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Glerum PJ, Yamada WM, Neely MN, Burger DM, Maliepaard M, Neef C. Interchangeability of generic drugs for subpopulations: Bioequivalence simulation from a nonparametric PK model of gabapentin generic drugs. Br J Clin Pharmacol 2024; 90:1576-1585. [PMID: 36482842 DOI: 10.1111/bcp.15629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 11/15/2022] [Accepted: 11/21/2022] [Indexed: 12/13/2022] Open
Abstract
Patients are often switched between generic formulations of the same drug, but in some cases generic interchangeability is questioned. For generic drugs to be approved, bioequivalence with the innovator drug should be demonstrated, but evidence of bioequivalence is not required in the intended patient population or relative to other approved generics. AIM We aim to identify pathophysiological pharmacokinetic subpopulations for whom there is a difference in comparative bioavailability compared to a healthy population. METHODS We used simulated exposures from a nonparametric model of multiple generics and the originator gabapentin. Exposure was simulated for virtual populations with pharmacokinetic characteristics beyond those of healthy subjects with regard to rate of absorption, volume of distribution and reduced renal function. Virtual parallel design bioequivalence studies were performed using a random sample of 24 simulated subjects, with standard acceptance criteria. RESULTS Results indicated increased pharmacokinetic variability for patient populations with a lower rate of absorption or a reduced renal function, but no change in the average comparable bioavailability ratio. This increased variability results in a reduced likelihood of demonstrating bioequivalence. Observations were similar for comparisons between all different formulations, as well as between subjects who received the identical formulation in a repeated fashion. No relevant effect was observed for simulations with increased volume of distribution. CONCLUSION Our simulations indicate that the reduced likelihood of demonstrating bioequivalence for subjects with altered pharmacokinetics is not influenced by a formulation switch, nor does the average comparable bioavailability ratio change, therefore these results support generic interchangeability and current approval requirements for generics.
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Affiliation(s)
- Pieter J Glerum
- Medicines Evaluation Board, Utrecht, The Netherlands
- Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Walter M Yamada
- Laboratory of Applied Pharmacokinetics and Bioinformatics, Children's Hospital Los Angeles, University of Southern California, Los Angeles, California, USA
| | - Michael N Neely
- Laboratory of Applied Pharmacokinetics and Bioinformatics, Children's Hospital Los Angeles, University of Southern California, Los Angeles, California, USA
| | - David M Burger
- Department of Pharmacy, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Marc Maliepaard
- Medicines Evaluation Board, Utrecht, The Netherlands
- Department of Pharmacology and Toxicology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Cees Neef
- Department of Clinical Pharmacy and Toxicology, CARIM, Maastricht University, Maastricht, The Netherlands
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Finocchietti M, Marino ML, Rosa AC, Bellini A, Masiero L, Cardillo M, Massari M, Spila Alegiani S, Pierobon S, Ferroni E, Zanforlini M, Leoni O, Ledda S, Garau D, Davoli M, Addis A, Belleudi V. Immunosuppression with Generics in Liver and Kidney Transplantation: A Real-World Evidence Study. Drug Des Devel Ther 2024; 18:53-69. [PMID: 38229916 PMCID: PMC10790661 DOI: 10.2147/dddt.s431121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 12/22/2023] [Indexed: 01/18/2024] Open
Abstract
Purpose This study evaluates the use, benefit-risk profile, and economic impact of generic immunosuppressants (tacrolimus-TAC, cyclosporine-CsA, and mycophenolate-MYC) in kidney and liver transplant recipients compared to brand-name drugs. Patients and Methods A retrospective multicentre observational study, involving four Italian regions, was conducted based on the national transplant Information system and regional healthcare claims data. The analysis focused on incident patients who received kidney and liver transplants between 2013 and 2019 and evaluated the use of generic of CsA, TAC, and MYC during the 30-day period following discharge. For each type of transplant and immunosuppressive agent, the benefit-risk profile of generic vs branded drugs in a two-year window was estimated by multivariate Cox models (HR; 95% CI). Furthermore, the potential cost savings per person associated with one year of treatment using generics were calculated. Results The utilization of generic drugs showed a significant increase; over the study years, the proportion of users among kidney recipients ranged from 14.2% to 40.5% for TAC, from 36.9% to 56.7% for MYC, and from 18.2% to 94.7% for CsA. A great variability in generic uptake for region was found. A comparable risk-benefit profile between generic and branded formulations was shown for all immunosuppressors considered. Choosing generic immunosuppressants during maintenance could result in yearly savings of around 2000 euros per person for each therapy ingredient. Conclusion The study shows an increasing proportion of patients using generic immunosuppressive drugs over time suggesting a growing acceptance of generics within the transplant community and reveals comparable risk-benefit profiles between the generic and branded formulations of TAC, CsA, and MYC. A significant variability in the use of generics immunosuppressive agents was found both at the regional level and among transplant centers and future research should delve into regional prescribing variations.
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Affiliation(s)
- Marco Finocchietti
- Department of Epidemiology, Lazio Regional Health Service-ASL Roma 1, Rome, Italy
| | - Maria Lucia Marino
- Department of Epidemiology, Lazio Regional Health Service-ASL Roma 1, Rome, Italy
| | - Alessandro C Rosa
- Department of Epidemiology, Lazio Regional Health Service-ASL Roma 1, Rome, Italy
| | - Arianna Bellini
- Department of Epidemiology, Lazio Regional Health Service-ASL Roma 1, Rome, Italy
| | - Lucia Masiero
- Italian National Transplant Center, Istituto Superiore di Sanità, Rome, Italy
| | - Massimo Cardillo
- Italian National Transplant Center, Istituto Superiore di Sanità, Rome, Italy
| | - Marco Massari
- National Center for Drug Research and Evaluation, Istituto Superiore Di Sanità, Rome, Italy
| | | | | | | | - Martina Zanforlini
- The innovation and procurement regional company, A.R.I.A. S.p.A.-Lombardy Region, Milan, Italy
| | - Olivia Leoni
- Regional Epidemiological Observatory, Lombardy Region, Milan, Italy
| | - Stefano Ledda
- General Directorate for Health, Sardinia Region, Cagliari, Italy
| | - Donatella Garau
- General Directorate for Health, Sardinia Region, Cagliari, Italy
| | - Marina Davoli
- Department of Epidemiology, Lazio Regional Health Service-ASL Roma 1, Rome, Italy
| | - Antonio Addis
- Department of Epidemiology, Lazio Regional Health Service-ASL Roma 1, Rome, Italy
| | - Valeria Belleudi
- Department of Epidemiology, Lazio Regional Health Service-ASL Roma 1, Rome, Italy
| | - On behalf of CESIT Study Group
- Department of Epidemiology, Lazio Regional Health Service-ASL Roma 1, Rome, Italy
- Italian National Transplant Center, Istituto Superiore di Sanità, Rome, Italy
- National Center for Drug Research and Evaluation, Istituto Superiore Di Sanità, Rome, Italy
- Azienda Zero, Veneto Region, Padua, Italy
- The innovation and procurement regional company, A.R.I.A. S.p.A.-Lombardy Region, Milan, Italy
- Regional Epidemiological Observatory, Lombardy Region, Milan, Italy
- General Directorate for Health, Sardinia Region, Cagliari, Italy
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Raghib MF, Bernitsas E. From Animal Models to Clinical Trials: The Potential of Antimicrobials in Multiple Sclerosis Treatment. Biomedicines 2023; 11:3069. [PMID: 38002068 PMCID: PMC10668955 DOI: 10.3390/biomedicines11113069] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 11/05/2023] [Accepted: 11/14/2023] [Indexed: 11/26/2023] Open
Abstract
Multiple sclerosis (MS) is a chronic, autoimmune, demyelinating disease of the central nervous system (CNS). Microbes, including bacteria and certain viruses, particularly Epstein-Barr virus (EBV), have been linked to the pathogenesis of MS. While there is currently no cure for MS, antibiotics and antivirals have been studied as potential treatment options due to their immunomodulatory ability that results in the regulation of the immune process. The current issue addressed in this systematic review is the effect of antimicrobials, including antibiotics, antivirals, and antiparasitic agents in animals and humans. We performed a comprehensive search of PubMed, Google Scholar, and Scopus for articles on antimicrobials in experimental autoimmune encephalomyelitis animal models of MS, as well as in people with MS (pwMS). In animal models, antibiotics tested included beta-lactams, minocycline, rapamycin, macrolides, and doxycycline. Antivirals included acyclovir, valacyclovir, and ganciclovir. Hydroxychloroquine was the only antiparasitic that was tested. In pwMS, we identified a total of 24 studies, 17 of them relevant to antibiotics, 6 to antivirals, and 1 relevant to antiparasitic hydroxychloroquine. While the effect of antimicrobials in animal models was promising, only minocycline and hydroxychloroquine improved outcome measures in pwMS. No favorable effect of the antivirals in humans has been observed yet. The number and size of clinical trials testing antimicrobials have been limited. Large, multicenter, well-designed studies are needed to further evaluate the effect of antimicrobials in MS.
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Affiliation(s)
- Muhammad Faraz Raghib
- Department of Neurology, Wayne State University School of Medicine, Detroit, MI 48201, USA;
| | - Evanthia Bernitsas
- Department of Neurology, Wayne State University School of Medicine, Detroit, MI 48201, USA;
- Sastry Neuroimaging Laboratory, Department of Neurology, Wayne State University School of Medicine, Detroit, MI 48201, USA
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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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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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Gantar K, Škerget K, Mochkin I, Bajc A. Meeting Regulatory Requirements for Drugs with a Narrow Therapeutic Index: Bioequivalence Studies of Generic Once-Daily Tacrolimus. Drug Healthc Patient Saf 2020; 12:151-160. [PMID: 32982466 PMCID: PMC7489937 DOI: 10.2147/dhps.s256455] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 08/15/2020] [Indexed: 12/21/2022] Open
Abstract
Despite growing clinical confidence in generics and their potential to reduce long-term healthcare costs, the transplant community have had real concerns about the use of generic immunosuppressants. One such immunosuppressant is tacrolimus, a cornerstone of lifelong treatment for patients who have undergone a solid organ transplant. Tacrolimus has a narrow therapeutic index (NTI), giving rise to questions about the potential for clinically relevant altered drug exposure. Its use in transplant patients also gives rise to questions about the most discriminative subject population for bioequivalence studies. The recognised need for stringent criteria to support approval of generic drugs with an NTI led the European Medicines Association and Health Canada to provide detailed information on requirements for bioequivalence studies and introduce tighter bioequivalence limits for these drugs, including tacrolimus. The aim of this article is to illustrate how regulatory guidance is implemented during the clinical development of generic immunosuppressants, using a generic, once-daily prolonged-release formulation of tacrolimus as an example.
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Affiliation(s)
- Kaja Gantar
- Sandoz Development Center Slovenia, Lek Pharmaceuticals d.d, Ljubljana1526, Slovenia
| | - Katja Škerget
- Sandoz Development Center Slovenia, Lek Pharmaceuticals d.d, Ljubljana1526, Slovenia
| | - Ilya Mochkin
- Sandoz International GmbH, Holzkirchen83607, Germany
| | - Aleksander Bajc
- Sandoz Development Center Slovenia, Lek Pharmaceuticals d.d, Ljubljana1526, Slovenia
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Chen L, Li C, Huo N, Mishuk AU, Hansen RA, Harris I, Kiptanui Z, Qian J. Oral generic tacrolimus initiation and substitution in the Medicaid population: a new user cohort study. Curr Med Res Opin 2020; 36:1533-1540. [PMID: 32644886 DOI: 10.1080/03007995.2020.1793750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Although existing studies have compared clinical efficacy and pharmacokinetics of generic with brand tacrolimus, little is known about generic tacrolimus utilization patterns or factors predicting generic substitution. This study examines associations between patient-level factors and generic tacrolimus initiation or substitution among new users of oral generic or brand-name tacrolimus. METHODS This new user retrospective cohort study identified 374 beneficiaries who initiated generic or brand tacrolimus treatment, using 100% Medicaid administrative claims data from 11 states in 2011-2012. Outcomes were generic tacrolimus initiation and substitution within 12 months of treatment initiation. Multivariable logistic regression and Cox proportional hazards models were used to identify factors associated with generic tacrolimus initiation and substitution. RESULTS Two-thirds of oral tacrolimus new users initiated generic tacrolimus. Patients who were older age and black were significantly more likely to initiate generic tacrolimus (adjusted odds ratio [AOR] = 1.02, 95% confidence interval [CI] = 1.001-1.03; AOR = 2.54, 95% CI = 1.40-4.62; respectively). Patients with more concomitant prescriptions, more comorbidities, or higher initial daily dosage had significantly lower likelihoods of initiating generic tacrolimus (AOR = 0.93, 95% CI = 0.87-0.99; AOR = 0.87, 95% CI = 0.77-0.99; AOR = 0.96, 95% CI = 0.93-0.993). Among brand tacrolimus new users, 23.6% substituted with generics within 12 months, and an addition of prior hospitalization or unit of initial daily dosage increment was associated with 35% (subdistribution hazard ratio [SHR] = 1.35, 95% CI = 1.02-1.76) or 2% (SHR = 1.02, 95% CI = 1.00-1.04) increase in likelihood of generic substitution, respectively. CONCLUSIONS Understanding associations between patient-level factors with generic tacrolimus initiation and substitution could help practitioners and policymakers monitor treatment effect and facilitate generic tacrolimus utilization.
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Affiliation(s)
- Li Chen
- Department of Medicine, Center for Computational Biology and Bioinformatics, Indiana University, Indianapolis, IN, USA
| | - Chao Li
- Department of Health Outcomes Research and Policy, Auburn University, Auburn, AL, USA
| | - Nan Huo
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Ahmed Ullah Mishuk
- Department of Health Outcomes Research and Policy, Auburn University, Auburn, AL, USA
| | - Richard A Hansen
- Department of Health Outcomes Research and Policy, Auburn University, Auburn, AL, USA
| | | | | | - Jingjing Qian
- Department of Health Outcomes Research and Policy, Auburn University, Auburn, AL, USA
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8
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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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Kim JM, Joh JW, Choi GS, Lee SK. Generic Tacrolimus (Tacrobell ®) Shows Comparable Outcomes to Brand-Name Tacrolimus in the Long-Term Period After Adult Deceased Donor Liver Transplantation. DRUG DESIGN DEVELOPMENT AND THERAPY 2019; 13:4431-4438. [PMID: 32021085 PMCID: PMC6948198 DOI: 10.2147/dddt.s229114] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 12/02/2019] [Indexed: 12/17/2022]
Abstract
Background Generic tacrolimus (Tacrobell®) is commonly used in liver transplant patients in Korea. No previous studies have assessed the long-term efficacy and safety of generic tacrolimus for adult deceased donor liver transplantation (DDLT) patients. The aim of the present study was to evaluate the long-term efficacy and safety of generic tacrolimus compared to brand-name tacrolimus (Prograf®) in adult DDLT recipients. Methods Two hundred sixty-five adult DDLTs were performed in our center between 2003 and 2017. To determine the efficacy and safety of generic tacrolimus, renal function (estimated glomerular filtration rate [eGFR] and creatinine), infectious complications, rejection-free survival rates, and patient survival rates were investigated. Results Of 265 patients, 193 were selected and divided into a generic tacrolimus group (n=147) and a brand-name group (n=46). Mean follow-up duration was 63.2 ± 44.3 months. The 1-year, 3-year, 5-year, and 10-year patient survival rates were 89.1%, 86.9%, 84.5%, and 75.2%, respectively, in the generic tacrolimus group and 95.7%, 88.9%, 86.3%, and 83.7% in the brand-name tacrolimus group. There were no statistically significant differences in the infectious complications, new-onset diabetes, and renal dysfunction included mean serum creatinine level or eGFR after DDLT between the two groups. Increased recipient age, continuous renal replacement therapy (CRRT) in the pre-transplant phase, and acute rejection were predisposing factors for patient death. Conclusion The present study shows that generic tacrolimus is an alternative comparable to brand-name tacrolimus in adult DDLT patients.
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Affiliation(s)
- Jong Man Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jae-Won Joh
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Gyu-Seong Choi
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Suk-Koo Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Generics in transplantation medicine: Randomized comparison of innovator and substitution products containing mycophenolate mofetil
. Int J Clin Pharmacol Ther 2019; 57:506-519. [PMID: 31397274 PMCID: PMC6751510 DOI: 10.5414/cp203487] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2019] [Indexed: 12/05/2022] Open
Abstract
Objective: Mycophenolate mofetil (MMF) is widely used as an immunosuppressant for the prophylaxis of acute organ rejection in recipients of solid organ transplants. Materials and methods: We have compared, in healthy subjects, the pharmacokinetics of mycophenolic acid when MMF was administered in the form of the innovator product CellCept (F. Hoffmann-La Roche Ltd.) or one of three commercially available generics, Renodapt (Biocon Ltd.), Mycept (Panacea Biotec), or Cellmune (Cipla Ltd.). The study was powered to detect a 20% difference in mean formulation performance measures, but not to formally evaluate bioequivalence. Geometric mean ratios of maximum concentrations (Cmax) and areas under plasma concentration-time curves were calculated. Results: Comparing generics against each other, the differences in point estimates of the geometric mean ratios of Cmax of two of the comparisons were either borderline within (Renodapt/Cellmune) or clearly outside (Mycept/Cellmune) a region of 80 – 125% around the reference mean, indicating that bioequivalence between these generics may be difficult to show. Conclusion: Physicians in the field of transplantation should be aware of the potential risk of altering the therapeutic outcome when switching from one preparation of MMF to another. ClinicalTrials.gov identifier: NCT02981290.
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12
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Therapeutic Drug Monitoring of Tacrolimus-Personalized Therapy: Second Consensus Report. Ther Drug Monit 2019; 41:261-307. [DOI: 10.1097/ftd.0000000000000640] [Citation(s) in RCA: 227] [Impact Index Per Article: 45.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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13
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Brunet M, van Gelder T, Åsberg A, Haufroid V, Hesselink DA, Langman L, Lemaitre F, Marquet P, Seger C, Shipkova M, Vinks A, Wallemacq P, Wieland E, Woillard JB, Barten MJ, Budde K, Colom H, Dieterlen MT, Elens L, Johnson-Davis KL, Kunicki PK, MacPhee I, Masuda S, Mathew BS, Millán O, Mizuno T, Moes DJAR, Monchaud C, Noceti O, Pawinski T, Picard N, van Schaik R, Sommerer C, Vethe NT, de Winter B, Christians U, Bergan S. Therapeutic Drug Monitoring of Tacrolimus-Personalized Therapy: Second Consensus Report. Ther Drug Monit 2019. [DOI: 10.1097/ftd.0000000000000640
expr 845143713 + 809233716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
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Critical Appraisal of International Clinical Practice Guidelines in Kidney Transplantation Using the Appraisal of Guidelines for Research and Education II Tool: A Systematic Review. Transplantation 2019; 102:1419-1439. [PMID: 30124634 DOI: 10.1097/tp.0000000000002255] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Although clinical practice guidelines (CPGs) are used for the development of local protocols in kidney transplantation (Ktx), the quality of their methodology is variable. This systematic review aimed to critically appraise international CPGs in all aspects of Ktx using the Appraisal of Guidelines for Research and Evaluation II tool. METHODS Clinical Practice Guidelines in Ktx and donation published between 2010 and 2017 were identified from MEDLINE, Embase, National Guideline Clearinghouse, National Health Service and National Institute for Health and Care Excellence Evidence Searches, and the websites of transplant societies. Using Appraisal of Guidelines for Research and Evaluation II, 3 appraisers assessed the quality of CPGs. Interrater reliability was measured using the intraclass correlation coefficient (ICC). RESULTS Searches identified 3168 records, and 115 CPGs were included. The highest scoring Appraisal of Guidelines for Research and Evaluation II domain was "scope and purpose" (80%; range, 30%-100%), followed by "clarity of presentation" (77%; range, 43%-98%), "editorial independence" (52%; range, 0%-94%), "rigor of development" (47%; range 6%-97%) and "stakeholder involvement" (41%; range, 11%-85%). The poorest scoring domain was "applicability" (31%; range, 3%-74%). Most CPGs were recommended for future use either with (63%) or without (18%) modifications. A small number (14%) were not recommended for future use or reviewers (5%) did not agree on recommending the CPG. The overall mean CPG quality score was 4 of 7 (range, 2-7). The mean ICC of 0.74 indicated substantial agreement between reviewers. CONCLUSIONS The quality of international CPGs in Ktx was variable, and most CPGs lacked key aspects of methodological robustness and transparency. Improvements in methodology, patient involvement, and strategies for implementation are required.
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Fung SKS, Chau KF, Chow KM. Clinical practice guidelines for the provision of renal service in Hong Kong: Potential Kidney Transplant Recipient Wait-listing and Evaluation, Deceased Kidney Donor Evaluation, and Kidney Transplant Postoperative Care. Nephrology (Carlton) 2019; 24 Suppl 1:60-76. [PMID: 30900332 DOI: 10.1111/nep.13502] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
| | - Ka Foon Chau
- Department of Medicine, Queen Elizabeth Hospital, Hong Kong
| | - Kai Ming Chow
- Department of Medicine & Therapeutics, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong
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16
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Medeiros M, Lumini J, Stern N, Castañeda-Hernández G, Filler G. Generic immunosuppressants. Pediatr Nephrol 2018; 33:1123-1131. [PMID: 28733752 DOI: 10.1007/s00467-017-3735-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 06/20/2017] [Indexed: 11/24/2022]
Abstract
Immunosuppressive drugs for solid organ transplantation are critical dose drugs with a narrow therapeutic index. Many of the most commonly used innovator drugs are off patent and have been replicated by generic counterparts, often at substantial cost-savings to the patient. However, serious adverse events caused by the transition from innovator to generic medications, specifically in pediatric solid organ transplant recipients, have questioned these autosubstitutions. The purpose of this review is to summarize the criteria set forth by the regulatory bodies, and to examine how major immunosuppressive drugs conform to these recommendations. Regulatory bodies have established inconsistent criteria to demonstrate bioequivalence between innovator and generic medications, causing approved generic variations to have varying levels of equivalence with the innovator drugs. In order to minimize the risk for under-immunosuppression, the following recommendations have been concluded. Brand prescribing of cyclosporine and tacrolimus are recommended due to evidence of adverse events after conversion to generic formulations and differences in dissolution parameters. Mycophenolate mofetil (MMF) shows better bioequivalence between innovator and generic formulations, however caution should be advised when switching between formulations. The institution of 'innovator only' policies may be appropriate at this time in order to minimize the risk of under-immunosuppressing patients until the evidence of more stringent bioequivalence has been established.
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Affiliation(s)
- Mara Medeiros
- Unidad de Investigacion en Nefrologia, Hospital Infantil de Mexico Federico Gomez, Mexico City, Mexico.,Departamento de Farmacología, Facultad de Medicina, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Julia Lumini
- Department of Biomedical Life Sciences, University of Waterloo, Waterloo, ON, N2L 3G1, Canada
| | - Noah Stern
- Department of Paediatrics, Schulich School of Medicine & Dentistry, University of Western Ontario, London, ON, N6A 5W9, Canada
| | | | - Guido Filler
- Department of Paediatrics, Schulich School of Medicine & Dentistry, University of Western Ontario, London, ON, N6A 5W9, Canada. .,Department of Medicine, Schulich School of Medicine & Dentistry, University of Western Ontario, London, ON, N6A 5W9, Canada. .,Department of Pathology and Laboratory Medicine, Schulich School of Medicine & Dentistry, University of Western Ontario, London, ON, N5A 5A5, Canada. .,Paediatric Nephrology, University of Western Ontario, Children's Hospital, London Health Science Centre, 800 Commissioners Road East, London, ON, N6A 5W9, Canada.
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Buligan C, Pinzani C, Cimarosti R, Stinco G, Baraldo M. Comparison of clinical effects, trough and peak levels between branded and generic formulation of Cyclosporine in stable psoriatic patients. GIORN ITAL DERMAT V 2018; 155:452-458. [PMID: 29582618 DOI: 10.23736/s0392-0488.18.05860-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Cyclosporine A (CyA) is a drug for moderate-to-severe psoriasis. Recently, a generic formulation has been approved as bioequivalent to the branded one. The guidelines for the bioequivalence for critical-dose drugs with a narrow therapeutic range, such as CyA, are questionable. Therefore, it is important to assess the clinical outcome and the pharmacokinetics of different formulations in various patient groups. The current literature lacks of this information in dermatology. The primary objective of this prospective study is to investigate the clinical equivalence (in terms of maintenance of clinical effect) between the generic formulation of CyA and its branded one in patients with psoriasis. A secondary objective is to analyze their trough (C<inf>0</inf>) and peak levels (C<inf>2</inf>). METHODS Twenty patients with stable psoriasis under treatment with the branded CyA were monitored in terms of clinical efficacy (psoriasis area severity index, PASI), safety (laboratory values), and their pharmacokinetics utilizing trough (C<inf>0</inf>) and peak plasma concentration (C<inf>2</inf>). The same patients were subsequently shifted to the generic formulation for comparison. RESULTS In our sample the efficacy of the two formulations was equal in most cases (P=0.863). A non-significant difference between the C<inf>0</inf> and C<inf>2</inf> of the branded CyA compared to the generic one emerged (respectively P=0.738 and P=0.695). CONCLUSIONS The branded and the generic formulations of CyA seem to be not only bioequivalent, but also comparable in terms of clinical efficacy in patients with psoriasis. However, larger samples are required to confirm these findings.
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Affiliation(s)
- Cinzia Buligan
- Department of Medical Area, Institute of Dermatology, Santa Maria della Misericordia University Hospital, University of Udine, Udine, Italy -
| | - Caterina Pinzani
- Department of Medical Area, Institute of Dermatology, University of Udine, Udine, Italy
| | - Rossella Cimarosti
- Department of Medical Area, Institute of Hygiene and Clinical Epidemiology, University of Udine, Udine, Italy
| | - Giuseppe Stinco
- Department of Medical Area, Institute of Dermatology, University of Udine, Udine, Italy
| | - Massimo Baraldo
- Department of Medical Area, Institute of Clinical Pharmacology, University of Udine, Udine, Italy
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18
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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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20
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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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21
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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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Tremblay S, Alloway RR. Clinical Evaluation of Modified Release and Immediate Release Tacrolimus Formulations. AAPS JOURNAL 2017; 19:1332-1347. [PMID: 28717926 DOI: 10.1208/s12248-017-0119-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 06/27/2017] [Indexed: 12/21/2022]
Abstract
The science of drug delivery has evolved considerably and has led to the development of multiple sustained release formulations. Each of these formulations can present particular challenges in terms of clinical evaluation and necessitate careful study to identify their optimal use in practice. Tacrolimus is an immunosuppressive agent that is widely used in organ transplant recipients. However, it is poorly soluble, has an unpredictable pharmacokinetic profile subject to important genetic polymorphisms and drug-drug interactions, and has a narrow therapeutic index. For these reasons, it represents an agent that could benefit from modified release formulations to overcome these limitations. The objective of this review is to discuss the clinical evaluation of immediate and modified release tacrolimus formulations in renal transplant recipients. Clinical trials from early development of immediate release tacrolimus to formulation-specific post-marketing trials of modified release tacrolimus formulations are reviewed with an emphasis on key elements relating to trial design end endpoint assessment. Particular elements that can be addressed with formulation alterations, such as pharmacokinetics, pharmacogenomics, and toxicity and corresponding clinical evaluations are discussed. In addition, current knowledge gaps in the clinical evaluation of immediate and modified release tacrolimus formulations are discussed to highlight potential avenues for the future development of different tacrolimus formulations with outcomes relevant to the regulators, the transplant community, and to transplant recipients. This review shows that new formulations may alter tacrolimus bioavailability, alleviate certain adverse events while potentially enhancing patient convenience.
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Affiliation(s)
- Simon Tremblay
- Department of Surgery, Division of Transplantation, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML0519, Cincinnati, OH, 45267, USA. .,Department of Environmental Health, Division of Epidemiology, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML0519, Cincinnati, OH, 45267, USA.
| | - Rita R Alloway
- Department of Internal Medicine, Division of Nephrology, Kidney C.A.R.E Program, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Ericson JE, Zimmerman KO, Gonzalez D, Melloni C, Guptill JT, Hill KD, Wu H, Cohen-Wolkowiez M. A Systematic Literature Review Approach to Estimate the Therapeutic Index of Selected Immunosuppressant Drugs After Renal Transplantation. Ther Drug Monit 2017; 39:13-20. [PMID: 28081041 PMCID: PMC5235278 DOI: 10.1097/ftd.0000000000000364] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Drugs that exhibit close margins between therapeutic and toxic blood concentrations are considered to have a narrow therapeutic index (NTI). The Food and Drug Administration has proposed that NTI drugs should have more stringent bioequivalence standards for approval of generic formulations. However, many immunosuppressant drugs do not have a well-defined therapeutic index (TI). METHODS We sought to determine whether safety, efficacy, and pharmacokinetic data obtained from the medical literature through a comprehensive literature search could be used to estimate the TI of cyclosporine, tacrolimus, and sirolimus. In this analysis, we considered TI ≤2 as a criterion to define a drug as having an NTI. RESULTS Published literature indicates that cyclosporine has a TI of 2-3, which falls just short of our criteria to be classified as having an NTI. We found sirolimus and tacrolimus to have a therapeutic range of 5-12 ng/mL and of 5-20 ng/mL, respectively, but were unable to calculate the TI. CONCLUSIONS Although the current literature does not provide a clear indication that these drugs have an NTI, the routine use of therapeutic drug monitoring in clinical practice suggests that more stringent testing of their pharmacokinetic and pharmacodynamic properties should be performed before the approval of generic formulations.
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Affiliation(s)
- Jessica E. Ericson
- Departments of Pediatrics, Pennsylvania State University, Hershey, PA
- Duke Clinical Research Institute, Durham, NC
| | - Kanecia O. Zimmerman
- Duke Clinical Research Institute, Durham, NC
- Department of Pediatrics, Duke University, Durham, NC
| | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, USA
| | | | | | - Kevin D. Hill
- Duke Clinical Research Institute, Durham, NC
- Department of Pediatrics, Duke University, Durham, NC
| | - Huali Wu
- Duke Clinical Research Institute, Durham, NC
| | - Michael Cohen-Wolkowiez
- Duke Clinical Research Institute, Durham, NC
- Department of Pediatrics, Duke University, Durham, NC
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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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Bamoulid J, Staeck O, Halleck F, Khadzhynov D, Paliege A, Brakemeier S, Dürr M, Budde K. Immunosuppression and Results in Renal Transplantation. ACTA ACUST UNITED AC 2016. [DOI: 10.1016/j.eursup.2016.04.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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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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Affiliation(s)
- Gitanjali P Mansukhani
- Pediatric Cardiology, Stollery Children's Hospital, University of Alberta, Edmonton, AB, Canada
| | - Jennifer Conway
- Pediatric Cardiology, Stollery Children's Hospital, University of Alberta, Edmonton, AB, Canada.
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Bamoulid J, Staeck O, Halleck F, Dürr M, Paliege A, Lachmann N, Brakemeier S, Liefeldt L, Budde K. Advances in pharmacotherapy to treat kidney transplant rejection. Expert Opin Pharmacother 2015; 16:1627-48. [PMID: 26159444 DOI: 10.1517/14656566.2015.1056734] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Current immunosuppressive combination therapy provides excellent prevention of T-cell-mediated rejection following renal transplantation; however, antibody-mediated rejection remains of high concern and accounts for a large number of long-term allograft losses. The recent development of protocol biopsies resulted in the definition of subclinical rejection (SCR), showing histologic evidence for rejection but unremarkable clinical course. AREAS COVERED This review describes the current knowledge and evidence of pharmacotherapy to treat kidney allograft rejections and covers SCR treatment options. Each substance is analyzed with regard to its classical indication and further discussed for the treatment of other forms of rejection. EXPERT OPINION Despite a lack of randomized trials, early acute T-cell-mediated rejection can be treated effectively in most cases without graft loss. The necessity to treat SCR is currently unclear. Due to a lack of effective therapies, new treatment approaches for antibody-mediated rejection are an urgent medical need to improve long-term outcomes. Future research should aim to better define pathophysiology and histology, stratify risk, and develop rational treatment strategies from randomized controlled trials, in order to establish the value of novel therapies in the arsenal of rejection pharmacotherapy. However, the effective prevention of rejection with minimal side effects still remains the goal in immunosuppression.
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Affiliation(s)
- Jamal Bamoulid
- Charité Universitätsmedizin Berlin, Department of Nephrology , Berlin , Germany +49 30 450 514002 ; +49 30 450 514902 ;
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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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Agüera ML, Martin-Malo A, Alvarez-Lara MA, Garcia-Montemayor VE, Canton P, Soriano S, Aljama P. Efficiency of Original versus Generic Intravenous Iron Formulations in Patients on Haemodialysis. PLoS One 2015; 10:e0135967. [PMID: 26322790 PMCID: PMC4555833 DOI: 10.1371/journal.pone.0135967] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2015] [Accepted: 07/28/2015] [Indexed: 01/04/2023] Open
Abstract
AIMS The appropriate use of intravenous (i.v.) iron is essential to minimise the requirements for erythropoiesis-stimulating agents (ESAs). The clinical efficacy of generic i.v. iron compared to the original formulation is controversial. We evaluated the changes that were induced after switching from a generic i.v. iron to an original formulation in a stable, prevalent haemodialysis (HD) population. METHODS A total of 342 patients were included, and the follow-up period was 56 weeks for each formulation. Anaemia parameters and doses of ESA and i.v. iron were prospectively recorded before and after the switch from generic to original i.v. iron. RESULTS To maintain the same haemoglobin (Hb) levels after switching from the generic to the original formulation, the requirements for i.v. iron doses were reduced by 34.3% (from 52.8±33.9 to 34.7±31.8 mg/week, p<0.001), and the ESA doses were also decreased by 12.5% (from 30.6±23.6 to 27±21 μg/week, p<0.001). The erythropoietin resistance index declined from 8.4±7.7 to 7.4±6.7 IU/kg/week/g/dl after the switch from the generic to the original drug (p = 0.001). After the switch, the transferrin saturation ratio (TSAT) and serum ferritin levels rose by 6.8% (p<0.001) and 12.4% (p = 0.001), respectively. The mortality rate was similar for both periods. CONCLUSIONS The iron and ESA requirements are lower with the original i.v. iron compared to the generic drug. In addition, the uses of the original formulation results in higher ferritin and TSAT levels despite the lower dose of i.v. iron. Further studies are necessary to analyse the adverse effects of higher i.v. iron dosages.
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Affiliation(s)
- Maria Luisa Agüera
- Servicio de Nefrología. Hospital Universitario Reina Sofía, Córdoba, Spain; Instituto Maimónides de investigación biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Córdoba, Spain; RedInRen, Instituto de salud Carlos III, Spain
- * E-mail:
| | - Alejandro Martin-Malo
- Servicio de Nefrología. Hospital Universitario Reina Sofía, Córdoba, Spain; Instituto Maimónides de investigación biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Córdoba, Spain; RedInRen, Instituto de salud Carlos III, Spain
| | - Maria Antonia Alvarez-Lara
- Servicio de Nefrología. Hospital Universitario Reina Sofía, Córdoba, Spain; Instituto Maimónides de investigación biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Córdoba, Spain; RedInRen, Instituto de salud Carlos III, Spain
| | | | | | - Sagrario Soriano
- Servicio de Nefrología. Hospital Universitario Reina Sofía, Córdoba, Spain; Instituto Maimónides de investigación biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Córdoba, Spain; RedInRen, Instituto de salud Carlos III, Spain
| | - Pedro Aljama
- Servicio de Nefrología. Hospital Universitario Reina Sofía, Córdoba, Spain; Instituto Maimónides de investigación biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Córdoba, Spain; RedInRen, Instituto de salud Carlos III, Spain
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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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The Effect of Tacrolimus on Reactive Oxygen Species and Total Antioxidant Status in Pancreatic Beta Cell Line. EXP CLIN TRANSPLANT 2015; 13:300. [PMID: 26086839 DOI: 10.6002/ect.2014.0028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Yu Y, Teerenstra S, Neef C, Burger D, Maliepaard M. Investigation into the interchangeability of generic formulations using immunosuppressants and a broad selection of medicines. Eur J Clin Pharmacol 2015; 71:979-90. [PMID: 26062932 PMCID: PMC4500859 DOI: 10.1007/s00228-015-1878-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 05/25/2015] [Indexed: 11/08/2022]
Abstract
Purpose To date, the interchangeability of generic drugs has only been investigated for a limited number of medicines. The objective of this study was to investigate generic-generic drug interchangeability in a large subset of generic formulations in order to cover a broad spectrum of drugs. Methods Orally administered drugs for investigation in this study were selected using strict, predefined criteria, with the purpose to avoid bias. This selection procedure yielded atorvastatin, bicalutamide, naratriptan, olanzapine, perindopril, and venlafaxine. Further, ciclosporin, tacrolimus, and mycophenolate mofetil were investigated as test immunosuppressants. Adjusted indirect comparisons were conducted between generic drugs containing the same active substance, and the 90 % confidence interval (CI) for AUC and Cmax was calculated. Results In total, 120 bioequivalence studies were identified in the Dutch medicine regulatory agency’s database, allowing 292 indirect comparisons between generic drugs. The indirect comparison results indicated that in the vast majority of cases, i.e., 80.5 %, the 90 % CIs for both AUCt and Cmax fell within the bioequivalence criteria (in 90.1 and 87.0 % for AUCt and Cmax, respectively). In 1 % of the 292 indirect comparison for AUCt and 3 % for Cmax, a wider range of 75–133 % (or 80–125 %) was exceeded. Conclusions Overall, our study suggests that exposure-related risks associated with the exchange of different generic drugs in clinical practice are not increased to a relevant extent compared to the situation in which a generic is exchanged with the innovator. Electronic supplementary material The online version of this article (doi:10.1007/s00228-015-1878-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yang Yu
- Department of Pharmacology and Toxicology, CARIM, Maastricht University Medical Centre, Maastricht, The Netherlands,
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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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von Knethen A, Sha LK, Knape T, Kuchler L, Giegerich AK, Schulz M, Hauser IA, Brüne B. Activation of the peroxisome proliferator-activated receptor γ counteracts sepsis-induced T cell cytotoxicity toward alloantigenic target cells. J Mol Med (Berl) 2015; 93:633-44. [PMID: 25559266 DOI: 10.1007/s00109-014-1249-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Revised: 12/04/2014] [Accepted: 12/22/2014] [Indexed: 01/14/2023]
Abstract
UNLABELLED Sepsis still emerges as a major cause of patient death in intensive care units. Therefore, new therapeutic approaches are mandatory. Because during sepsis progression cytotoxic T lymphocytes (CTLs) can be activated in an autoimmune fashion contributing to multiorgan damage, it remains unclear whether CTLs are activated toward alloantigenic cells. This is important for patients receiving an immunosuppressive therapy to permit organ transplantation and, thus, known to be at high risk for developing sepsis. Therefore, we analyzed whether sepsis activates CTL toward alloantigenic target cells and whether this can be inhibited by PPARγ activation, known to block T helper cell responses. To mimic septic conditions, CTLs were isolated from cecal ligation and puncture-operated mice. CTL cytotoxicity was analyzed following a direct alloantigenic activation regime or following classical ex vivo splenocyte-driven activation in a cytotoxicity assay. With this readout, we found that CTL derived from septic mice enhanced cytotoxicity toward alloantigenic target cells, which was lowered by in vivo and ex vivo PPARγ activation. With CTL derived from T cell-specific PPARγ knockout mice, PPARγ activation was ineffective, pointing to a PPARγ-dependent mechanism. In vivo and ex vivo PPARγ activation reduced Fas and granzyme B expression in activated CTL. KEY MESSAGE In the sepsis CLP mouse model, CTLs are activated toward alloantigenic target cells. Sepsis-mediated alloantigenic CTL activation is blocked in vivo by PPARγ activation. PPARγ deletion or antagonization restored rosiglitazone-dependent inhibition of CTL cytotoxicity. PPARγ inhibits the expression of Fas and granzyme B in CTLs.
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Affiliation(s)
- Andreas von Knethen
- Institute of Biochemistry I-Pathobiochemistry, Faculty of Medicine, Goethe-University Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany,
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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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Therapeutic monitoring of pediatric renal transplant patients with conversion to generic cyclosporin. Int J Clin Pharm 2014; 36:779-86. [DOI: 10.1007/s11096-014-9959-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2013] [Accepted: 05/10/2014] [Indexed: 11/26/2022]
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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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Kim JM, Kwon CHD, Yun IJ, Lee KW, Yu HC, Suh KS, Joh JW, Cho BH. A multicenter experience with generic mycophenolate mofetil conversion in stable liver transplant recipients. Ann Surg Treat Res 2014; 86:192-8. [PMID: 24783178 PMCID: PMC3996716 DOI: 10.4174/astr.2014.86.4.192] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Revised: 12/02/2013] [Accepted: 12/04/2013] [Indexed: 11/30/2022] Open
Abstract
Purpose Generic substitution of brand-name medications can lead to significant cost savings and is an accepted medical practice. This study evaluated clinical and safety outcomes among liver transplant recipients whose mycophenolate mofetil (MMF) was converted from the brand-name formulation (Cellcept) to a generic formulation (My-rept). Methods Clinical data from multiple centers were prospectively collected for determination of complications, safety, and quality of life after in 154 clinically stable, adult liver transplant recipients whose MMF was converted to a generic formulation between April 2010 and September 2012. This protocol was approved by Institutional Review Boards of all involved sites. Results In eight patients (5.19%), nine instances of drug-related complications occurred after medication conversion. Half of these complications were gastrointestinal disorders (n = 4), and most (7 of 9) were mild. No significant differences were noted in mean pre- and postconversion gastrointestinal symptoms via a rating system (8.9 vs. 10.4) or gastrointestinal quality-of-life index scores (125.6 vs. 123.1). More than 90% of patients reported a status of "about the same" when questioned about the brand-name and generic formulation using the Patient Overall Treatment Effect and Investigator Overall Treatment Effect measures. The incidence of serious adverse events was 5.8%. Acute rejection occurred in two patients, with no graft loss or death. Conclusion Clinical experience as well as research data showed that generic MMF was comparable in efficacy to the brand-name drug. Given the lack of adverse events and the safety findings, conversion from brand-name MMF to generic MMF should be encouraged.
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Affiliation(s)
- Jong Man Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Choon Hyuck David Kwon
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ik Jin Yun
- Department of Surgery, Konkuk University School of Medicine, Seoul, Korea
| | - Kwang-Woong Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Hee Chul Yu
- Department of Surgery, Chonbuk National University Medical School, Jeonju, Korea
| | - Kyung-Suk Suh
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jae-Won Joh
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Baik Hwan Cho
- Department of Surgery, Chonbuk National University Medical School, Jeonju, Korea
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Kraeuter M, Helmschrott M, Erbel C, Gleissner CA, Frankenstein L, Schmack B, Ruhparwar A, Ehlermann P, Katus HA, Doesch AO. Conversion to generic cyclosporine A in stable chronic patients after heart transplantation. DRUG DESIGN DEVELOPMENT AND THERAPY 2013; 7:1421-6. [PMID: 24348018 PMCID: PMC3849002 DOI: 10.2147/dddt.s54245] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background Cyclosporine A (CSA) is a narrow therapeutic index drug. Available CSA products differ in the constitution of their emulsion. To compare intra-individual differences after a conversion to a generic CSA, a retrospective single-center study was initiated. Methods Twenty adult stable chronic (>24 months post heart transplant) recipients were included in the present retrospective study. These patients were previously switched from Sandimmune Neoral® to the generic CSA (Equoral®) according to the patients’ preference during the clinical routine. Dose-normalized trough levels (DNL) and trough levels (C0) at 8 months, 4 months, and 2 weeks before the switch were retrospectively compared with the corresponding values at 2 weeks, 4 months, and 8 months after the switch to the generic CSA. Additionally, changes in the routine laboratory parameters, the number of treated rejection episodes, and the adherence to the CSA target levels were compared. Results The mean DNL (adapted to the daily CSA dose in mg) was 0.71±0.26 (ng/mL)/mg on Neoral therapy; on Equoral it was 0.68±0.23 (ng/mL)/mg, (P=0.38). In comparison to the CSA daily dose prior to the conversion, at postconversion, no significant changes of CSA daily dose were observed (Neoral 140.67±39.81 mg versus Equoral 134.58±41.61 mg; P=0.13). No rejection episodes requiring therapy occurred prior to or postconversion (P=0.99). Additionally, no statistically significant changes of routine laboratory parameters regarding the Modification of Diet in Renal Disease or hematological parameters were seen (all P=not significant). No adverse events after the conversion were observed. Conclusion This study in chronic and stable HTx patients demonstrated no statistically significant differences in the CSA DNL after a conversion to generic CSA (Equoral). The generic CSA was generally well-tolerated. We concluded that a conversion from Neoral to Equoral is safe and clinically feasible in this distinct patient population. However, multiple switches between different generic immunosuppressants must especially be avoided in the interest of patient safety, and close follow-up examinations must be warranted.
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Affiliation(s)
| | | | - Christian Erbel
- Department of Cardiology, University of Heidelberg, Heidelberg, Germany
| | | | - Lutz Frankenstein
- Department of Cardiology, University of Heidelberg, Heidelberg, Germany
| | - Bastian Schmack
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Arjang Ruhparwar
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Philipp Ehlermann
- Department of Cardiology, University of Heidelberg, Heidelberg, Germany
| | - Hugo A Katus
- Department of Cardiology, University of Heidelberg, Heidelberg, Germany
| | - Andreas O Doesch
- Department of Cardiology, University of Heidelberg, Heidelberg, Germany
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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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Zhang AH, Wang XQ, Han WB, Sun Y, Guo Y, Wu Q, Ge HM, Song YC, Ng SW, Xu Q, Tan RX. Discovery of a new class of immunosuppressants from Trichothecium roseum co-inspired by cross-kingdom similarity in innate immunity and pharmacophore motif. Chem Asian J 2013; 8:3101-7. [PMID: 24108442 DOI: 10.1002/asia.201300734] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Revised: 07/19/2013] [Indexed: 11/09/2022]
Abstract
The limited selection of immunosuppressants in the clinic hampers the efficient management of immune disorders such as rejections after organ transplantations. However, the search for new immunosuppressive compounds remains random and creates inevitably financial and laborious wastes. Herein, we present an immunity-inspired discovery strategy that rationally allows an efficient identification of immunosuppressive compounds from the endophyte culture, as exemplified by the new peptide trichomide A. This compound exerts its immunosuppressive action more selectively than cyclosporin A. It was found that trichomide A decreases the expression of Bcl-2, increases the expression of Bax, and has a small or negligible effect on the expressions of p-Akt, CD25, and CD69. Our study strengthens the idea that the cross-kingdom similarity in immunity among living things could provide a shorter route towards the identification of natural products valuable for the development of new immunosuppressants.
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Affiliation(s)
- Ai Hua Zhang
- Institute of Functional Biomolecules, State Key Laboratory of Pharmaceutical Biotechnology, Nanjing University, 22 Hankou Road, Nanjing, 210093 (P. R. China), Fax: (+86) 25-8330 2728
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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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Stock ML, Fiedler KJ, Acharya S, Lange JK, Mlynarczyk GSA, Anderson SJ, McCormack GR, Kanuri SH, Kondru NC, Brewer MT, Carlson SA. Antibiotics acting as neuroprotectants via mechanisms independent of their anti-infective activities. Neuropharmacology 2013; 73:174-82. [PMID: 23748053 DOI: 10.1016/j.neuropharm.2013.04.059] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2013] [Revised: 03/23/2013] [Accepted: 04/26/2013] [Indexed: 12/29/2022]
Abstract
This review considers available evidence that some antibiotics have ancillary neuroprotective effects. Notably, β-lactam antibiotics are believed to increase the expression of glutamate transporter GLT1, potentially relieving the neurological excitotoxicity that characterizes disorders like amyotrophic lateral sclerosis. Minocycline has shown promise in reducing the severity of a number of neurological diseases, including multiple sclerosis, most likely by reducing apoptosis and the expression of inflammatory mediators in the brain. Rapamycin inhibits the activity of a serine/threonine protein kinase that has a role in the pathogenesis of numerous neurologic diseases. Herein we examine the unique neuroprotective aspects of these drugs originally developed as anti-infective agents.
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Affiliation(s)
- Matthew L Stock
- Department of Biomedical Sciences, Iowa State University College of Veterinary Medicine, 2028 VetMed, Ames, IA 50011, USA
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van Gelder T, Gabardi S. Methods, strengths, weaknesses, and limitations of bioequivalence tests with special regard to immunosuppressive drugs. Transpl Int 2013; 26:771-7. [DOI: 10.1111/tri.12074] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2012] [Revised: 11/12/2012] [Accepted: 01/11/2013] [Indexed: 11/29/2022]
Affiliation(s)
- Teun van Gelder
- Departments of Hospital Pharmacy and Internal Medicine; Erasmus Medical Center; CA; Rotterdam; The Netherlands
| | - Steven Gabardi
- Departments of Transplant Surgery and Pharmacy Services, and the Renal Division; Brigham and Women's Hospital; Harvard Medical School; Boston; MA; USA
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Connor A, Prowse A, Newell P, Rowe PA. A single-centre comparison of the clinical outcomes at 6 months of renal transplant recipients administered Adoport ® or Prograf ® preparations of tacrolimus. Clin Kidney J 2012; 6:21-28. [PMID: 27818747 PMCID: PMC5094386 DOI: 10.1093/ckj/sfs154] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2012] [Accepted: 10/03/2012] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The use of generic formulations of immunosuppressive drugs in place of brand name drugs offers considerable cost savings. Brand name tacrolimus (Prograf®) came off patent in April 2008. However, published evidence supporting therapeutic equivalence of generic formulations of tacrolimus in solid organ transplantation is lacking. The South West Transplant Centre switched from administering Prograf® to a generic formulation (Adoport®) for de novo transplant recipients in November 2010. This study sought to compare the clinical outcomes of renal transplant recipients administered Prograf® with those receiving Adoport®. METHODS Data regarding patient characteristics and clinical outcomes were collected retrospectively for all patients undergoing renal transplantation at the South West Transplant Centre between 8 November 2009 and 8 November 2011 to whom tacrolimus was prescribed. RESULTS A total of 48 patients received Prograf® and 51 received Adoport®. At 6 months, no statistically significant differences were identified in the rates of patient survival, graft survival, acute allograft rejection, delayed graft function, calcineurin inhibitor toxicity or cytomegalovirus infection occurring within the two groups. CONCLUSIONS This is the first study to compare the clinical outcomes of patients receiving Adoport® with those receiving brand name tacrolimus. We report comparable clinical outcomes at 6 months in patients receiving either Prograf® or Adoport® from the time of renal transplantation. These early outcome data therefore support the use of Adoport® in place of Prograf® as a potential cost-saving measure.
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Affiliation(s)
- Andrew Connor
- South West Transplant Centre , Derriford Hospital , Plymouth , UK
| | - Andrew Prowse
- South West Transplant Centre , Derriford Hospital , Plymouth , UK
| | - Paul Newell
- Centre for Health & Environmental Statistics , Plymouth University , Plymouth , UK
| | - Peter A Rowe
- South West Transplant Centre , Derriford Hospital , Plymouth , UK
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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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50
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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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