant]. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2013; 78:198-200. [PMID: 23866966 DOI: 10.1016/j.rgmx.2013.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2012] [Revised: 01/15/2013] [Accepted: 01/28/2013] [Indexed: 10/26/2022]
Affiliation(s)
- G Castillo
- Servicio de Gastroenterología, Hospital General de México «Dr. Eduardo Liceaga» O.D, México DF, México
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Petruševska M, Homar M, Petek B, Resman A, Kocjan D, Urleb U, Peternel L. Hydroxypropyl Methylcellulose Mediated Precipitation Inhibition of Sirolimus: From a Screening Campaign to a Proof-of-Concept Human Study. Mol Pharm 2013; 10:2299-310. [DOI: 10.1021/mp300641h] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Marija Petruševska
- Sandoz Development Center Slovenia,
Pharmaceutical and Biological Profiling, Lek Pharmaceuticals d.d.,
1526 Ljubljana, Slovenia
| | - Miha Homar
- Sandoz Development Center Slovenia,
Pharmaceutical and Biological Profiling, Lek Pharmaceuticals d.d.,
1526 Ljubljana, Slovenia
| | - Boštjan Petek
- Sandoz Development Center Slovenia,
Pharmaceutical and Biological Profiling, Lek Pharmaceuticals d.d.,
1526 Ljubljana, Slovenia
| | - Aleksander Resman
- Sandoz Development Center Slovenia,
Pharmaceutical and Biological Profiling, Lek Pharmaceuticals d.d.,
1526 Ljubljana, Slovenia
| | - Darko Kocjan
- EN-FIST Centre of Excellence,
1000 Ljubljana, Slovenia
| | - Uroš Urleb
- Sandoz International, Global Product
Development, 83607 Holzkirchen, Germany
| | - Luka Peternel
- Sandoz Development Center Slovenia,
Pharmaceutical and Biological Profiling, Lek Pharmaceuticals d.d.,
1526 Ljubljana, Slovenia
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Lee RA, Gabardi S. Current trends in immunosuppressive therapies for renal transplant recipients. Am J Health Syst Pharm 2013; 69:1961-75. [PMID: 23135563 DOI: 10.2146/ajhp110624] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
PURPOSE Current trends in immunosuppressive therapies for renal transplant recipients are reviewed. SUMMARY The common premise for immunosuppressive therapies in renal transplantation is to use multiple agents to work on different immunologic targets. The use of a multidrug regimen allows for pharmacologic activity at several key steps in the T-cell replication process and lower dosages of each individual agent, thereby producing fewer drug-related toxicities. In general, there are three stages of clinical immunosuppression: induction therapy, maintenance therapy, and treatment of an established acute rejection episode. Only immunosuppressive therapies used for maintenance therapy are discussed in detail in this review. The most common maintenance immunosuppressive agents can be divided into five classes: (1) the calcineurin inhibitors (CNIs) (cyclosporine and tacrolimus), (2) costimulation blockers (belatacept), (3) mammalian target of rapamycin inhibitors (sirolimus and everolimus), (4) antiproliferatives (azathioprine and mycophenolic acid derivatives), and (5) corticosteroids. Immunosuppressive regimens vary among transplantation centers but most often include a CNI and an adjuvant agent, with or without corticosteroids. Selection of appropriate immunosuppressive regimens should be patient specific, taking into account the medications' pharmacologic properties, adverse-event profile, and potential drug-drug interactions, as well as the patient's preexisting diseases, risk of rejection, and medication regimen. CONCLUSION Advancements in transplant immunosuppression have resulted in a significant reduction in acute cellular rejection and a modest increase in long-term patient and graft survival. Because the optimal immunosuppression regimen is still unknown, immunosuppressant use should be influenced by institutional preference and tailored to the immunologic risk of the patient and adverse-effect profile of the drug.
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Affiliation(s)
- Ruth-Ann Lee
- Department of Pharmacy, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC 27599-7574, USA.
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Transplant coordinators' perceived impact of availability of multiple generic immunosuppression therapies on patients, workload, and posttransplant maintenance therapy. J Transplant 2013; 2013:897434. [PMID: 23365717 PMCID: PMC3556842 DOI: 10.1155/2013/897434] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2012] [Accepted: 12/07/2012] [Indexed: 11/17/2022] Open
Abstract
Background. No studies have evaluated the impact of multiple generic immunosuppression medications on transplant coordinators (TCs) and patients.
Methods. A cross-sectional, multicenter online survey of TCs managing transplant recipients' outpatient immunosuppression was undertaken to assess TCs' perceptions of the impact of multiple generic immunosuppression therapies on patients and workload.
Results. Forty-six of 106 transplant centers contacted (43%) completed the survey, with usable information from 34 TCs (53% in centers performing >100 solid organ transplants annually, 82% registered nurses, and 68% with >5-year experience working with transplant patients). TCs indicated that “change in strength,” “switching from branded to generics,” “heavy pill burden,” and “switching from one generic to another” were the four most frequent reasons for patient confusion regarding immunosuppression. TCs reported increased patient confusion over the previous year for patients on generic immunosuppression therapy: 44% answered ≥3 patient calls/day regarding confusion over immunosuppression therapy. Most TCs indicated increased workload since the introduction of generic immunosuppression therapy. TCs perceived “acute rejection rates,” “rate of graft loss,” and “poor patient adherence” as the three most likely consequences of multiple generic immunosuppression therapy. Conclusion. TCs associated availability of multiple generic immunosuppression therapy with increased patient confusion and time spent addressing patient concerns.
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40
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Bioequivalence between generic tacrolimus products marketed in Spain by adjusted indirect comparison. Eur J Clin Pharmacol 2012. [DOI: 10.1007/s00228-012-1456-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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41
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Alloway RR, Sadaka B, Trofe-Clark J, Wiland A, Bloom RD. A randomized pharmacokinetic study of generic tacrolimus versus reference tacrolimus in kidney transplant recipients. Am J Transplant 2012; 12:2825-31. [PMID: 22759200 PMCID: PMC3472020 DOI: 10.1111/j.1600-6143.2012.04174.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Pharmacokinetic analyses comparing generic tacrolimus preparations versus the reference drug in kidney transplant patients are lacking. A prospective, multicenter, open-label, randomized, two-period (14 days per period), two-sequence, crossover and steady-state pharmacokinetic study was undertaken to compare twice-daily generic tacrolimus (Sandoz) versus reference tacrolimus (Prograf®) in stable renal transplant patients. AUC(0-12h) and peak concentration (C(max) ) were calculated from 12 h pharmacokinetic profiles at the end of each period (days 14 and 28). Of 71 patients enrolled, 68 provided evaluable pharmacokinetic data. The ratios of geometric means were 1.02 (90% CI 97-108%, p = 0.486) for AUC(0-12h) and 1.09 (90% CI 101-118%, p = 0.057) for C(max) . Mean (SD) C(0) was 7.3(1.8) ng/mL for generic tacrolimus versus 7.0(2.1) ng/mL for reference tacrolimus based on data from days 14 and 28. Correlations between 12 h trough levels and AUC were r = 0.917 for generic tacrolimus and r = 0.887 for reference drug at day 28. These data indicate that generic tacrolimus (Sandoz) has a similar pharmacokinetic profile to the reference drug and is bioequivalent in kidney transplant recipients according to US Food and Drug Administration and European Medicines Agency guidelines.
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Affiliation(s)
- R R Alloway
- Division of Nephrology, Section of Transplantation, University of CincinnatiCincinnati, OH,*Corresponding author: Rita R. Alloway,
| | - B Sadaka
- Division of Nephrology, Section of Transplantation, University of CincinnatiCincinnati, OH
| | - J Trofe-Clark
- Renal Division, Perelman School of Medicine, University of Pennsylvania, and Department of Pharmacy, Hospital University of PennsylvaniaPhiladelphia, PA
| | - A Wiland
- Novartis Pharmaceuticals CorporationEast Hanover, NJ
| | - R D Bloom
- Renal Division, Perelman School of Medicine, University of PennsylvaniaPhiladelphia, PA
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Remport A, Dankó D, Gerlei Z, Czebe K, Kiss I. [Special considerations in generic substitution of immunosuppressive drugs in transplantation]. Orv Hetil 2012; 153:1341-9. [PMID: 22913916 DOI: 10.1556/oh.2012.29429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Long-term success in solid organ transplantation strongly depends on the optimal use of maintenance immunosuppressive treatment. Cyclosporin and tacrolimus are the most frequently administered immunosuppressants and they are designed to narrow therapeutic index drugs. The substitution of the branded formulation by their generic counterparts may lead to economic benefit only if equivalent clinical outcomes can be achieved. There is no published evidence to date on the guarantee of their long-term therapeutic equivalence and cases of therapeutic failures have been reported due to inadvertent drug conversion. The disadvantageous clinical consequences of a non medical, mechanistic forced switch from the original to generic formulation of tacrolimus and the estimated loss of the payer's presumed savings are presented in a kidney transplant recipient population. Special problems related to pediatric patients, drug interactions with concurrent medications and the burden of additional therapeutic drug monitoring and follow up visits are also discussed. The authors are convinced that the implementation of the European Society of Organ Transplantation guidelines on generic substitution may provide a safe way for patients and healthcare payers.
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Affiliation(s)
- Adám Remport
- Szent Imre Kórház Nefrológia-Hypertonia Profil Budapest Tétényi.
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Abstract
The introduction of generic immunosuppressant medications may present an opportunity for cost savings in solid organ transplantation if equivalent clinical outcomes to the branded counterparts can be achieved. An interprofessional working group of the Canadian Society of Transplantation was established to develop recommendations on the use of generic immunosuppression in solid organ transplant recipients (SOTR) based on a review of the available data. Under current Health Canada licensing requirements, a demonstration of bioequivalence with the branded formulation in healthy volunteers allows for bridging of clinical data. Cyclosporine, tacrolimus, and sirolimus are designated as "critical dose drugs" and are held to stricter criteria. However, whether this provides sufficient guarantee of therapeutic equivalence in SOTR remains controversial, and failure to maintain an appropriate balance of immunosuppression may have serious consequences, including rejection, graft loss, and death. Published evidence supporting therapeutic equivalence of generic formulations in SOTR is lacking. Moreover, in the setting of multiple generic formulations the potential for uncontrolled product switching is a major concern, since generic preparations are not required to demonstrate bioequivalence with each other. Although close monitoring is recommended with any change in formulation, drug product switches are likely to occur without prescriber knowledge and may pose a significant patient safety risk. The advent of generic immunosuppression will require new practices including more frequent therapeutic drug and clinical monitoring, and increased patient education. The additional workload placed on transplant centers without additional funding will create challenges and could ultimately jeopardize patient outcomes. Until more robust clinical data are available and adequate regulatory safeguards are instituted, caution in the use of generic immunosuppressive drugs in solid organ transplantation is warranted.
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Hulbert AL, Pilch NA, Taber DJ, Chavin KD, Baliga PK. Generic immunosuppression: deciphering the message our patients are receiving. Ann Pharmacother 2012; 46:671-7. [PMID: 22570436 DOI: 10.1345/aph.1r028] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND The introduction of generic immunosuppressants elicited controversy within the transplant community and it is unknown whether patient attitudes mirror the ambiguity of provider perceptions. With the current health care economic crisis, it is necessary to consider generic immunosuppression as an option. A greater understanding of patient perceptions would enhance vital communication between providers and patients to facilitate education and appropriate monitoring. OBJECTIVE To evaluate transplant recipients' perceptions of generic versus brand immunosuppressants based on experience with these agents and the willingness of patients to convert treatment from brand to generic formulations based on socioeconomic variables and baseline demographics. METHODS Key informant interviews were conducted to inform the development of the survey instrument. The survey was distributed to solid organ transplant recipients at a large, academic medical center from October to December 2010. RESULTS Nine patients participated in key informant interviews. Financial considerations and provider recommendations were the most commonly identified factors to influence perceptions of generic immunosuppressants. A total of 255 patients completed the survey; treatment in 81 (32%) participants had been converted to a generic immunosuppressant. Those currently receiving a generic immunosuppressant expressed higher beliefs of generic and brand equivalency (75% vs 54%, p = 0.006) and an increased willingness to convert treatment to a generic given equivalent cost (51% vs 32%, p = 0.024). African American participants were found to have a decreased belief of generic and brand equivalency compared to other ethnicities (60% vs 75%, p = 0.013). Participants with an annual income of less than $30,000 had higher beliefs of generic and brand equivalency (60% vs 40%, p = 0.0001). Education level and age did not impact beliefs of generic efficacy or willingness to convert therapy. CONCLUSIONS Patient ethnicity, income, and experience with generic immunosuppressants appear to contribute to perceptions of generic immunosuppressants. The prevalence of generic immunosuppressant use supports the importance of communication of this issue between providers and patients.
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Affiliation(s)
- Amanda L Hulbert
- Department of Pharmacy Services, The Ohio State University Medical Center, Columbus, OH, USA
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Sunder-Plassmann G, Reinke P, Rath T, Wiecek A, Nowicki M, Moore R, Lutz J, Gaggl M, Ferkl M. Comparative pharmacokinetic study of two mycophenolate mofetil formulations in stable kidney transplant recipients. Transpl Int 2012; 25:680-6. [PMID: 22500920 PMCID: PMC3528070 DOI: 10.1111/j.1432-2277.2012.01475.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
We compared steady-state pharmacokinetics of mycophenolate mofetil (MMF) - Myfenax(®) (Teva) and CellCept(®) (Roche) - in stable kidney transplant recipients (KTRs). This was an international, multi-centre, randomized, open-label, two-treatment, two-sequence crossover study with a 3-month follow-up. We included KTRs at least 12 months post-transplantation with stable renal graft function for at least 3 months. The maintenance treatment consisted of MMF in combination with tacrolimus with or without steroids. At the end of the two treatment periods, 6-h or 12-h PK studies of mycophenolic acid (MPA) were performed. A total of 43 patients (mean age: 50.7 ± 13.5 years; 19 females, 24 males) were randomized. Estimates of test to reference ratios (90% CIs) were 0.959 (0.899; 1.023) h*μg/ml for AUC((0-tau)) and 0.873 (0.787; 0.968) μg/ml for C(max). Estimates for AUC((0-6h)) were 0.923 (0.865; 0.984) h*μg/ml and 0.985 (0.877; 1.106) μg/ml for C(min). Thus, AUC((0-tau)), AUC((0-6h)), and C(min) of MPA were within the predefined margins. C(max) was somewhat outside of these margins in this set of patients. The numbers and types of adverse events were not different between the two treatments. The steady-state pharmacokinetics of MPA as well as adverse events are comparable for Myfenax(®) and CellCept(®) in tacrolimus-treated stable KTRs.
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Affiliation(s)
- Gere Sunder-Plassmann
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University Vienna, Austria.
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Trofe-Clark J, Gabardi S, McDevitt-Potter L, Alloway RR. Immunosuppression, generic drugs and the FDA. Am J Transplant 2012; 12:792-3; author reply 794. [PMID: 22176626 DOI: 10.1111/j.1600-6143.2011.03875.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Cyclosporine: A Commentary on Brand versus Generic Formulation Exchange. J Transplant 2011; 2011:480642. [PMID: 22174986 PMCID: PMC3235899 DOI: 10.1155/2011/480642] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2011] [Accepted: 09/26/2011] [Indexed: 11/25/2022] Open
Abstract
The evidence for conversion from brand name to generic equivalent cyclosporine is conflicting. Cyclosporine is a narrow therapeutic-range drug for which small variations in exposure may have severe clinical consequences for transplant patients. There is currently a lack of comparative outcome data relating to the pharmacokinetics of the reference formulation, Neoral, and generic formulations in transplant recipients. A major common concern is the potential inability to attain similar trough levels, an issue that can be easily corrected by ongoing therapeutic drug monitoring to ensure that the new steady state falls within an intended target range. Prospective clinical studies investigating the efficacy and safety of generic formulations in both de novo and long-term transplant patients are also awaited. Until further evidence is available on the conversion of transplant patients to or between generic formulations of cyclosporine, any transfer to a different cyclosporine formulation should be undertaken with close supervision. The best available information to date, however, does not support the frequently held but unsubstantiated belief that generic preparations of immunosuppressive drugs are not as effective as brand names or that conversion from brand to generic is associated with significant danger. This paper attempts to initiate a discussion of these issues.
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Ensor CR, Trofe-Clark J, Gabardi S, McDevitt-Potter LM, Shullo MA. Generic Maintenance Immunosuppression in Solid Organ Transplant Recipients. Pharmacotherapy 2011; 31:1111-29. [DOI: 10.1592/phco.31.11.1111] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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