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Bae EK, Chandran MM, Everitt MD, Benz E, Bock M. LCP-Tacrolimus Extended-Release (Envarsus XR) Use in Adolescent and Young Adult Solid Organ Transplant Recipients. Clin Transplant 2024; 38:e15417. [PMID: 39087462 DOI: 10.1111/ctr.15417] [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: 03/27/2024] [Revised: 06/30/2024] [Accepted: 07/15/2024] [Indexed: 08/02/2024]
Abstract
INTRODUCTION Limited published experience describes once daily, extended-release tacrolimus (LCP-Tac) use in pediatric solid organ transplantation (SOT), particularly nonrenal SOT. LCP-Tac can simplify immunosuppression (IS) regimens, minimize immediate release-tacrolimus (IR-Tac)-associated adverse effects, and promote adherence. This study describes the successful use of LCP-Tac in adolescent and young adult (AYA) SOT populations. METHODS A single-center, retrospective chart review of AYA SOT recipients (age < 25 years) converted from IR-Tac to LCP-Tac. Graft survival, biopsy-proven acute rejection (BPAR), infection rates, estimated glomerular filtration rate (eGFR), and pill burden were assessed at five time points postconversion (1, 3, 6, 12, and 24 months). Intrapatient variability of tacrolimus, as assessed by coefficient of variability (CV%), was also analyzed. RESULTS Twenty-nine AYA SOT recipients (19 heart, 6 kidney, and 4 liver) were converted to LCP-Tac, with a median age of 17.4 years at conversion. Conversion, mainly due to perceived or identified medication nonadherence, occurred at a median of 5.4 years posttransplant. No graft loss occurred within 24 months of conversion, and BPAR incidence rate was consistent with previous reports for these populations. Only one patient experienced CMV infection. Renal function remained stable postconversion. CONCLUSION Successful conversion from IR-Tac to LCP-Tac was demonstrated in AYA heart, kidney, and liver transplant recipients. These AYA SOT recipients experienced reduced pill burden and improved tacrolimus trough concentration variability. However, the impact on medication adherence warrants further investigation. Future research should explore the targeted use of LCP-Tac to enhance IS tolerability and medication adherence in young SOT populations.
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Affiliation(s)
- Esther K Bae
- Pharmacy, Children's Hospital Colorado, Aurora, Colorado, USA
| | | | - Melanie D Everitt
- Heart Institute, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Eric Benz
- Nephrology, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Margret Bock
- Nephrology, Children's Hospital Colorado, Aurora, Colorado, USA
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Giral M, Grimbert P, Morin B, Bouvier N, Buchler M, Dantal J, Garrigue V, Bertrand D, Kamar N, Malvezzi P, Moreau K, Athea Y, Le Meur Y. Impact of Switching From Immediate- or Prolonged-Release to Once-Daily Extended-Release Tacrolimus (LCPT) on Tremor in Stable Kidney Transplant Recipients: The Observational ELIT Study. Transpl Int 2024; 37:11571. [PMID: 38694490 PMCID: PMC11061389 DOI: 10.3389/ti.2024.11571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 01/31/2024] [Indexed: 05/04/2024]
Abstract
Once-daily extended-release tacrolimus (LCPT) exhibits increased bioavailability versus immediate-release (IR-TAC) and prolonged release (PR-TAC) tacrolimus. Improvements in tremor were previously reported in a limited number of kidney transplant patients who switched to LCPT. We conducted a non-interventional, non-randomized, uncontrolled, longitudinal, prospective, multicenter study to assess the impact of switching to LCPT on tremor and quality of life (QoL) in a larger population of stable kidney transplant patients. The primary endpoint was change in The Essential Tremor Rating Assessment Scale (TETRAS) score; secondary endpoints included 12-item Short Form Survey (SF-12) scores, tacrolimus trough concentrations, neurologic symptoms, and safety assessments. Subgroup analyses were conducted to assess change in TETRAS score and tacrolimus trough concentration/dose (C0/D) ratio by prior tacrolimus formulation and tacrolimus metabolizer status. Among 221 patients, the mean decrease of TETRAS score after switch to LCPT was statistically significant (p < 0.0001 vs. baseline). There was no statistically significant difference in change in TETRAS score after switch to LCPT between patients who had received IR-TAC and those who had received PR-TAC before switch, or between fast and slow metabolizers of tacrolimus. The overall increase of C0/D ratio post-switch to LCPT was statistically significant (p < 0.0001) and from baseline to either M1 or M3 (both p < 0.0001) in the mITT population and in all subgroups. In the fast metabolizers group, the C0/D ratio crossed over the threshold of 1.05 ng/mL/mg after the switch to LCPT. Other neurologic symptoms tended to improve, and the SF-12 mental component summary score improved significantly. No new safety concerns were evident. In this observational study, all patients had a significant improvement of tremor, QoL and C0/D ratio post-switch to LCPT irrespective of the previous tacrolimus formulation administered (IR-TAC or PR-TAC) and irrespective from their metabolism status (fast or slow metabolizers).
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Affiliation(s)
| | | | | | | | | | | | | | | | - Nassim Kamar
- CHU Toulouse, Université Paul Sabatier Toulouse III, Toulouse, France
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Wiseman A, Alhamad T, Alloway RR, Concepcion BP, Cooper M, Formica R, Klein CL, Kumar V, Leca N, Shihab F, Taber DJ, Mulnick S, Bushnell DM, Hadi M, Bunnapradist S. Use of LCP-Tacrolimus (LCPT) in Kidney Transplantation: A Delphi Consensus Survey of Expert Clinicians. Ann Transplant 2024; 29:e943498. [PMID: 38526543 PMCID: PMC10944009 DOI: 10.12659/aot.943498] [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: 12/14/2023] [Accepted: 02/06/2024] [Indexed: 03/26/2024] Open
Abstract
BACKGROUND LCPT (Envarsus XR®) is a common once-daily, extended-release oral tacrolimus formulation used in kidney transplantation. However, there are minimal evidence-based recommendations regarding optimal dosing and treatment in the de novo and conversion settings. MATERIAL AND METHODS Using Delphi methodology, 12 kidney transplantation experts with LCPT experience reviewed available data to determine potential consensus topics. Key statements regarding LCPT use were generated and disseminated to the panel in an online Delphi survey. Statements were either accepted, revised, or rejected based on the level of consensus, perceived strength of evidence, and alignment with clinical practice. Consensus was defined a priori as ≥75% agreement. RESULTS Twenty-three statements were generated: 14 focused on de novo LCPT use and 9 on general administration or LCPT conversion use. After 2 rounds, consensus was achieved for 11/14 of the former and 7/9 of the latter statements. In a de novo setting, LCPT was recognized as a first-line option based on its safety and efficacy compared to immediate-release tacrolimus. In particular, African Americans and rapid metabolizer populations were identified as preferred for first-line LCPT therapy. In a conversion setting, full consensus was achieved for converting to LCPT to address neurological adverse effects related to immediate-release tacrolimus and for the time required (approximately 7 days) for steady-state LCPT trough levels to be reached. CONCLUSIONS When randomized clinical trials do not replicate current utilization patterns, the Delphi process can successfully generate consensus statements by expert clinicians to inform clinical decision-making for the use of LCPT in kidney transplant recipients.
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Affiliation(s)
- Alexander Wiseman
- AdventHealth Transplant Institute, Porter Adventist Hospital, Denver, CO, USA
| | - Tarek Alhamad
- Division of Nephrology, Washington University School of Medicine in St. Louis, Saint Louis, MO, USA
| | - Rita R. Alloway
- Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | | - Matthew Cooper
- Transplant Center – Center for Advanced Care – Froedtert Hospital, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Richard Formica
- Yale New Haven Transplantation Center, Yale University School of Medicine, New Haven, CT, USA
| | - Christina L. Klein
- Department of Transplant Nephrology, Piedmont Transplant Institute, Atlanta, GA, USA
| | - Vineeta Kumar
- Renal Transplant Program, University of Alabama at Birmingham Hospital, Birmingham, AL, USA
| | - Nicolae Leca
- Kidney Care and Transplantation Services, University of Washington, Seattle, WA, USA
| | - Fuad Shihab
- Kidney and Liver Clinic, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - David J. Taber
- Transplant Immunobiology Laboratory, Medical University of South Carolina, Charleston, SC, USA
| | - Sarah Mulnick
- Patient-Centered Research, Evidera, Bethesda, MD, USA
| | | | - Monica Hadi
- Patient-Centered Research, Evidera, London, United Kingdom
| | - Suphamai Bunnapradist
- Division of Nephrology and Department of Medicine, David Geffen School of Medicine, Los Angeles, CA, USA
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Kim JJ, Lawless L, Marshall D, Maxted A, Lunn A, Mallik M, Williams A. Pharmacokinetics of Envarsus in pediatric kidney transplant recipients - phase 1 pilot conversion study. Pediatr Transplant 2024; 28:e14703. [PMID: 38433334 DOI: 10.1111/petr.14703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 01/10/2024] [Accepted: 01/22/2024] [Indexed: 03/05/2024]
Abstract
INTRODUCTION Tacrolimus is the standard immunosuppressant for pediatric kidney transplants and is routinely administered twice daily (BD-tac). Envarsus (LCP-tac), an extended-release formulation, is approved for adults but not for pediatric patients. METHODS We conducted a pilot open-label phase 1 study in stable pediatric kidney transplant recipients (age < 18 at the time of study). Our primary objective was to compare the pharmacokinetics (Pk) of LCP-tac versus BD-tac. We conducted two 24-h Pk studies: pre-conversion (BD-tac) and 4 weeks post-conversion to LCP-tac. Patients were followed for 6 months, with the option to continue LCP-tac. RESULTS Five patients completed the study, with no returns to BD-tac. Median age was 15 years (range 11-17). LCP-tac exhibited an extended-release profile versus the bimodal profile of BD-tac. Time to maximum concentration was delayed (5 h vs. 1 h), and maximum concentration was lower (9.9 ng/mL vs. 14.4 ng/mL). Tacrolimus area under the curve (24 h) was comparable (141 ± 46.5 ng/mL vs. 164 ± 27.8 ng/mL). No new safety concerns arose. There were no rejection and no difference in eGFR at the study's end (1.5 mL/min/1.73 m2 , range - 1.7 to 2.3 mL/min/1.73 m2 ). Concentration/dose ratio was higher in LCP-tac (1.8 ± 0.64 vs. 0.8 ± 0.39). The final conversion ratio was 0.6 (BD-tac: LCP-tac). CONCLUSION Our pilot study confirms the extended-release Pk profile and improved absorption of LCP-tac compared to BD-tac. A larger study is needed to further evaluate the population Pk characteristics in children.
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Affiliation(s)
- Jon Jin Kim
- Department of Paediatric Nephrology, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Department of Surgery, University of Cambridge, Cambridge, UK
| | - Laura Lawless
- Research and Innovation, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - David Marshall
- Department of Clinical Biochemistry, Wythenshawe Hospital, Manchester, UK
| | - Andrew Maxted
- Department of Paediatric Nephrology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Andrew Lunn
- Department of Paediatric Nephrology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Meeta Mallik
- Department of Paediatric Nephrology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Alun Williams
- Department of Paediatric Nephrology, Nottingham University Hospitals NHS Trust, Nottingham, UK
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Romine MM, Leeser DB, Kennamer K, Nguyen C, Jones H, McLawhorn K, Kendrick S, Irish W. Early outcomes associated with de novo once-daily extended-release versus twice-daily immediate-release tacrolimus in a predominantly African American kidney transplant population: A single-center observational study. Clin Transplant 2024; 38:e15268. [PMID: 38450751 DOI: 10.1111/ctr.15268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 01/31/2024] [Accepted: 02/02/2024] [Indexed: 03/08/2024]
Abstract
INTRODUCTION The purpose of this study was to compare early outcomes of de novo LCPT (once-daily extended-release tacrolimus) to IR TAC (twice-daily immediate-release tacrolimus) in a predominantly African American (AA) adult kidney transplant population. METHODS This is a single center, retrospective cohort study. Patients were divided into two cohorts: IR TAC (administered between January 1, 2017, and January 31, 2019) and LCPT (administered between February 1, 2019, and May 31, 2020). Primary endpoints were changes in tacrolimus trough levels (ng/mL) and estimated glomerular filtration rate up to 12 months post-transplantation. Clinical endpoints included graft survival, delayed graft function, biopsy-proven rejection, CMV viremia, and BK. A propensity score weighted generalized linear mixed effects model was used for analysis. RESULTS The rate of change in tacrolimus levels was significantly higher in the LCPT cohort compared to the IR TAC cohort at 14 days post-discharge (.2455 ng/mL per day vs. .1073 ng/mL, respectively; p < .001). Subsequently, the LCPT cohort had a slightly higher rate of decline (-.015 ng/mL per day vs. -.010 ng/mL with IR TAC; p = .0894) up to 12 months post-discharge. Although eGFR was similar between the two cohorts at 12 months post-transplant, the rate of increase was slower in the LCPT cohort (.1371 mL/min per day vs. .1852 mL/min per day, p = .0314). No significant differences were found in graft survival, DGF, BPAR, CMV, or BK infection. CONCLUSION This study demonstrates that despite higher early trough levels with immediate post-transplant LCPT use, clinical outcomes are comparable to IR TAC at one-year post-transplant. Notably, LCPT use does not increase the incidence of DGF and that this formulation of CNI can be used as first line therapy post-transplant.
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Affiliation(s)
- Margaret M Romine
- Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, North Carolina, USA
| | - David B Leeser
- Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, North Carolina, USA
| | - Karen Kennamer
- Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, North Carolina, USA
| | - Catherine Nguyen
- East Carolina University Health System, Greenville, North Carolina, USA
| | - Heather Jones
- Eastern Nephrology Associates, Greenville, North Carolina, USA
| | | | - Scott Kendrick
- Eastern Nephrology Associates, Greenville, North Carolina, USA
| | - William Irish
- Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, North Carolina, USA
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Huang X, Hapgood K, Allan K, Pruette C, Goswami E. Extended-release tacrolimus dosing and outcomes in pediatric and young adult transplant recipients - A single-center experience. Pediatr Transplant 2024; 28:e14611. [PMID: 37735900 DOI: 10.1111/petr.14611] [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] [Received: 11/16/2022] [Revised: 06/09/2023] [Accepted: 08/29/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Published data on LCP-tacrolimus (LCPT) in the pediatric population are limited. METHODS This single-center, retrospective, observational study describes LCPT doses needed to reach therapeutic ranges in pediatric and young adult kidney and liver transplant recipients in both de novo usage and conversion from immediate-release tacrolimus (IR-Tac). Adverse outcomes up to 12 months after LCPT initiation were also evaluated. RESULTS Forty-one transplant recipients (30 kidney, 11 liver) were included. The median initial doses of LCPT were 0.034 mg/kg (IQR 0.019) de novo and 0.09 mg/kg (IQR = 0.076) converted. The median doses at first therapeutic level were 0.086 mg/kg (IQR 0.028) de novo and 0.1 mg/kg (IQR 0.066) converted. The median LCPT:IR-Tac conversion ratio initially was 0.7 and 0.75 at therapeutic levels. The rate of AKI per 100 days of exposure to IR-Tac was 0.546 and 0.439 on LCPT. The percentage of patients with rejection was not different before and after conversion (clinical rejection 8.6% [n = 3] vs 11.4% [n = 4], p = .6; biopsy-proven rejection 2.9% [n = 1] vs 11.4% [n = 4], p = .11). One patient had graft loss unrelated to rejection, and the graft was explanted. CONCLUSION In this study, pediatric and young adult abdominal transplant recipients had therapeutic tacrolimus levels at LCPT doses below the adult-labeled dose; the conversion ratio from IR-Tac to LCPT at therapeutic level was similar. There were no identified safety concerns in de novo or converted LCPT use in pediatric and young adult patients.
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Affiliation(s)
- Xinyi Huang
- Arnold and Marie Schwartz College of Pharmacy, Long Island University, Brooklyn, New York, USA
- Department of Pharmacy, New York Presbyterian Hospital, New York, New York, USA
| | - Katherine Hapgood
- Department of Pharmacy, The Johns Hopkins Hospital, Maryland, Baltimore, USA
| | - Kari Allan
- Department of Pharmacy, Children's Hospital Colorado, Colorado, Aurora, USA
| | - Cozumel Pruette
- Department of Pediatrics, The Johns Hopkins Hospital, Maryland, Baltimore, USA
| | - Elizabeth Goswami
- Department of Pharmacy, The Johns Hopkins Hospital, Maryland, Baltimore, USA
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King CP, Cossart AR, Isbel NM, Campbell SB, Staatz CE. The association between tacrolimus exposure and tremor, headache and insomnia in adult kidney transplant recipients: A systematic review. Transplant Rev (Orlando) 2024; 38:100815. [PMID: 38071930 DOI: 10.1016/j.trre.2023.100815] [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: 10/23/2023] [Revised: 11/28/2023] [Accepted: 11/30/2023] [Indexed: 01/08/2024]
Abstract
PURPOSE Tremor, headache and insomnia have been linked to the immunosuppressant, tacrolimus. The aim of this systematic review was to determine if there is a correlation between tacrolimus exposure and new-onset tremor, headache and insomnia experienced by adult kidney transplant recipients. METHODS PubMed, Embase, Cochrane Library and CINAHL databases were searched up to 11 April 2023 for published studies which reported on tacrolimus exposure in adult kidney transplant recipients, alongside information on treatment-emergent neurologic manifestations, including tremor, headache and insomnia. Review articles, case studies, conference abstracts and articles not published in English in peer-reviewed journals were excluded. The Physiotherapy Evidence Database and Newcastle-Ottawa Quality Assessment Scales were used to assess risk of bias. Extracted data was analysed via a narrative synthesis. RESULTS Eighteen studies involving 4030 patients in total were included in the final analysis. These comprised five randomised control trials and thirteen observational studies. Studies failed to find significant association between tacrolimus trough concentrations in whole blood and the incidence of neurologic side effects such as tremor, headache and insomnia; however, in one study the incidence of toxicity requiring a dose reduction increased with increasing, supratherapeutic targeted levels. Females, especially Black females, and older age were positively associated with the prevalence of neurologic adverse effects. Results were conflicting regarding whether extended-release formulations were associated with fewer neurologic complications than immediate-release formulations. CONCLUSION The varied study designs and criteria for reporting tremor, headache and insomnia impacted on the quality of the data for exploring the relationship between tacrolimus exposure and the onset of neurologic manifestations experienced after kidney transplantation. Studies that examine defined neurologic complications as the primary outcome, and that consider novel markers of tacrolimus exposure while assessing the potential contribution of multiple covariate factors, are required.
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Affiliation(s)
- Catherine P King
- School of Pharmacy, The University of Queensland, Brisbane, QLD, Australia.
| | - Amelia R Cossart
- School of Pharmacy, The University of Queensland, Brisbane, QLD, Australia
| | - Nicole M Isbel
- Department of Nephrology, The Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Scott B Campbell
- Department of Nephrology, The Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Christine E Staatz
- School of Pharmacy, The University of Queensland, Brisbane, QLD, Australia
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Bilbao I, Gómez Bravo MÁ, Otero A, Lladó L, Montero JL, González Dieguez L, Graus J, Pons Miñano JA. Effectiveness and safety of once-daily tacrolimus formulations in de novo liver transplant recipients: The PRETHI study. Clin Transplant 2023; 37:e15105. [PMID: 37615653 DOI: 10.1111/ctr.15105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 07/14/2023] [Accepted: 08/13/2023] [Indexed: 08/25/2023]
Abstract
Data comparing long-term effectiveness and safety of once-daily tacrolimus formulations in de novo liver transplantation are scarce. We compared the effectiveness, pharmacokinetic profile, and safety of LCPT (Envarsus) and PR-Tac (Advagraf) for up to 12 months post-transplant. Adult de novo liver transplant recipients who started IR-Tac (Prograf) and were converted to LCPT or PR-Tac 3-5 days post-transplant were included. Data from 163 patients were analyzed, 87 treated with LCPT and 76 with PR-Tac. The incidence of treatment failure was 30.5% in the LCPT group versus 23.0% in the PR-Tac group (p = .291). Biopsy-proven acute rejection (BPAR) was reported in 26.8% of patients in the LCPT group and 17.6% in the PR-Tac group (p = .166). Graft loss was experienced in one patient (1.2%) in the LCPT group and three patients (4.1%) in the PR-Tac group (p = .346). Death was registered in three patients (3.7%) in the LCPT group and three patients (4.1%) in the PR-Tac group (p > .999). Patients in the LCPT group showed 45.7% higher relative bioavailability (Cmin /total daily dose [TDD]; p < .01) with similar Cmin and 33.3% lower TDD versus PR-Tac (p < .01). The evolution of renal function, safety profile, and the incidence of post-transplant renal failure, dyslipidemia, obesity, hypertension, and diabetes mellitus were similar in patients treated with LCPT and PR-Tac. In de novo liver transplant patients, LCPT and PR-Tac showed comparable effectiveness with higher relative bioavailability, similar Cmin and lower TDD in the LCPT group. Renal function, safety, and post-transplant complications were comparable in LCPT and PR-Tac groups.
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Affiliation(s)
- Itxarone Bilbao
- Servicio de Cirugía Hepatobiliopancreática y Trasplantes Digestivos, Hospital Universitario Vall d'Hebron, VHIR, Universidad Autónoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
| | | | | | - Laura Lladó
- Hospital U Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
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Monchaud C, Woillard JB, Crépin S, Tafzi N, Micallef L, Rerolle JP, Dharancy S, Conti F, Choukroun G, Thierry A, Buchler M, Salamé E, Garrouste C, Duvoux C, Colosio C, Merville P, Anglicheau D, Etienne I, Saliba F, Mariat C, Debette-Gratien M, Marquet P. Tacrolimus Exposure Before and After a Switch From Twice-Daily Immediate-Release to Once-Daily Prolonged Release Tacrolimus: The ENVARSWITCH Study. Transpl Int 2023; 36:11366. [PMID: 37588007 PMCID: PMC10425592 DOI: 10.3389/ti.2023.11366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 07/06/2023] [Indexed: 08/18/2023]
Abstract
LCP-tacrolimus displays enhanced oral bioavailability compared to immediate-release (IR-) tacrolimus. The ENVARSWITCH study aimed to compare tacrolimus AUC0-24 h in stable kidney (KTR) and liver transplant recipients (LTR) on IR-tacrolimus converted to LCP-tacrolimus, in order to re-evaluate the 1:0.7 dose ratio recommended in the context of a switch and the efficiency of the subsequent dose adjustment. Tacrolimus AUC0-24 h was obtained by Bayesian estimation based on three concentrations measured in dried blood spots before (V2), after the switch (V3), and after LCP-tacrolimus dose adjustment intended to reach the pre-switch AUC0-24 h (V4). AUC0-24 h estimates and distributions were compared using the bioequivalence rule for narrow therapeutic range drugs (Westlake 90% CI within 0.90-1.11). Fifty-three KTR and 48 LTR completed the study with no major deviation. AUC0-24 h bioequivalence was met in the entire population and in KTR between V2 and V4 and between V2 and V3. In LTR, the Westlake 90% CI was close to the acceptance limits between V2 and V4 (90% CI = [0.96-1.14]) and between V2 and V3 (90% CI = [0.96-1.15]). The 1:0.7 dose ratio is convenient for KTR but may be adjusted individually for LTR. The combination of DBS and Bayesian estimation for tacrolimus dose adjustment may help with reaching appropriate exposure to tacrolimus rapidly after a switch.
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Affiliation(s)
- Caroline Monchaud
- Department of Pharmacology, Toxicology and Pharmacovigilance, Centre Hospitalier Universitaire de Limoges, Limoges, France
- INSERM1248 Pharmacolgy and Transplantation, Limoges, France
- Fédération Hospitalo-Universitaire Survival Optimization in Organ Transplantation (FHU SUPORT), Limoges, France
| | - Jean-Baptiste Woillard
- Department of Pharmacology, Toxicology and Pharmacovigilance, Centre Hospitalier Universitaire de Limoges, Limoges, France
- INSERM1248 Pharmacolgy and Transplantation, Limoges, France
- Fédération Hospitalo-Universitaire Survival Optimization in Organ Transplantation (FHU SUPORT), Limoges, France
| | - Sabrina Crépin
- Department of Pharmacology, Toxicology and Pharmacovigilance, Centre Hospitalier Universitaire de Limoges, Limoges, France
- INSERM1248 Pharmacolgy and Transplantation, Limoges, France
- Fédération Hospitalo-Universitaire Survival Optimization in Organ Transplantation (FHU SUPORT), Limoges, France
- Unité de Vigilance des Essais Cliniques, Centre Hospitalier Universitaire de Limoges, Limoges, France
| | - Naïma Tafzi
- Department of Pharmacology, Toxicology and Pharmacovigilance, Centre Hospitalier Universitaire de Limoges, Limoges, France
| | - Ludovic Micallef
- Department of Pharmacology, Toxicology and Pharmacovigilance, Centre Hospitalier Universitaire de Limoges, Limoges, France
- Fédération Hospitalo-Universitaire Survival Optimization in Organ Transplantation (FHU SUPORT), Limoges, France
| | - Jean-Philippe Rerolle
- INSERM1248 Pharmacolgy and Transplantation, Limoges, France
- Fédération Hospitalo-Universitaire Survival Optimization in Organ Transplantation (FHU SUPORT), Limoges, France
- Department of Nephrology, Dialysis and Transplantation, Centre Hospitalier Universitaire de Limoges, Limoges, France
| | | | - Filomena Conti
- Department of Hepato-Gastro-Enterology, Hôpital Pitié-Salpêtrière, Paris, France
| | - Gabriel Choukroun
- Department of Nephrology, Internal Medicine, Transplantation, Centre Hospitalier Universitaire (CHU) d'Amiens, Amiens, France
| | - Antoine Thierry
- Fédération Hospitalo-Universitaire Survival Optimization in Organ Transplantation (FHU SUPORT), Poitiers, France
- Department of Nephrology, Hemodialysis and Renal Transplantation, Centre Hospitalier Universitaire (CHU) de Poitiers, Poitiers, France
| | - Matthias Buchler
- Fédération Hospitalo-Universitaire Survival Optimization in Organ Transplantation (FHU SUPORT), Tours, France
- Department of Nephrology–Arterial Hypertension, Dialyses, Renal Transplantation, Centre Hospitalier Universitaire de Tours, Tours, France
| | - Ephrem Salamé
- Fédération Hospitalo-Universitaire Survival Optimization in Organ Transplantation (FHU SUPORT), Tours, France
- Center for Hepatobiliary and Pancreatic Surgery, Hepatic Transplantation, Centre Hospitalier Universitaire de Tours, Tours, France
| | - Cyril Garrouste
- Department of Nephrology–Hemodialyses, Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand, France
| | - Christophe Duvoux
- Department of Hepatology, Hôpital Henri-Mondor, Assistance Publique Hôpitaux de Paris, Créteil, France
| | - Charlotte Colosio
- Department of Nephrology, Centre Hospitalier Universitaire de Reims, Reims, France
| | - Pierre Merville
- Department of Nephrology, Transplantation, Dialysis and Aphereses, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Dany Anglicheau
- Department of Kidney and Metabolism Diseases, Transplantation and Clinical Immunology, Hôpital Necker-Enfants Malades, Paris, France
| | - Isabelle Etienne
- Department of Nephrology, Hemodialysis, Transplantation, Centre Hospitalier Universitaire (CHU) de Rouen, Rouen, France
| | | | - Christophe Mariat
- Department of Nephrology, Dialysis and Renal Transplantation, Centre Hospitalier Universitaire (CHU) de Saint-Étienne, Saint-Etienne, France
| | - Marilyne Debette-Gratien
- INSERM1248 Pharmacolgy and Transplantation, Limoges, France
- Fédération Hospitalo-Universitaire Survival Optimization in Organ Transplantation (FHU SUPORT), Limoges, France
- Department of Hepato-Gastro-Enterology and Nutrition, Centre Hospitalier Universitaire de Limoges, Limoges, France
| | - Pierre Marquet
- Department of Pharmacology, Toxicology and Pharmacovigilance, Centre Hospitalier Universitaire de Limoges, Limoges, France
- INSERM1248 Pharmacolgy and Transplantation, Limoges, France
- Fédération Hospitalo-Universitaire Survival Optimization in Organ Transplantation (FHU SUPORT), Limoges, France
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10
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Wöhl DS, James B, Götz M, Brennfleck F, Holub-Hayles I, Mutzbauer I, Baccar S, Brunner SM, Geissler EK, Schlitt HJ. EnGraft: a multicentre, open-label, randomised, two-arm, superiority study protocol to assess bioavailability and practicability of Envarsus® versus Advagraf™ in liver transplant recipients. Trials 2023; 24:325. [PMID: 37170284 PMCID: PMC10176804 DOI: 10.1186/s13063-023-07344-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Accepted: 05/02/2023] [Indexed: 05/13/2023] Open
Abstract
BACKGROUND Graft rejection and chronic CNI toxicity remain obstacles to organ transplant success. Current formulations of tacrolimus, such as Prograf® and Advagraf™, exhibit limitations in terms of pharmacokinetics and tolerability, related in part to suboptimal bioavailability. As dosing non-compliance can result in graft rejection, the once daily formulation of tacrolimus, Advagraf™, was developed (vs 2x/day Prograf®). Benefits of Advagraf™ are counterbalanced by delayed achievement of therapeutic trough levels and need for up to 50% higher doses to maintain Prograf®-equivalent troughs. Envarsus® is also a prolonged-release once-daily tacrolimus formulation, developed using MeltDose™ drug-delivery technology to increase drug bioavailability; improved bioavailability results in low patient drug absorption variability and less pronounced peak-to-trough fluctuations. In phase III de novo kidney transplant studies, Envarsus® proved non-inferior to twice-daily tacrolimus; however, no phase IV studies show superiority of Envarsus® vs Advagraf™ in de novo liver transplant (LTx) recipients. METHODS The EnGraft compares bioavailability and tests superiority of Envarsus® (test arm) versus Advagraf™ (comparator arm) in de novo LTx recipients. A total of 268 patients from 15 German transplant centres will be randomised 1:1 within 14 days post-LTx. The primary endpoint is dose-normalised trough level (C/D ratio) measured 12 weeks after randomisation. Secondary endpoints include the number of dose adjustments, time to reach first defined trough level and incidence of graft rejections. Additionally, clinical and laboratory parameters will be assessed over a 3-year period. DISCUSSION C/D ratio is an estimate for tacrolimus bioavailability. Improving bioavailability and increasing C/D ratio using Envarsus could reduce renal dysfunction and other tacrolimus-related toxicities; previous trials have shown that a higher C/D ratio (i.e. slower tacrolimus metabolism) is not only associated with improved renal function but also linked to reduced neurotoxic side effects. A higher C/D ratio could improve clinical outcomes for LTx recipients; EnGraft has begun, with one third of patients recruited by January 2022. TRIAL REGISTRATION This trial has been registered (4 May 2020) in the EU Clinical Trials Register, EudraCT-Nummer: 2020-000796-20. Additionally, this trial has been registered (22 January 2021) at ClinicalTrials.gov: NCT04720326. The trial received a favourable opinion from the concerned lead ethics committee at the University of Regensburg, under the reference 20-1842-112.
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Affiliation(s)
- D S Wöhl
- Department of Surgery, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany.
| | - B James
- coTrial Associates, Department of Surgery, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - M Götz
- Department of Surgery, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - F Brennfleck
- Department of Surgery, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - I Holub-Hayles
- coTrial Associates, Department of Surgery, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - I Mutzbauer
- coTrial Associates, Department of Surgery, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - S Baccar
- coTrial Associates, Department of Surgery, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - S M Brunner
- Department of Surgery, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - E K Geissler
- Department of Surgery, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - H J Schlitt
- Department of Surgery, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
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11
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ElChaki R, Ettenger R, Lee S, Chen L, Gales B, Srivastava R, Pearl M. Envarsus XR® pharmacokinetics in adolescents post-kidney transplantation - A pilot study. Pediatr Transplant 2023; 27:e14480. [PMID: 36732080 DOI: 10.1111/petr.14480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 01/08/2023] [Accepted: 01/18/2023] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Envarsus XR® (LCPT), a once daily dosage formulation of tacrolimus, is an FDA-approved medication in adult renal transplant recipients (RTRs). There are limited data on its pharmacokinetics (PK) in adolescent RTRs. We report here the PK profile of LCPT in adolescent RTRs. METHODS The dose of LCPT was determined using a dose conversion ratio targeting 0.7 relative to the total daily immediate-release tacrolimus (IR-Tac) dose. On day 7 after converting to LCPT, patients had an abbreviated PK assessment with sampling at: 0 h (pre-dose), 8-, and 12-h post-dose. The PK data analysis was performed using Bayesian estimators. Our results were compared to those of published adult PK data for LCPT and pediatric PK data for IR-Tac and extended release tacrolimus (ER-Tac) formulation (Advagraf). RESULTS PK data from three adolescent patients on LCPT were evaluated. The mean (±SD) area under the time-concentration curve (AUC) was 240 (±20.22) h*ng/mL. The mean Tmax was 9.01 ± 2.12 h, and the % fluctuation was 77.71 ± 3.96%. The AUC, Tmax , and % fluctuation were similar to reported results in adult patients taking LCPT. The AUC was higher and the Tmax was longer than what has been reported in pediatric patients taking IR-Tac and ER-Tac. In addition, the LCPT group showed a lower % fluctuation than patients receiving ER-Tac. CONCLUSION The PK evaluation of LCPT in adolescent RTRs showed similar results to adults. Adolescents taking LCPT had a higher AUC, a more attenuated Tmax , and a lower fluctuation than that seen with ER-Tac in pediatrics.
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Affiliation(s)
- Rim ElChaki
- Division of Pediatric Nephrology, Department of Pediatrics, University of California Los Angeles, Los Angeles, California, USA
| | - Robert Ettenger
- Division of Pediatric Nephrology, Department of Pediatrics, University of California Los Angeles, Los Angeles, California, USA
| | - Sabrina Lee
- Department of Pharmaceutical Services, Ronald Reagan UCLA Medical Center, Los Angeles, California, USA
| | - Lucia Chen
- Department of Medicine Statistics Core, University of California Los Angeles, Los Angeles, California, USA
| | - Barbara Gales
- Division of Pediatric Nephrology, Department of Pediatrics, University of California Los Angeles, Los Angeles, California, USA
| | - Rachana Srivastava
- Division of Pediatric Nephrology, Department of Pediatrics, University of California Los Angeles, Los Angeles, California, USA
| | - Meghan Pearl
- Division of Pediatric Nephrology, Department of Pediatrics, University of California Los Angeles, Los Angeles, California, USA
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12
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Magid M, Sanoff S, Lee HJ, Yang Z, Byrns J. Evaluation of Weight-Based Dose During Transition From Immediate-Release to Extended-Release Tacrolimus in Kidney Transplant Recipients. J Pharm Pract 2023; 36:39-45. [PMID: 34098779 DOI: 10.1177/08971900211021054] [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] [Indexed: 02/04/2023]
Abstract
BACKGROUND Manufacturer recommendations for conversion from immediate-release to extended-release tacrolimus, Envarsus XR®, suggests 80% of the total daily dose of the immediate-release formulation. This conversion has not consistently achieved therapeutic levels in the kidney transplant population. OBJECTIVES To determine if a reliable weight-based dosing strategy could be utilized to transition kidney transplant patients from immediate-release to extended-release tacrolimus. This may help establish a safe protocol to guide transition between formulations. METHODS Retrospective, single-center study of adult kidney transplant recipients between July 2015 and December 2018. Excluded patients received dual organs, lacked appropriately drawn tacrolimus levels, or were prescribed interacting medications. Patients were identified by querying prescriptions for extended-release tacrolimus and chart review was performed to exclude any patients without sufficient follow-up after transition. RESULTS 30 patients who transitioned from immediate-release tacrolimus to tacrolimus XR were included in the final analysis. The median weight-based dose of tacrolimus XR that achieved a therapeutic level among the cohort was 0.158 mg/kg/day (Q1-Q3: 0.0587-0.221), which was about 80% of the original median weight-based immediate-release tacrolimus dose. Therapeutic dosing strategies were widely variable, represented by an R2 of 0.33 on linear regression. There was a statistically significant difference in median weight-based dosing strategies among patients of various racial backgrounds (p = 0.0148). CONCLUSIONS A weight-based dose of tacrolimus XR could not reliably predict a therapeutic level among the total cohort due to the wide inter-patient variability. The median weight-based rate of conversion from immediate-release to extended-release tacrolimus was 80%.
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Affiliation(s)
- Mackenzie Magid
- Department of Pharmacy, Duke University Hospital, Durham, NC, USA
| | - Scott Sanoff
- Department of Medicine, Duke University Hospital, Durham, NC, USA
| | - Hui-Jie Lee
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Zidanyue Yang
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Jennifer Byrns
- Department of Pharmacy, Duke University Hospital, Durham, NC, USA
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13
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Cholbi Vives E, Espí Reig J, Cruz Sánchez A, Moreno Maestre E, Ventura Galiano A, Ramos Escorihuela D, Ramos Cebrián M, González-Calero Borrás P, Beneyto Castelló I, Hernández Jaras J. Comparative Study of 2 Extended-Release Tacrolimus Formulations in Kidney Transplantation. Transplant Proc 2022; 54:2434-2438. [PMID: 36334963 DOI: 10.1016/j.transproceed.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 08/30/2022] [Accepted: 10/01/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND During the 1900s, tacrolimus became the mainstay immunosuppressive agent to prevent rejection after kidney transplant. Subsequently, an extended-release tacrolimus (ER-Tac) formulation was developed to improve adherence, and its generic version has been marketed over the last years. This study examines the differences in efficacy and safety between the generic ER-Tac (Conferoport) and the reference brand-name drug (Advagraf). METHODS Prospective, randomized and parallel single-center study (May 2020 to June 2021) with 52 kidney transplant recipients who were randomly assigned to 1 of the following groups: study group (Conferoport, n = 31) and control group (Advagraf, n = 21). The variables of interest were collected and analyzed to compare tacrolimus efficacy and safety between them. Demographic characteristics of the patients and clinical donor data were homogeneous in both groups (P > .05). RESULTS No statistically significant differences were found among treatments regarding dosage used, levels, creatinine, and proteinuria (P > .05), with these variables presenting a downward trend during follow-up and, consequently, the improvement of graft function. Analyses also revealed the absence of differences concerning the incidence of acute rejection and intrapatient variability (coefficient of variation) throughout the first year of evolution between both formulations (P > .05). A total of 5 graft losses occurred, 2 resulting from patient death. CONCLUSIONS In our experience, we found no significant differences between the measured parameters in relation to the efficacy and safety profile of both drugs, with generic ER-Tac being an alternative comparable with the reference brand-name ER-Tac.
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Affiliation(s)
- Ester Cholbi Vives
- Kidney Transplant Unit, Department of Nephrology, Hospital Universitario La Fe, Valencia, Spain
| | - Jordi Espí Reig
- Kidney Transplant Unit, Department of Nephrology, Hospital Universitario La Fe, Valencia, Spain
| | | | - Elena Moreno Maestre
- IIS La Fe - Medical Research Institute Hospital La Fe, Hospital Universitario La Fe, Valencia, Spain
| | - Ana Ventura Galiano
- Kidney Transplant Unit, Department of Nephrology, Hospital Universitario La Fe, Valencia, Spain
| | - David Ramos Escorihuela
- Kidney Transplant Unit, Department of Nephrology, Hospital Universitario La Fe, Valencia, Spain
| | - María Ramos Cebrián
- Kidney Transplant Unit, Department of Nephrology, Hospital Universitario La Fe, Valencia, Spain
| | | | - Isabel Beneyto Castelló
- Kidney Transplant Unit, Department of Nephrology, Hospital Universitario La Fe, Valencia, Spain.
| | - Julio Hernández Jaras
- Kidney Transplant Unit, Department of Nephrology, Hospital Universitario La Fe, Valencia, Spain
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14
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Nelson J, Alvey N, Bowman L, Schulte J, Segovia M, McDermott J, Te HS, Kapila N, Levine DJ, Gottlieb RL, Oberholzer J, Campara M. Consensus recommendations for use of maintenance immunosuppression in solid organ transplantation: Endorsed by the American College of Clinical Pharmacy, American Society of Transplantation, and the International Society for Heart and Lung Transplantation. Pharmacotherapy 2022; 42:599-633. [DOI: 10.1002/phar.2716] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 03/29/2022] [Accepted: 04/08/2022] [Indexed: 12/17/2022]
Affiliation(s)
- Joelle Nelson
- Department of Pharmacotherapy and Pharmacy Services University Health San Antonio Texas USA
- Pharmacotherapy Education and Research Center University of Texas Health San Antonio San Antonio Texas USA
- Department of Pharmacy, Pharmacotherapy Division, College of Pharmacy The University of Texas at Austin Austin Texas USA
| | - Nicole Alvey
- Department of Pharmacy Rush University Medical Center Chicago Illinois USA
- Science and Pharmacy Roosevelt University College of Health Schaumburg Illinois USA
| | - Lyndsey Bowman
- Department of Pharmacy Tampa General Hospital Tampa Florida USA
| | - Jamie Schulte
- Department of Pharmacy Services Thomas Jefferson University Hospital Philadelphia Pennsylvania USA
| | | | - Jennifer McDermott
- Richard DeVos Heart and Lung Transplant Program, Spectrum Health Grand Rapids Michigan USA
- Department of Medicine, Michigan State University College of Human Medicine Grand Rapids Michigan USA
| | - Helen S. Te
- Liver Transplantation, Center for Liver Diseases, Department of Medicine University of Chicago Medical Center Chicago Illinois USA
| | - Nikhil Kapila
- Department of Transplant Hepatology Duke University Hospital Durham North Carolina USA
| | - Deborah Jo Levine
- Division of Critical Care Medicine, Department of Medicine The University of Texas Health Science Center at San Antonio San Antonio Texas USA
| | - Robert L. Gottlieb
- Baylor University Medical Center and Baylor Scott and White Research Institute Dallas Texas USA
| | - Jose Oberholzer
- Department of Surgery/Division of Transplantation University of Virginia Charlottesville Virginia USA
| | - Maya Campara
- Department of Surgery University of Illinois Chicago Chicago Illinois USA
- Department of Pharmacy Practice University of Illinois Chicago Chicago Illinois USA
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15
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Wings E, Spinner M, Eckardt J. Evaluation of clotrimazole prophylaxis on tacrolimus trough concentrations in kidney transplant recipients. Transpl Infect Dis 2022; 24:e13882. [PMID: 35689488 PMCID: PMC9540224 DOI: 10.1111/tid.13882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 04/12/2022] [Accepted: 05/18/2022] [Indexed: 11/28/2022]
Abstract
Background Clotrimazole troches are used as prophylaxis against oropharyngeal candidiasis post‐transplant and have limited systemic absorption. Following several occurrences of tacrolimus concentration fluctuations after clotrimazole discontinuation, its use as prophylaxis was discontinued post‐kidney transplant. Methods We conducted a retrospective cohort study to evaluate the effect of clotrimazole prophylaxis on tacrolimus trough concentrations post‐kidney transplant. The study included adult patients who received a kidney transplant at Cleveland Clinic Main Campus from August 1, 2019 to July 1, 2020 and were maintained on per‐protocol, standard‐dose tacrolimus through 90 days post‐transplant. Patients were excluded if they received cyclosporine, systemic antifungals, strong CYP3A4 inhibitors or inducers, or a simultaneous multiorgan transplant. The primary objective was to compare tacrolimus trough concentrations before and after completion of clotrimazole prophylaxis. Secondary objectives were to compare the time to first post‐transplant goal tacrolimus trough concentration, the rate of for‐cause allograft biopsies within 90 days after transplant, and the incidence and type of candidiasis within 30 days after transplant, pre‐ and post‐protocol change. Results Following clotrimazole discontinuation, the median tacrolimus trough concentration decreased from 10.5 ng/ml (IQR 8.4–12.2) to 6.6 ng/ml (IQR 5–8.7, p < 0.0001). No statistically significant differences in the rate of for‐cause allograft biopsies (4.9% vs. 9.7%, p = 0.264) or incidence of candidiasis (1.2% vs. 5.4%, p = 0.217) were observed between those who received clotrimazole and those who did not receive clotrimazole. Conclusions Our study provides further evidence of a significant drug–drug interaction between tacrolimus and clotrimazole among kidney transplant recipients that can potentially lead to negative allograft outcomes.
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Affiliation(s)
- Emily Wings
- Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio, USA
| | - Michael Spinner
- Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jamie Eckardt
- Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio, USA
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16
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Hidaka Y, Goto N, Yamanaga S, Kinoshita K, Tanaka K, Kawabata C, Toyoda M, Tomosugi T, Futamura K, Okada M, Tsujita M, Hiramitsu T, Yokomizo H, Miyata A, Narumi S, Kobayashi T, Watarai Y. Two-Year Outcomes of Low-Exposure Extended-Release Tacrolimus and Mycophenolate Mofetil Regimen in De Novo Kidney Transplantation: A Multi-center Randomized Controlled Trial. Clin Transplant 2022; 36:e14655. [PMID: 35343620 DOI: 10.1111/ctr.14655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 03/08/2022] [Accepted: 03/18/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Once-daily extended-release tacrolimus (TACER) is commonly administered following kidney transplantation (KTx); however, its optimal dosage remains unknown. METHODS In this multi-center, randomized controlled trial, 62 living donor KTx recipients were assigned to either standard-exposure (SE; n = 32) or low-exposure (LE; n = 30) TACER (Graceptor®, Astellas Pharm Inc.) groups. All patients received basiliximab and mycophenolate mofetil (MMF). The primary outcomes were acute rejection, graft/patient survival, and the secondary outcomes were incidence of cytomegalovirus infection, and de novo donor-specific antibodies (dnDSA) production. RESULTS The tacrolimus trough level and estimated area under the blood concentration-time curve (eAUC) were significantly higher in SE than in LE (SE vs LE; one year: 5.0 ± 0.9 ng/mL and 206.9 ± 26.8 ngཥh/mL vs 3.4 ± 1.0 ng/mL and 153.9 ± 26.4 ngཥh/mL; two years: 4.8 ± 1.0 ng/mL and 204.9 ± 30.1 ngཥh/mL vs 3.8 ± 0.9 ng/mL and 164.4 ± 27.0 ngཥh/mL). In contrast, the dosage and eAUC of MMF did not differ between groups. Two-year graft and patient survival rates were 100% in both groups, and acute rejection rates were 0% and 10% in the SE and LE, respectively (p = 0.11). The mean estimated glomerular filtration rates did not differ between the groups. Cytomegalovirus infection was slightly lower in the LE (SE: 12.5% and LE: 6.7%, p = 0.37). In the LE, four cases of dnDSA were noted within two years of transplantation; no case was observed in the SE (p = 0.034). CONCLUSIONS Although the LE TACER regimen showed similar rates of acute rejection, as well as graft and patient survival compared with SE after KTx, LE was significantly more associated with dnDSA. Further investigation of its long-term effect on graft survival is warranted. (University Hospital Medical Information Network Clinical Trials Registry ID: UMIN000033089). This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Yuji Hidaka
- Department of Surgery, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan.,Department of Renal Transplant Surgery, Aichi Medical University School of Medicine, Aichi, Japan
| | - Norihiko Goto
- Department of Transplant Nephrology and Transplant Surgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan
| | - Shigeyoshi Yamanaga
- Department of Surgery, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
| | - Kohei Kinoshita
- Department of Surgery, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
| | - Kosuke Tanaka
- Department of Surgery, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
| | - Chiaki Kawabata
- Department of Nephrology, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
| | - Mariko Toyoda
- Department of Nephrology, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
| | - Toshihide Tomosugi
- Department of Transplant Nephrology and Transplant Surgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan
| | - Kenta Futamura
- Department of Transplant Nephrology and Transplant Surgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan
| | - Manabu Okada
- Department of Transplant Nephrology and Transplant Surgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan
| | - Makoto Tsujita
- Department of Transplant Nephrology and Transplant Surgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan
| | - Takahisa Hiramitsu
- Department of Transplant Nephrology and Transplant Surgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan
| | - Hiroshi Yokomizo
- Department of Surgery, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
| | - Akira Miyata
- Department of Nephrology, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
| | - Shunji Narumi
- Department of Transplant Nephrology and Transplant Surgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan
| | - Takaaki Kobayashi
- Department of Renal Transplant Surgery, Aichi Medical University School of Medicine, Aichi, Japan
| | - Yoshihiko Watarai
- Department of Transplant Nephrology and Transplant Surgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan
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17
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Budde K, Rostaing L, Maggiore U, Piotti G, Surace D, Geraci S, Procaccianti C, Nicolini G, Witzke O, Kamar N, Albano L, Büchler M, Pascual J, Gutiérrez-Dalmau A, Kuypers D, Wekerle T, Głyda M, Carmellini M, Tisone G, Midtvedt K, Wennberg L, Grinyó JM. Prolonged-Release Once-Daily Formulation of Tacrolimus Versus Standard-of-Care Tacrolimus in de novo Kidney Transplant Patients Across Europe. Transpl Int 2022; 35:10225. [PMID: 36017158 PMCID: PMC9397503 DOI: 10.3389/ti.2021.10225] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 12/27/2021] [Indexed: 11/24/2022]
Abstract
Background: Tacrolimus is the calcineurin inhibitor of choice for preventing acute rejection episodes in kidney transplant patients. However, tacrolimus has a narrow therapeutic range that requires regular monitoring of blood concentrations to minimize toxicity. A new once-daily tacrolimus formulation, LCP-tacrolimus (LCPT), has been developed, which uses MeltDose™ drug-delivery technology to control drug release and enhance overall bioavailability. Our study compared dosing of LCPT with current standard-of-care tacrolimus [immediate-release tacrolimus (IR-Tac) or prolonged-release tacrolimus (PR-Tac)] during the 6 months following de novo kidney transplantation. Comparisons of graft function, clinical outcomes, safety, and tolerability for LCPT versus IR-Tac/PR-Tac were also performed. Methods: Standard immunological risk patients with end-stage renal disease who had received a de novo kidney transplant were randomized (1:1) to LCPT (N = 200) or IR-Tac/PR-Tac (N = 201). Results: Least squares (LS) mean tacrolimus total daily dose from Week 3 to Month 6 was significantly lower for LCPT than for IR-Tac/PR-Tac. Although LS mean tacrolimus trough levels were significantly higher for LCPT than IR-Tac/PR-Tac, tacrolimus trough levels remained within the standard reference range for most patients. There were no differences between the groups in treatment failure measures or safety profile. Conclusion: LCPT can achieve similar clinical outcomes to other tacrolimus formulations, with a lower daily dose. Clinical Trial Registration:https://clinicaltrials.gov/, identifier NCT02432833.
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Affiliation(s)
- Klemens Budde
- Department of Nephrology, Charité Universitätsmedizin Berlin, Berlin, Germany
- *Correspondence: Klemens Budde,
| | - Lionel Rostaing
- Service de Néphrologie, Dialyse, Aphérèses et Transplantation, CHU Grenoble Alpes, Grenoble, France
| | - Umberto Maggiore
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | | | | | | | | | | | - Oliver Witzke
- Department of Infectious Diseases, West German Centre of Infectious Diseases, Universitätsmedizin Essen, University of Duisburg-Essen, Essen, Germany
| | - Nassim Kamar
- Departments of Nephrology and Organ Transplantation, CHU Rangueil, INSERM U1043, IFR–BMT, Université Paul Sabatier, Toulouse, France
| | - Laetitia Albano
- Unité de Transplantation Rénale, Hôpital Pasteur 2, CHU Nice, Nice, France
| | - Matthias Büchler
- Service de Néphrologie et Transplantation Rénale, CHRU de Tours, Tours, France
| | - Julio Pascual
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
| | - Alex Gutiérrez-Dalmau
- Department of Nephrology, Hospital Universitario Miguel Servet, IIS Aragón, Zaragoza, Spain
| | - Dirk Kuypers
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Thomas Wekerle
- Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Maciej Głyda
- Department of Transplantology, Surgery and Urology, District Hospital, Poznan, Poland, and Nicolaus Copernicus University Collegium Medicum, Bydgoszcz, Poland
| | - Mario Carmellini
- Department of Surgery and Bioengineering, University of Siena, Siena, Italy
| | | | - Karsten Midtvedt
- Department of Transplant Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Lars Wennberg
- Department of Transplantation Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Josep M. Grinyó
- Department of Nephrology, Hospital Universitari de Bellvitge, University of Barcelona, Barcelona, Spain
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18
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Bunthof KLW, Al-Hassany L, Nakshbandi G, Hesselink DA, van Schaik RHN, Ten Dam MAGJ, Baas MC, Hilbrands LB, van Gelder T. A randomized crossover study comparing different tacrolimus formulations to reduce intrapatient variability in tacrolimus exposure in kidney transplant recipients. Clin Transl Sci 2021; 15:930-941. [PMID: 34905302 PMCID: PMC9010272 DOI: 10.1111/cts.13206] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 10/23/2021] [Accepted: 11/17/2021] [Indexed: 12/05/2022] Open
Abstract
A high intrapatient variability (IPV) in tacrolimus exposure is a risk factor for poor long‐term outcomes after kidney transplantation. The main objective of this trial was to investigate whether tacrolimus IPV decreases after switching patients from immediate‐release (IR)‐tacrolimus to either extended‐release (ER)‐tacrolimus or LifeCyclePharma (LCP)‐tacrolimus. In this randomized, prospective, open‐label, cross‐over trial, adult kidney transplant recipients on a stable immunosuppressive regimen, including IR‐tacrolimus, were randomized for conversion to ER‐tacrolimus or LCP‐tacrolimus, and for the order in which IR‐tacrolimus and the once‐daily formulations were taken. Patients were followed 6 months for each formulation, with monthly tacrolimus predose concentration assessments to calculate the IPV. The IPV was defined as the coefficient of variation (%) of dose corrected predose concentrations. Ninety‐two patients were included for analysis of the primary outcome. No significant differences between the IPV of IR‐tacrolimus (16.6%) and the combined once‐daily formulations (18.3%) were observed (% difference +1.7%, 95% confidence interval [CI] −1.1% to ‒4.5%, p = 0.24). The IPV of LCP‐tacrolimus (20.1%) was not significantly different from the IPV of ER‐tacrolimus (16.5%, % difference +3.6%, 95% CI −0.1% to 7.3%, p = 0.06). In conclusion, the IPV did not decrease after switching from IR‐tacrolimus to either ER‐tacrolimus or LCP‐tacrolimus. These results provide no arguments to switch kidney transplant recipients from twice‐daily (IR) tacrolimus formulations to once‐daily (modified‐release) tacrolimus formulations when the aim is to lower the IPV.
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Affiliation(s)
- Kim L W Bunthof
- Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Internal Medicine, Bravis Hospital, Roosendaal, The Netherlands
| | - Linda Al-Hassany
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Gizal Nakshbandi
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Dennis A Hesselink
- Internal Medicine, Division of Nephrology and Transplantation, Erasmus University Medical Center, Rotterdam, The Netherlands.,Erasmus University Medical Center, Erasmus MC Transplant Institute, Rotterdam, The Netherlands
| | - Ron H N van Schaik
- Clinical Chemistry, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Marc A G J Ten Dam
- Department of Internal Medicine, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Marije C Baas
- Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Luuk B Hilbrands
- Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Teun van Gelder
- Internal Medicine, Division of Nephrology and Transplantation, Erasmus University Medical Center, Rotterdam, The Netherlands.,Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
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19
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Fernandez Rivera C, Calvo Rodríguez M, Poveda JL, Pascual J, Crespo M, Gomez G, Cabello Pelegrin S, Paul J, Lauzurica R, Perez Mir M, Moreso F, Perelló M, Andres A, González E, Fernandez A, Mendiluce A, Fernández Carbajo B, Sanchez Fructuoso A, Calvo N, Suarez A, Bernal Blanco G, Osuna A, Ruiz-Fuentes MC, Melilli E, Montero Perez N, Ramos A, Fernández B, López V, Hernandez D. Bioavailability of once-daily tacrolimus formulations used in clinical practice in the management of De Novo kidney transplant recipients: the better study. Clin Transplant 2021; 36:e14550. [PMID: 34851532 PMCID: PMC9285676 DOI: 10.1111/ctr.14550] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 10/26/2021] [Accepted: 11/13/2021] [Indexed: 12/21/2022]
Abstract
Multicenter, prospective, observational study to compare the relative bioavailability of once‐daily tacrolimus formulations in de novo kidney transplant recipients. De novo kidney transplant recipients who started a tacrolimus‐based regimen were included 14 days post‐transplant and followed up for 6 months. Data from 218 participants were evaluated: 129 in the LCPT group (Envarsus) and 89 in the PR‐Tac (Advagraf) group. Patients in the LCPT group exhibited higher relative bioavailability (Cmin /total daily dose [TDD]) vs. PR‐Tac (61% increase; P < .001) with similar Cmin and 30% lower TDD levels (P < .0001). The incidence of treatment failure was 3.9% in the LCPT group and 9.0% in the PR‐Tac group (P = .117). Study discontinuation rates were 6.2% in the LCPT group and 12.4% in the PR‐Tac group (P = .113). Adverse events, renal function and other complications were comparable between groups. The median accumulated dose of tacrolimus in the LCPT group from day 14 to month 6 was 889 mg. Compared to PR‐Tac, LCPT showed higher relative bioavailability, similar effectiveness at preventing allograft rejection, comparable effect on renal function, safety, adherence, treatment failure and premature discontinuation rates.
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Affiliation(s)
| | | | | | - Julio Pascual
- Nephrology Department, University Hospital del Mar, Barcelona, Spain
| | - Marta Crespo
- Nephrology Department, University Hospital del Mar, Barcelona, Spain
| | - Gonzalo Gomez
- Nephrology Department, University Hospital Son Espases, Palma de Mallorca, Spain
| | | | - Javier Paul
- Nephrology Department, Hospital Miguel Servet, Zaragoza, Spain
| | - Ricardo Lauzurica
- Nephrology Department, University Hospital Germans Trias y Pujol, Badalona, Spain
| | - Mònica Perez Mir
- Nephrology Department, University Hospital Germans Trias y Pujol, Badalona, Spain
| | - Francesc Moreso
- University Hospital Vall d'Hebron, Department of Medicine, Universitat Autònoma de Barcelona, Nephrology Department, Barcelona, Spain
| | - Manel Perelló
- University Hospital Vall d'Hebron, Department of Medicine, Universitat Autònoma de Barcelona, Nephrology Department, Barcelona, Spain
| | - Amado Andres
- Nephrology Department, University Hospital Doce de Octubre, Madrid, Spain
| | - Esther González
- Nephrology Department, University Hospital Doce de Octubre, Madrid, Spain
| | - Ana Fernandez
- Nephrology Department, University Hospital Ramón y Cajal, Madrid, Spain
| | - Alicia Mendiluce
- Nephrology Department, University Hospital Clínico de Valladolid, Valladolid, Spain
| | | | | | - Natividad Calvo
- Nephrology Department, University Hospital Clínico San Carlos, Madrid, Spain
| | - Alejandro Suarez
- Nephrology Department, University Hospital Virgen del Rocio, Sevilla, Spain
| | | | - Antonio Osuna
- Nephrology Department, University Hospital Virgen de las Nieves, Granada, Spain
| | | | - Edoardo Melilli
- Nephrology Department, University Hospital Bellvitge, Hospitalet de Llobregat, Spain
| | - Nuria Montero Perez
- Nephrology Department, University Hospital Bellvitge, Hospitalet de Llobregat, Spain
| | - Ana Ramos
- Nephrology Department, Fundación Jiménez Díaz, Madrid, Spain
| | | | - Verónica López
- University Hospital Regional, Málaga, IBIMA, University of Málaga, REDinREN (RED16/0009/0006), Nephrology Department, Spain
| | - Domingo Hernandez
- University Hospital Regional, Málaga, IBIMA, University of Málaga, REDinREN (RED16/0009/0006), Nephrology Department, Spain
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20
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Del Bello A, Gaible C, Longlune N, Hebral AL, Esposito L, Gandia P, Kamar N. Tacrolimus Intrapatient Variability After Switching From Immediate or Prolonged-Release to Extended-Release Formulation, After an Organ Transplantation. Front Pharmacol 2021; 12:602764. [PMID: 34690747 PMCID: PMC8529208 DOI: 10.3389/fphar.2021.602764] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 07/26/2021] [Indexed: 01/06/2023] Open
Abstract
Background and Purpose: Several formulations of tacrolimus are available, but evidence of the benefit of changing to the most recent formulations is lacking. Tacrolimus intra-patient variability (tacrolimus IPV) is an emerging risk factor associated with poor graft outcomes after solid organ transplantations. Here, we examined the modifications of tacrolimus IPV after switching to a different formulation of tacrolimus. Experimental Approach: We identified 353 solid organ transplant recipients that were switched in our center from immediate-release (IR-tacrolimus) or prolonged-release tacrolimus (PR-tacrolimus) to extended-release, LCP-tacrolimus (LCP-tacrolimus). Among them, 54 patients underwent at least 3 available tacrolimus blood concentrations before and after the switch, allowing us to investigate tacrolimus IPV. Key Results: The switch was considered as a safe procedure since only four of the 353 patients presented a graft rejection after the switch, and no patient was hospitalized for tacrolimus overdose. The tacrolimus IPV estimated by the coefficient of variation (CV-IPV) was stable before and after the switch to LCP-tacrolimus (CV-IPV: 29.0% (IQR 25-75 (15.5; 38.5) before and 24.0% (15.8; 36.5) after the switch, p = 0.65). Conclusion and Implications: Switching from IR- or PR-tacrolimus to LCP-tacrolimus is a safe procedure. However, the CV-tacrolimus IPV was not impacted by the change of formulation.
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Affiliation(s)
- Arnaud Del Bello
- Department of Nephrology and Organ Transplantation, CHU Rangueil, Toulouse, France.,INSERM U1043, IFR-BMT, CHU Purpan, Toulouse, France.,Université Paul Sabatier, Toulouse, France
| | - Clotilde Gaible
- Department of Nephrology and Organ Transplantation, CHU Rangueil, Toulouse, France
| | - Nathalie Longlune
- Department of Nephrology and Organ Transplantation, CHU Rangueil, Toulouse, France
| | - Anne-Laure Hebral
- Department of Nephrology and Organ Transplantation, CHU Rangueil, Toulouse, France
| | - Laure Esposito
- Department of Nephrology and Organ Transplantation, CHU Rangueil, Toulouse, France
| | - Peggy Gandia
- Pharmacokinetics and Toxicology Laboratory, Toulouse University Hospital, Toulouse, France.,INTHERES, INRAE, ENVT, Université de Toulouse, Toulouse, France
| | - Nassim Kamar
- Department of Nephrology and Organ Transplantation, CHU Rangueil, Toulouse, France.,INSERM U1043, IFR-BMT, CHU Purpan, Toulouse, France.,Université Paul Sabatier, Toulouse, France
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21
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van Zyl JS, Sam T, Clark DM, Felius J, Doss AK, Kerlee KR, Cheung ZO, Martits-Chalangari K, Jamil AK, Carey SA, Gottlieb RL, Guerrero-Miranda CY, Kale P, Hall SA. De novo tacrolimus extended-release tablets (LCPT) versus twice-daily tacrolimus in adult heart transplantation: Results of a single-center non-inferiority matched control trial. Clin Transplant 2021; 35:e14487. [PMID: 34529289 PMCID: PMC9285033 DOI: 10.1111/ctr.14487] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 08/27/2021] [Accepted: 09/08/2021] [Indexed: 11/30/2022]
Abstract
Extended-release tacrolimus for prophylaxis of allograft rejection in orthotopic heart transplant (OHT) recipients is currently not FDA-approved. One such extended-release formulation of tacrolimus known as LCPT allows once-daily dosing and improves bioavailability compared to immediate-release tacrolimus (IR-tacrolimus). We compared the efficacy and safety of LCPT to IR-tacrolimus applied de novo in adult OHT recipients. Twenty-five prospective recipients on LCPT at our center from 2017 to 2019 were matched 1:2 with historical control recipients treated with IR-tacrolimus based on age, gender, and baseline creatinine. The primary composite outcome of death, acute cellular rejection, and/or new graft dysfunction within 1 year was compared using non-inferiority analysis. LCPT demonstrated non-inferiority to IR-tacrolimus, with a primary outcome risk reduction of 20% (90% CI: -40%, -.5%; non-inferiority P = .001). Tacrolimus trough levels peaked at 2-3 months and were higher in LCPT (median 14.5 vs. 12.7 ng/ml; P = .03) with similar dose levels (LCPT vs. IR-tacrolimus: .08 vs. .09 mg/kg/day; P = .33). Cardiovascular-related readmissions were reduced by 62% (P = .046) in LCPT patients. The complication rate per transplant admission and all-cause readmission rate did not differ significantly. These results suggest that LCPT is non-inferior in efficacy to IR-tacrolimus with a similar safety profile and improved bioavailability in OHT.
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Affiliation(s)
- Johanna S van Zyl
- Baylor Scott & White Research Institute, Baylor Scott & White Health, Dallas, Texas, USA.,Texas A&M University College of Medicine Health Science Center, Dallas, Texas, USA
| | - Teena Sam
- Department of Pharmacy, Baylor University Medical Center, Baylor Scott & White Health, Dallas, Texas, USA
| | - Donna M Clark
- Baylor Scott & White Research Institute, Baylor Scott & White Health, Dallas, Texas, USA
| | - Joost Felius
- Baylor Scott & White Research Institute, Baylor Scott & White Health, Dallas, Texas, USA.,Texas A&M University College of Medicine Health Science Center, Dallas, Texas, USA
| | - Amanda K Doss
- Baylor Scott & White Research Institute, Baylor Scott & White Health, Dallas, Texas, USA
| | - Kacie R Kerlee
- Texas A&M University College of Medicine Health Science Center, Dallas, Texas, USA
| | - Zi-On Cheung
- Texas A&M University College of Medicine Health Science Center, Dallas, Texas, USA
| | | | - Aayla K Jamil
- Baylor Scott & White Research Institute, Baylor Scott & White Health, Dallas, Texas, USA.,Texas A&M University College of Medicine Health Science Center, Dallas, Texas, USA
| | - Sandra A Carey
- Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Baylor Scott & White Health, Dallas, Texas, USA
| | - Robert L Gottlieb
- Baylor Scott & White Research Institute, Baylor Scott & White Health, Dallas, Texas, USA.,Texas A&M University College of Medicine Health Science Center, Dallas, Texas, USA.,Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Baylor Scott & White Health, Dallas, Texas, USA.,Division of Precision Medicine, Baylor University Medical Center, Dallas, Texas, USA
| | - Cesar Y Guerrero-Miranda
- Baylor Scott & White Research Institute, Baylor Scott & White Health, Dallas, Texas, USA.,Texas A&M University College of Medicine Health Science Center, Dallas, Texas, USA.,Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Baylor Scott & White Health, Dallas, Texas, USA
| | - Parag Kale
- Baylor Scott & White Research Institute, Baylor Scott & White Health, Dallas, Texas, USA.,Texas A&M University College of Medicine Health Science Center, Dallas, Texas, USA.,Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Baylor Scott & White Health, Dallas, Texas, USA
| | - Shelley A Hall
- Baylor Scott & White Research Institute, Baylor Scott & White Health, Dallas, Texas, USA.,Texas A&M University College of Medicine Health Science Center, Dallas, Texas, USA.,Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Baylor Scott & White Health, Dallas, Texas, USA
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22
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Tan T, Bunnapradist S. Comparing the pharmacokinetics of extended-release tacrolimus (LCP-TAC) to immediate-release formulations in kidney transplant patients. Expert Opin Drug Metab Toxicol 2021; 17:1175-1186. [PMID: 34459696 DOI: 10.1080/17425255.2021.1974399] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION One of the most commonly used immunosuppressants in organ transplant, tacrolimus exhibits wide interpatient and intrapatient variability and narrow therapeutic index that necessitates routine concentration monitoring and dosage adjustments. Availability of modified -release tacrolimus products offer once-daily dosing options. The objective of this review is to highlight and compare available pharmacokinetic (PK) data of extended-release tacrolimus tablets (LCP-TAC) to immediate-release tacrolimus (IR-TAC) in kidney transplant recipients. AREAS COVERED A review of the literature was performed using PubMed and Embase search to identify relevant articles evaluating PK data for LCP-TAC compared to IR-TAC in kidney transplant patients including special populations. EXPERT OPINION LCP-TAC's unique PK profile may be more favorable than IR-TAC. While the clinical impact of these PK differences have not been established, several outcomes are being evaluated in ongoing studies. Results of these studies will add information incrementally to care for kidney transplant patients. Larger prospective studies evaluating kidney and patient survival differences are needed but it is unlikely that they will be conducted. Given that the patent exclusivity of LCP-TAC for the next several years and imminent loss of exclusivity of PR-TAC, our opinion is the use of LCP-TAC will be increasing, especially in Europe.
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Affiliation(s)
- Teresa Tan
- Department of Pharmaceutical Services, Ronald Reagan UCLA Medical Center, Los Angeles, CA
| | - Suphamai Bunnapradist
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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23
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Hurwitz JT, Grizzle AJ, Tyler CS, Zapata LV, Malone DC. Cost-effectiveness of once-daily vs twice-daily tacrolimus among Hispanic and Black kidney transplant recipients. J Manag Care Spec Pharm 2021; 27:948-960. [PMID: 34185556 PMCID: PMC10390924 DOI: 10.18553/jmcp.2021.27.7.948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND: Tacrolimus is a first-line immunosuppressive therapy to prevent rejection and graft failure in kidney transplant recipients. Once-daily extended-release tacrolimus tablets (LCPT) have been shown to be efficacious, particularly for Hispanic and Black patient subpopulations who are rapid metabolizers, but is more costly than twice-daily immediate-release tacrolimus (IR-Tac). OBJECTIVE: To evaluate the cost-effectiveness of LCPT during the first year of treatment vs IR-Tac in kidney transplant recipients who are Hispanic or Black. METHODS: A decision analytic model from a US payer perspective was developed using (1) subgroup outcomes data pooled from two phase 3 clinical trials that compared LCPT and IR-Tac, and (2) direct costs from real-world data sources (ie, costs of LCPT and IR-Tac treatments, biopsy-proven acute rejection, treatment-related serious adverse events [SAEs], graft failure, and consequent dialysis). The primary outcome was cost per successfully treated patient, defined as having a functioning graft after 1 year and without treatment-related SAEs. Probabilistic sensitivity analyses established distributions for cost and outcomes estimates, and a series of one-way sensitivity analyses identified parameters that had the most effect on results. RESULTS: Total overall cost for the Hispanic group was $14,765 for LCPT and $12,416 for IR-Tac, and total cost in the Black group was $16,626 for LCPT and $9,871 for IR-Tac. Total overall effectiveness of LCPT and IR-Tac was 88.32% and 84.75% in the Hispanic group and 93.24% and 85.78% in the Black group, respectively. The incremental cost-effectiveness ratio (ICER) for using LCPT over IR-Tac during the first year of treatment in the Hispanic group was $65,643 per additional successfully treated patient. The ICER for the Black group was $90,458. The single parameter having the most impact on results in both groups was the probability of a treatment-related SAE in IR-Tac, which accounted for 49% of variation in results in the Hispanic group and 46% in the Black group. CONCLUSIONS: Overall results for both groups show that LCPT is incrementally more costly and more effective compared with IR-Tac, indicating a trade-off scenario. LCPT is a cost-effective strategy if a decision makers' willingness to pay for 1 additional successfully treated patient exceeds the ICER and must be weighed against the costs of graft loss, continuing dialysis, and potential retransplant. This study provides a foundation for further research to update and expand inputs as more data become available to improve real-world relevance and decision making. DISCLOSURES: This study was funded by Veloxis Pharmaceuticals, Inc., which provided clinical trial file data and nonbinding feedback on the model structure, data interpretation, clinical expertise, manuscript review, and areas of publication interest (ie, managed care). Hurwitz, Grizzle, Villa Zapata, and Malone received grant funding from Veloxis Pharmaceuticals, Inc., through University of Arizona to conduct research and analysis for this study. Tyler is employed by Veloxis Pharmaceuticals, Inc. Some of the data reported and used in this research were available from the US Renal Data System, the US Bureau of Labor Statistics, and the Agency for Healthcare Research and Quality's Healthcare Cost and Utility Project. The interpretation and reporting of these data are the responsibility of the authors and in no way should be seen as an official policy or interpretation of the US government.
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Affiliation(s)
- Jason T Hurwitz
- Center for Health Outcomes and PharmacoEconomic Research (HOPE Center), University of Arizona, Tucson
| | - Amy J Grizzle
- Center for Health Outcomes and PharmacoEconomic Research (HOPE Center), University of Arizona, Tucson
| | | | - Lorenzo Villa Zapata
- Department of Pharmacy Practice, College of Pharmacy, Mercer University, Atlanta, GA
| | - Daniel C Malone
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City
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24
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Faravardeh A, Akkina S, Villicana R, Guerra G, Moten MA, Meier-Kriesche U, Stevens DR, Patel SJ, Bunnapradist S. Efficacy and Safety of Once-Daily LCP-Tacrolimus Versus Twice-Daily Immediate-Release Tacrolimus in Adult Hispanic Stable Kidney Transplant Recipients: Sub-Group Analysis from a Phase 3 Trial. Ann Transplant 2021; 26:e929535. [PMID: 33859155 PMCID: PMC8056872 DOI: 10.12659/aot.929535] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND The pharmacokinetics and metabolism of tacrolimus, an immunosuppressant commonly used to prevent transplant rejection, can differ in specific subpopulations. This analysis examined treatment outcomes and safety of immediate-release tacrolimus (IR-Tac) and LCP-tacrolimus (LCPT) in stable Hispanic kidney transplant recipients. MATERIAL AND METHODS This was a post hoc analysis of clinical trial data from Hispanic adult stable kidney transplant recipients randomized to remain on IR-Tac or convert from IR-Tac to a reduced dose of LCPT (NCT00817206). Composite treatment failure was evaluated at 12 months. Estimated glomerular filtration rate and tacrolimus trough concentrations were evaluated over 12 months. RESULTS Fifty-five stable (LCPT n=26, IR-Tac n=29) kidney transplant recipients who self-identified as Hispanic or Latino were included in this analysis. Composite treatment failure occurred in 1 patient (4%) who converted to LCPT and 1 (3%) who remained on IR-Tac. The estimated glomerular filtration rate was stable over time and similar in the 2 treatment groups (P=0.08). Tacrolimus trough levels for both groups were similar over time in the 2 treatment groups (P=0.98). Treatment-emergent adverse events were similar in patients who converted to LCPT and in those who remained on IR-Tac. CONCLUSIONS Efficacy and safety were similar in Hispanic kidney transplant recipients who converted from IR-Tac to LCPT and in those remaining on IR-Tac.
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Affiliation(s)
| | - Sanjeev Akkina
- Loyola Outpatient Center, Loyola University Medical Center, Maywood, IL, USA
| | - Rafael Villicana
- Loma Linda University Transplant Institute, Loma Linda University Health, Loma Linda, CA, USA
| | - Giselle Guerra
- Miami Transplant Institute, University of Miami Health System, Miami, FL, USA
| | - Misbah A Moten
- Department of Medical Affairs, Veloxis Pharmaceuticals, Cary, NC, USA
| | | | - Daniel R Stevens
- Department of Medical Affairs, Veloxis Pharmaceuticals, Cary, NC, USA
| | - Samir J Patel
- Department of Medical Affairs, Veloxis Pharmaceuticals, Cary, NC, USA
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25
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January SE, Hagopian JC, Nesselhauf NM, Progar K, Horwedel TA, Santos RD. Clinical Experience with Extended-Release Tacrolimus in Older Adult Kidney Transplant Recipients: A Retrospective Cohort Study. Drugs Aging 2021; 38:397-406. [PMID: 33755934 DOI: 10.1007/s40266-021-00842-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Extended-release tacrolimus (LCP-Tac) prescribing information states that there is insufficient data in older adult patients from which to make recommendations on use in this population. This study sought to provide information on de novo use of LCP-Tac in the older adult kidney transplant population. METHODS This single-center retrospective study had two distinct objectives; to determine if weight-based doses of LCP-Tac differ based on recipient age and to compare safety and efficacy between LCP-Tac and immediate-release tacrolimus (IR-Tac) in older adult transplant recipients. Data was obtained through electronic chart review up to 2 years after transplant with censoring for graft loss and death. RESULTS Weight-based doses were compared between patients aged ≥ 65 years (n = 84), 36-64 years (n = 64), and ≤35 years (n = 44). LCP-Tac weight-based doses were lower at all time points in patients ≥ 65 years of age. Both age and race significantly impacted required dose on linear regression. The doses required to achieve therapeutic tacrolimus troughs were significantly lower in all age groups compared with the current FDA de novo dosing recommendation. In the older adult population, graft outcomes and infectious and metabolic complications were compared between recipients of LCP-Tac (n = 84) and IR-Tac (n = 42). Within this cohort, there were no differences between LCP-Tac and IR-Tac on graft function, rejection, graft loss, death, cytomegalovirus viremia, BK viremia, hypertension, diabetes, alopecia, or tremor up to 2 years after transplant. CONCLUSIONS Older adult recipients required significantly lower LCP-Tac doses compared with younger recipients and with the FDA-labeled starting dose. There were no differences in graft outcomes or adverse effects in older adult patients who received LCP-Tac versus IR-Tac.
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Affiliation(s)
- Spenser E January
- Department of Pharmacy, Barnes-Jewish Hospital, 1 Barnes-Jewish Hospital Plaza, Mailstop 90-52-411, Saint Louis, MO, 63130, USA.
| | - Jennifer C Hagopian
- Department of Pharmacy, Barnes-Jewish Hospital, 1 Barnes-Jewish Hospital Plaza, Mailstop 90-52-411, Saint Louis, MO, 63130, USA
| | - Nicole M Nesselhauf
- Department of Pharmacy, Barnes-Jewish Hospital, 1 Barnes-Jewish Hospital Plaza, Mailstop 90-52-411, Saint Louis, MO, 63130, USA
| | - Kristin Progar
- Department of Pharmacy, Barnes-Jewish Hospital, 1 Barnes-Jewish Hospital Plaza, Mailstop 90-52-411, Saint Louis, MO, 63130, USA
| | | | - Rowena Delos Santos
- Division of Nephrology, Washington University in Saint Louis, Saint Louis, MO, USA
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26
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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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27
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Jorgenson MR, Descourouez JL, Brady BL, Bowman L, Hammad S, Kaiser TE, Laub MR, Melaragno JI, Park JM, Chandran MM. Alternatives to immediate release tacrolimus in solid organ transplant recipients: When the gold standard is in short supply. Clin Transplant 2020; 34:e13903. [DOI: 10.1111/ctr.13903] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 04/25/2020] [Accepted: 05/07/2020] [Indexed: 12/28/2022]
Affiliation(s)
| | | | - Bethany L. Brady
- Pharmacy Department Indiana University Health University Hospital Indianapolis IN USA
| | - Lyndsey Bowman
- Department of Pharmacy Tampa General Hospital Tampa FL USA
| | - Sara Hammad
- Department of Pharmacy University of Maryland Medical Center Baltimore MD USA
| | - Tiffany E. Kaiser
- Department of Pharmacy University of Cincinnati Medical Center Cincinnati OH USA
| | - Melissa R. Laub
- Department of Pharmacy Augusta University Medical Center Augusta GA USA
| | | | - Jeong M. Park
- Department of Clinical Pharmacy University of Michigan College of Pharmacy Ann Arbor MI USA
| | - Mary M. Chandran
- Department of Pharmacy Children's Hospital of Colorado Aurora CO USA
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Chronopharmacokinetics and Food Effects of Single-Dose LCP-Tacrolimus in Healthy Volunteers. Ther Drug Monit 2020; 42:679-685. [DOI: 10.1097/ftd.0000000000000773] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Alshamsan A, Binkhathlan Z, Kalam MA, Qamar W, Kfouri H, Alghonaim M, Lavasanifar A. Mitigation of Tacrolimus-Associated Nephrotoxicity by PLGA Nanoparticulate Delivery Following Multiple Dosing to Mice while Maintaining its Immunosuppressive Activity. Sci Rep 2020; 10:6675. [PMID: 32317681 PMCID: PMC7174389 DOI: 10.1038/s41598-020-63767-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 04/06/2020] [Indexed: 12/13/2022] Open
Abstract
The aim of this study was to assess the ability of PLGA nanoparticles (NPs) to reduce the tacrolimus (TAC)-associated nephrotoxicity following multiple dose administration. The mean diameter of prepared NPs was in the range of 227 to 263 nm with an 8.32% drug loading (w/w). Moreover, in vitro release profile of TAC-loaded NPs showed a sustained release of the drug with only less than 30% release within 12 days. Flow cytometry as well as fluorescence microscopy results confirmed the uptake of FITC-labelled PLGA NPs by dendritic cells. The ex vivo study showed that TAC-loaded NPs caused a significant suppression of the proliferation of CD4+ and CD8+ cells, which was comparable to the control formulation (Prograf). In vivo immunosuppressive activity as well as the kidney function were assessed following drug administration to mice. The animals received TAC subcutaneously at a daily dose of 1 mg/kg for 30 days delivered as the control formulation (Prograf) or TAC-loaded NPs. The results revealed significantly lower drug-associated toxicity with an activity comparable to Prograf for TAC-loaded PLGA NPs. These findings show a potential for PLGA NPs in reducing the nephrotoxicity of TAC while preserving the immunosuppressive activity.
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Affiliation(s)
- Aws Alshamsan
- Nanobiotechnology Unit, College of Pharmacy, King Saud University, P.O. Box 2457, Riyadh, 11451, Saudi Arabia. .,Department of Pharmaceutics, College of Pharmacy, King Saud University, P.O. Box 2457, Riyadh, 11451, Saudi Arabia.
| | - Ziyad Binkhathlan
- Nanobiotechnology Unit, College of Pharmacy, King Saud University, P.O. Box 2457, Riyadh, 11451, Saudi Arabia.,Department of Pharmaceutics, College of Pharmacy, King Saud University, P.O. Box 2457, Riyadh, 11451, Saudi Arabia.,Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Alberta, T6G 2H7, Canada
| | - Mohd Abul Kalam
- Nanobiotechnology Unit, College of Pharmacy, King Saud University, P.O. Box 2457, Riyadh, 11451, Saudi Arabia.,Department of Pharmaceutics, College of Pharmacy, King Saud University, P.O. Box 2457, Riyadh, 11451, Saudi Arabia
| | - Wajhul Qamar
- Central Laboratory, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia.,Department of Pharmacology and Toxicology, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Hala Kfouri
- Department of Pathology, College of Medicine, King Saud University, Riyadh, 11451, Saudi Arabia
| | - Mohammed Alghonaim
- King Salman Bin Abdulaziz Chair for Kidney Disease, King Saud University, Riyadh, 11451, Saudi Arabia
| | - Afsaneh Lavasanifar
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Alberta, T6G 2H7, Canada.,Department of Chemical and Material Engineering, University of Alberta, Edmonton, Alberta, T6G 2V4, Canada
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Camilleri B, Pararajasingam R, Buttigieg J, Halawa A. Immunosuppression strategies in elderly renal transplant recipients. Transplant Rev (Orlando) 2020; 34:100529. [DOI: 10.1016/j.trre.2020.100529] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 11/09/2019] [Accepted: 12/18/2019] [Indexed: 01/23/2023]
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31
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Torabi J, Konicki A, Rocca JP, Ajaimy M, Campbell A, Azzi Y, Pynadath C, Liriano-Ward L, Akalin E, Kinkhabwala M, Graham JA. The use of LCP-Tacrolimus (Envarsus XR) in simultaneous pancreas and kidney (SPK) transplant recipients. Am J Surg 2020; 219:583-586. [PMID: 32122660 DOI: 10.1016/j.amjsurg.2020.02.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 01/23/2020] [Accepted: 02/13/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Extended release LCP-tacrolimus (LCPT) allows once-daily dosing in transplant recipients. The improved bioavailability may be beneficial for simultaneous pancreas-kidney recipients (SPK). METHODS This is a study of 39 SPK recipients on standard immediate-release tacrolimus (IR-TAC, n = 21) or LCPT (n = 18). Coefficient of variability (CV = 100∗standard deviation/mean) was calculated to assess drug levels. Hemoglobin A1c (HbA1c), tacrolimus and creatinine levels were measured postoperatively. RESULTS There was no difference in tacrolimus CV in the IR-TAC and LCPT groups at 1 month or 3 months postoperatively; however, a greater difference was observed at 1 year (41.0 vs. 33.1%; p = 0.19). There were six episodes of acute rejection in the IR-TAC group compared to zero episodes in the LCPT group (p = 0.01). HbA1c was significantly higher in the IR-TAC group compared to LCPT at 3 (5.5 vs. 4.9%, p = 0.01), 6 (5.6 vs. 4.9%, p = 0.01) and 12 months (5.8 vs. 5.1%, p = 0.07). CONCLUSIONS Significantly lower rates of rejection were observed in patients receiving LCPT. The once daily dosing may facilitate medication adherence and result in improved long-term outcomes.
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Affiliation(s)
- Julia Torabi
- Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Juan P Rocca
- Albert Einstein College of Medicine, Bronx, NY, USA; Montefiore-Einstein Center for Transplantation, Montefiore Medical Center, Bronx, NY, USA
| | - Maria Ajaimy
- Albert Einstein College of Medicine, Bronx, NY, USA; Montefiore-Einstein Center for Transplantation, Montefiore Medical Center, Bronx, NY, USA
| | - Alesa Campbell
- Montefiore-Einstein Center for Transplantation, Montefiore Medical Center, Bronx, NY, USA
| | - Yorg Azzi
- Albert Einstein College of Medicine, Bronx, NY, USA; Montefiore-Einstein Center for Transplantation, Montefiore Medical Center, Bronx, NY, USA
| | - Cindy Pynadath
- Albert Einstein College of Medicine, Bronx, NY, USA; Montefiore-Einstein Center for Transplantation, Montefiore Medical Center, Bronx, NY, USA
| | - Luz Liriano-Ward
- Albert Einstein College of Medicine, Bronx, NY, USA; Montefiore-Einstein Center for Transplantation, Montefiore Medical Center, Bronx, NY, USA
| | - Enver Akalin
- Albert Einstein College of Medicine, Bronx, NY, USA; Montefiore-Einstein Center for Transplantation, Montefiore Medical Center, Bronx, NY, USA
| | - Milan Kinkhabwala
- Albert Einstein College of Medicine, Bronx, NY, USA; Montefiore-Einstein Center for Transplantation, Montefiore Medical Center, Bronx, NY, USA
| | - Jay A Graham
- Albert Einstein College of Medicine, Bronx, NY, USA; Montefiore-Einstein Center for Transplantation, Montefiore Medical Center, Bronx, NY, USA.
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32
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Oberbauer R, Bestard O, Furian L, Maggiore U, Pascual J, Rostaing L, Budde K. Optimization of tacrolimus in kidney transplantation: New pharmacokinetic perspectives. Transplant Rev (Orlando) 2020; 34:100531. [PMID: 31955920 DOI: 10.1016/j.trre.2020.100531] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 11/05/2019] [Accepted: 12/08/2019] [Indexed: 02/07/2023]
Abstract
Tacrolimus is the cornerstone of immunosuppressive therapy after kidney transplantation (KT), but its use is complicated by a narrow therapeutic index and high inter- and intra-patient pharmacokinetic variability. There are three available oral formulations of tacrolimus: immediate-release tacrolimus (IR-Tac), extended-release tacrolimus (ER-Tac) and a MeltDose® (LCPT) formulation, the latter favoring a prolonged drug release and increased bioavailability. The time-concentration curves of these formulations are different. Compared with IR-Tac and ER-Tac, LCPT has a relatively flat pharmacokinetic profile with less fluctuation between trough and peak exposures, and a delayed peak concentration. This translates to a more stable delivery of tacrolimus and may alleviate the risk of underexposure and allograft rejection or overexposure and toxicity. The once-daily formulation of both ER-TAC and LCPT may also offer a potential advantage on patient adherence. Fast metabolizers of tacrolimus, the elderly, and human leukocyte antigen-sensitized patients are at risk of poorer outcomes after KT, possibly associated with a different exhibited pharmacokinetics of tacrolimus or different requirements in terms of exposure. Simple, practical strategies are needed to identify patients at risk of suboptimal KT outcomes and those who would benefit from a more proactively personalized approach to tacrolimus treatment. This review aims to increase awareness of the link between the pharmacokinetics of oral tacrolimus formulations and the clinical needs of patients after KT, particularly among those who have clinically significant pharmacokinetic variation of tacrolimus.
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Affiliation(s)
- Rainer Oberbauer
- Department of Nephrology, Medical University of Vienna, Vienna, Austria
| | - Oriol Bestard
- Kidney Transplant Unit, Nephrology department, Bellvitge University Hospital, Barcelona, Spain
| | - Lucrezia Furian
- Kidney and Pancreas Transplantation Unit, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Italy
| | - Umberto Maggiore
- Kidney and Kidney-Pancreas Transplant Unit (Department of Nephrology), Parma University Hospital, Parma, Italy
| | - Julio Pascual
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
| | - Lionel Rostaing
- Nephrology and Transplantation Department, CHU Grenoble, Grenoble, France
| | - Klemens Budde
- Department of Nephrology, Internal Intensive Care Medicine, Campus Charité Mitte, Berlin, Germany.
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33
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Sánchez Fructuoso A, Ruiz JC, Franco A, Diekmann F, Redondo D, Calviño J, Serra N, Aladrén MJ, Cigarrán S, Manonelles A, Ramos A, Gómez G, González Posada JM, Andrés A, Beneyto I, Muñiz AL, Perelló M, Lauzurica R. Effectiveness and safety of the conversion to MeltDose ® extended-release tacrolimus from other formulations of tacrolimus in stable kidney transplant patients: A retrospective study. Clin Transplant 2019; 34:e13767. [PMID: 31815310 PMCID: PMC7050537 DOI: 10.1111/ctr.13767] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 11/14/2019] [Accepted: 11/25/2019] [Indexed: 12/24/2022]
Abstract
Tacrolimus is the cornerstone of immunosuppressive therapy after kidney transplantation. Its narrow therapeutic window mandates serum level strict monitoring and dose adjustments to ensure the optimal risk‐benefit balance. This observational retrospective study analyzed the effectiveness and safety of conversion from twice‐daily immediate‐release tacrolimus (IR‐Tac) or once‐daily prolonged‐release tacrolimus (PR‐Tac) to the recent formulation once‐daily MeltDose® extended‐release tacrolimus (LCP‐Tac) in 365 stable kidney transplant recipients. We compared kidney function three months before and three months after the conversion. Three months after conversion, the total daily dose was reduced ~35% (P < .0001), and improved bioavailability and stable serum LCP‐Tac concentrations were observed. There was no increase in the number of patients requiring tacrolimus dose adjustments after conversion. Renal function was unaltered, and no cases of BPAR were reported. Reports of tremors, as collected in the clinical histories for each patient, decreased from pre‐conversion (20.8%) to post‐conversion (11.8%, P < .0001). LCP‐Tac generated a cost reduction of 63% compared with PR‐Tac. In conclusion, the conversion strategy to LCP‐Tac from other tacrolimus formulations in stable kidney transplant patients showed safety and effectiveness in a real‐world setting, confirming the data from RCTs. The specific pharmacokinetic properties of LCP‐Tac could be potentially advantageous in patients with tacrolimus‐related adverse events.
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Affiliation(s)
| | - Juan Carlos Ruiz
- Nephrology, University Hospital Marqués de Valdecilla, Santander, Spain
| | - Antonio Franco
- Nephrology, University Hospital General, Alicante, Spain
| | - Fritz Diekmann
- Nephrology, University Hospital Clinic, Barcelona, Spain
| | | | | | - Nuria Serra
- Nephrology, Fundación Puigvert, Barcelona, Spain
| | | | | | - Ana Manonelles
- Nephrology, University Hospital Bellvitge, Hospitalet de Llobregat, Spain
| | - Ana Ramos
- Nephrology, Fundación Jiménez Díaz, Madrid, Spain
| | - Gonzalo Gómez
- Nephrology, University Hospital son Espases, Palma de Mallorca, Spain
| | | | - Amado Andrés
- Nephrology, University Hospital Doce de Octubre, Madrid, Spain
| | | | | | - Manel Perelló
- Nephrology, University Hospital Vall de Hebrón, Barcelona, Spain
| | - Ricardo Lauzurica
- Nephrology, University Hospital Germans Trias y Pujol, Badalona, Spain
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34
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DuBay DA, Teperman L, Ueda K, Silverman A, Chapman W, Alsina AE, Tyler C, Stevens DR. Pharmacokinetics of Once-Daily Extended-Release Tacrolimus Tablets Versus Twice-Daily Capsules in De Novo Liver Transplant. Clin Pharmacol Drug Dev 2019; 8:995-1008. [PMID: 30667591 PMCID: PMC6899533 DOI: 10.1002/cpdd.657] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 12/28/2018] [Indexed: 11/26/2022]
Abstract
The pharmacokinetics of once-daily extended-release tacrolimus tablets (LCPT) in de novo liver transplantation have not been previously reported. In this phase II, randomized, open-label study, de novo liver transplant recipients were randomized to LCPT 0.07-0.13 mg/kg/day (taken once daily; n = 29) or twice-daily immediate-release tacrolimus capsules (IR-Tac) at 0.10-0.15 mg/kg/day (divided twice daily; n = 29). Subsequent doses of both drugs were adjusted to maintain tacrolimus trough concentrations of 5 to 20 ng/mL through day 90, and 5-15 ng/mL thereafter. Twenty-four-hour pharmacokinetic profiles were obtained on days 1, 7, and 14, with trough concentration and efficacy/safety monitoring through year 1. Similar proportions of patients in both groups achieved therapeutic trough concentrations on days 7 and 14 (day 7: LCPT = 78%, IR-Tac = 75%; day 14: LCPT = 86%, IR-Tac = 91%) as well as similar systemic and peak exposure. There was a robust correlation between drug concentration at time 0 and area under the concentration-time curve for both LCPT and IR-Tac (respectively, day 7: r = 0.86 and 0.79; day 14: r = 0.93 and 0.86; P < .0001 for all). Dose adjustments during days 1 to 14 were frequent. Thirty-five patients completed the extended-use period. No significant differences in adverse events were seen between groups. Incidence of biopsy-proven acute rejection (LCPT = 6 and IR-Tac = 4) was similar on day 360. Between formulations, overall exposure was similar at 1 week after transplant with the characteristic delayed-release pharmacokinetic profile of LCPT demonstrated in this novel population. These data support further investigation of the safety and efficacy of LCPT in de novo liver transplantation.
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Affiliation(s)
- Derek A DuBay
- Medical University of South Carolina, Department of Surgery, Charleston, SC, USA
| | | | - Kimi Ueda
- California Pacific Medical Center, San Francisco, CA, USA
| | | | - William Chapman
- Washington University School of Medicine, Department of Surgery, St Louis, MO, USA
| | - Angel E Alsina
- Tampa General Hospital, Division of Transplantation, Tampa, FL, USA
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Franco A, Más-Serrano P, Balibrea N, Rodriguez D, Javaloyes A, Díaz M, Gascón I, Ramon-Lopez A, Perez-Contreras J, Selva J, Nalda-Molina R. Envarsus, a novelty for transplant nephrologists: Observational retrospective study. Nefrologia 2019; 39:506-512. [PMID: 30850218 DOI: 10.1016/j.nefro.2018.11.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 11/06/2018] [Accepted: 11/09/2018] [Indexed: 11/29/2022] Open
Abstract
The aim of this study was to evaluate the trough concentrations (Cptrough) and the tacrolimus dosage regimen after the conversion of Prograf or Advagraf to Envarsus (new pharmaceutical form with MeltDose technology that improves the absorption of fat-soluble drugs) in patients with stable renal transplantation, and their renal function. We selected stable renal transplant patients who were converted to Envarsus. Two periods were defined: Baseline and Conversion (Envarsus) and they were stratified according to the pharmaceutical form used in the Baseline period. Sixty-one patients were included (24 with Advagraf and 37 with Prograf), with an average age of 52years. The mean post-transplant time at the time of conversion to Envarsus was 76.3months and the mean follow-up in the Baseline and Conversion period was 10.1months and 11.6months, respectively. In the Prograf and Envarsus group, the Cptrough medians were 6.6 vs 6.4 ng/mL (P=.636), with a mean daily dose that decreased significantly from 3mg to 2mg (P<.001), respectively, maintaining the filtration rate. The median Cptrough values in the Advagraf and Envarsus groups were 5.7ng/mL and 6.3ng/mL (P=.07), with a median daily dose of 7mg and 4mg (P<.001), respectively, and the same renal function. In stable renal transplant patients, the conversion from Advagraf to Envarsus has allowed the dose of tacrolimus to be reduced by 42.9% and, in the case of Prograf, by 33.3%, maintaining similar Cptrough values, without renal function being altered.
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Affiliation(s)
- Antonio Franco
- Servicio de Nefrología, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL-Fundación FISABIO), Hospital General Universitario de Alicante, Alicante, España.
| | - Patricio Más-Serrano
- Servicio de Farmacia, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL-Fundación FISABIO), Hospital General Universitario de Alicante, Alicante, España; Área de Farmacia y Tecnología Farmacéutica, Departamento de Ingeniería, Universidad Miguel Hernández de Elche; Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL-Fundación FISABIO), Elche, Alicante, España
| | - Noelia Balibrea
- Servicio de Nefrología, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL-Fundación FISABIO), Hospital General Universitario de Alicante, Alicante, España
| | - David Rodriguez
- Servicio de Nefrología, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL-Fundación FISABIO), Hospital General Universitario de Alicante, Alicante, España
| | - Aurora Javaloyes
- Servicio de Farmacia, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL-Fundación FISABIO), Hospital General Universitario de Alicante, Alicante, España
| | - Marcos Díaz
- Servicio de Farmacia, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL-Fundación FISABIO), Hospital General Universitario de Alicante, Alicante, España
| | - Isabel Gascón
- Servicio de Farmacia, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL-Fundación FISABIO), Hospital General Universitario de Alicante, Alicante, España
| | - Amelia Ramon-Lopez
- Área de Farmacia y Tecnología Farmacéutica, Departamento de Ingeniería, Universidad Miguel Hernández de Elche; Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL-Fundación FISABIO), Elche, Alicante, España
| | - Javier Perez-Contreras
- Servicio de Nefrología, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL-Fundación FISABIO), Hospital General Universitario de Alicante, Alicante, España
| | - Juan Selva
- Servicio de Farmacia, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL-Fundación FISABIO), Hospital General Universitario de Alicante, Alicante, España; Área de Farmacia y Tecnología Farmacéutica, Departamento de Ingeniería, Universidad Miguel Hernández de Elche; Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL-Fundación FISABIO), Elche, Alicante, España
| | - Ricardo Nalda-Molina
- Área de Farmacia y Tecnología Farmacéutica, Departamento de Ingeniería, Universidad Miguel Hernández de Elche; Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL-Fundación FISABIO), Elche, Alicante, España
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Kamar N, Cassuto E, Piotti G, Govoni M, Ciurlia G, Geraci S, Poli G, Nicolini G, Mariat C, Essig M, Malvezzi P, Le Meur Y, Garrigue V, Del Bello A, Rostaing L. Pharmacokinetics of Prolonged-Release Once-Daily Formulations of Tacrolimus in De Novo Kidney Transplant Recipients: A Randomized, Parallel-Group, Open-Label, Multicenter Study. Adv Ther 2019; 36:462-477. [PMID: 30552587 PMCID: PMC6824349 DOI: 10.1007/s12325-018-0855-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Different prolonged-release formulations of tacrolimus are available. To date, the pharmacokinetic (PK) profile of LCP-tacrolimus (LCPT; Envarsus®) has not been compared with PR-Tac (Advagraf®) in de novo kidney transplant recipients. These profiles will guide clinical recommendations for the initiation and dose titration strategies of once-daily tacrolimus formulations. METHODS This randomized, parallel-group, open-label, multicenter PK study randomized 75 de novo, adult, white kidney transplant recipients to LCPT 0.17 mg/kg/day (n = 37) or PR-Tac 0.20 mg/kg/day (n = 38) for 4 weeks. Dose adjustments were permitted to target a pre-defined therapeutic range based on measured trough blood concentrations. RESULTS PK analysis (days 1, 3, 7 and 14) included 68 patients (LCPT, n = 33; PR-Tac, n = 35). Similar proportions of patients were within the pre-defined therapeutic tacrolimus trough blood concentration range, with < 12% in each group having below-target trough levels over the study period. LCPT demonstrated ~ 30% greater relative bioavailability [LCPT/PR-Tac adjusted geometric mean ratio: day 3, 1.32 (p = 0.007); day 7, 1.25 (p = 0.051); day 14, 1.43 (p = 0.002)] and ~ 30% lower peak-to-trough percentage fluctuation of blood concentration [LCPT/PR-Tac adjusted geometric mean ratio: day 3, 0.70 (p < 0.001); day 7, 0.68 (p < 0.001); day 14, 0.73 (p = 0.004)] in addition to longer time to maximum blood concentration (tmax), lower maximum concentration (Cmax) and a consistently lower daily dose (~ 40% dose reduction with LCPT vs. PR-Tac by day 28). Safety profiles were similar. CONCLUSION In de novo kidney transplant recipients, prolonged-release formulations of tacrolimus can reach therapeutic concentrations in the immediate post-transplant period. LCPT has greater relative bioavailability and lower peak-to-trough fluctuation compared with PR-Tac. TRIAL REGISTRATION Registered at ClinicalTrials.gov; study number NCT02500212. FUNDING Chiesi Farmaceutici S.p.A.
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Affiliation(s)
- Nassim Kamar
- Departments of Nephrology and Organ Transplantation, CHU Rangueil, INSERM U1043, IFR-BMT, Université Paul Sabatier, Toulouse, France
| | - Elisabeth Cassuto
- Unité de Transplantation Rénale, Hôpital Pasteur 2, CHU Nice, Nice, France
| | - Giovanni Piotti
- Kidney and Pancreas Transplantation Unit, University Hospital of Parma, 43121, Parma, Italy
- Global Clinical Development, Department of Clinical Pharmacology, Chiesi Farmaceutici, Parma, Italy
| | - Mirco Govoni
- Global Clinical Development, Department of Clinical Pharmacology, Chiesi Farmaceutici, Parma, Italy.
| | - Giorgia Ciurlia
- Global Clinical Development, Department of Clinical Pharmacology, Chiesi Farmaceutici, Parma, Italy
| | - Silvia Geraci
- Global Clinical Development, Department of Clinical Pharmacology, Chiesi Farmaceutici, Parma, Italy
| | - Gianluigi Poli
- Global Clinical Development, Department of Clinical Pharmacology, Chiesi Farmaceutici, Parma, Italy
| | - Gabriele Nicolini
- Global Clinical Development, Department of Clinical Pharmacology, Chiesi Farmaceutici, Parma, Italy
| | - Christophe Mariat
- CHU Saint-Etienne, Hôpital Nord Avenue Albert Raimond, Saint Priest en Jarez, France
| | - Marie Essig
- Nephrology Unit, CHU Limoges, 2 Avenue Martin Luther King, Limoges, France
| | - Paolo Malvezzi
- Service de Néphrologie, Dialyse, Aphérèses et Transplantation, CHU Grenoble Alpes, Grenoble, France
| | - Yannick Le Meur
- Service de Nephrologie-Transplantation Rénale et Hémodialyse, CHRU Brest, Hôpital de la Cavale Blanche, Brest, France
| | - Valerie Garrigue
- Service de Néphrologie-Transplantation-Dialyse péritonéale CHU Lapeyronie, Montpellier, France
| | - Arnaud Del Bello
- Departments of Nephrology and Organ Transplantation, CHU Rangueil, INSERM U1043, IFR-BMT, Université Paul Sabatier, Toulouse, France
| | - Lionel Rostaing
- Service de Néphrologie, Dialyse, Aphérèses et Transplantation, CHU Grenoble Alpes, Grenoble, France
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Early Versus Late Conversion From Immediate to Prolonged-Release Tacrolimus After Renal Transplantation: Clinical Effects and Treatment Costs. Transplant Direct 2018; 5:e417. [PMID: 30656215 PMCID: PMC6324909 DOI: 10.1097/txd.0000000000000853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 09/14/2018] [Accepted: 11/08/2018] [Indexed: 12/03/2022] Open
Abstract
Introduction Prolonged-release tacrolimus (PR-TAC) was associated with improved renal function after transplantation when compared to immediate-release tacrolimus (IR-TAC) although evidence is still scarce. This study aimed to compare clinical outcomes and treatment costs in patients who converted from IR-TAC to PR-TAC during the first year after renal transplantation (RT) (early converters [EC]) or after that period (late converters [LC]). Methods We performed a retrospective study including 79 patients (EC, 39; LC, 41) which were followed up over 60 months. A mixed-effects approach was used to investigate the differences between both groups regarding renal and metabolic outcomes as well as treatment costs. Results The median time from RT to conversion was 3 months for EC and 25 months for LC. For both EC and LC, a significant increase in estimated glomerular filtration rate was observed after conversion (5.2 and 4.9 mL/min per 1.73 m2, respectively). During the first year after RT, EC presented a higher estimated glomerular filtration rate and inferior tacrolimus trough levels when compared to LC, with higher mean treatment costs associated. However, thereafter, these outcomes were similar between groups over the remaining time. At the end of follow-up, no significant differences were found regarding allograft acute rejection (2.6% and 2.4%), new-onset diabetes (15.7% vs 12.2%) or cardiovascular events (5.2% vs 7.3%). Conclusions There was a significant benefit on renal function after conversion from IR-TAC to PR-TAC. During the first year after RT, EC presented improved renal function, but higher treatment costs. None of these differences persisted at the end of follow-up.
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Pharmacokinetic Study of Conversion Between 2 Formulations of Once-daily Extended-release Tacrolimus in Stable Lung Transplant Patients. Transplantation 2018; 102:e439-e446. [PMID: 29965950 DOI: 10.1097/tp.0000000000002348] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The aim of this study was to compare the pharmacokinetic profile, tolerability, and safety of a novel once-daily extended-release formulation of tacrolimus (LCPT) with that of once-daily prolonged-release tacrolimus (ODT) in stable adult lung transplant (LT) recipients. METHODS Phase II, open-label, single-arm, single-center, prospective pilot pharmacokinetic study. Study population comprised 20 stable LT recipients receiving ODT, mean age 55.9 years (range, 38-67 years), 13 (65%) men. Patients were switched to LCPT in a 1:0.7 (mg/mg) conversion dose. Follow-up was 6 months, and cystic fibrosis patients were excluded. Two 24-hour pharmacokinetic profiles were obtained for each patient, the first on day -14 and the second on day +14 after switching to LCPT. Pharmacokinetic parameters and safety were compared. RESULTS Mean (SD) area under the concentration-time curve from 0 to 24 hours was 253.97 (61.90) ng/mL per hour for ODT and 282.44 (68.2) ng/mL per hour for LCPT. Systemic exposure was similar in both (Schuirmann two 1-sided test). Mean (SD) dose was 5.05 (1.67) mg in ODT and 3.36 (1.03) mg in LCPT (P = 0.0002). Time to maximum concentration was 125 minutes for ODT and 325 minutes for LCPT (P < 0.001). Correlation between area under the concentration-time curve from 0 to 24 hours and C24 was 0.896 (r) for ODT and 0.893 (r) for LCPT. There were no differences in adverse effects. At 6 months, conversion dose was 1:0.59 (mg/mg) in patients with unchanged minimum plasma concentration target levels. CONCLUSIONS Switching from ODT to LCPT was safe and well tolerated in stable LT recipients without cystic fibrosis. A significantly lower dose of LCPT allows similar bioavailability. A conversion ratio 1:0.6 could be enough to maintain similar target levels.
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Kuypers DRJ. Tacrolimus Formulations and African American Kidney Transplant Recipients: When Do Details Matter? Am J Kidney Dis 2018; 71:302-305. [PMID: 29477174 DOI: 10.1053/j.ajkd.2017.10.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 10/15/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Dirk R J Kuypers
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven; and Department of Microbiology and Immunology, KU Leuven - University of Leuven, Leuven, Belgium.
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Philosophe B, Leca N, West-Thielke PM, Horwedel T, Culkin-Gemmell C, Kistler K, Stevens DR. Evaluation of Flexible Tacrolimus Drug Concentration Monitoring Approach in Patients Receiving Extended-Release Once-Daily Tacrolimus Tablets. J Clin Pharmacol 2018; 58:891-896. [PMID: 29462506 PMCID: PMC6032903 DOI: 10.1002/jcph.1082] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 12/21/2017] [Indexed: 11/10/2022]
Abstract
The majority of United States kidney transplant patients are treated with tacrolimus, a drug effective in preventing graft rejection, but with a narrow therapeutic range, necessitating close monitoring to avoid increased risks of transplant rejection or toxicity if the tacrolimus concentration is too low or too high, respectively. The trough drug concentration tests are time sensitive; patients treated on a twice-daily basis have blood draws exactly 12 hours after their previous dose. The schedule's rigidity causes problems for both patients and health care providers. Novel once-daily tacrolimus formulations such as LCPT (an extended-release tablet by Veloxis Pharmaceuticals, Inc., Cary, North Carolina) have allowed for blood draws on a once-daily basis; however, even that schedule can be restrictive. Results from tests taken either before or after that 24-hour target time may be discarded, or worse, may lead to inappropriate dose changes. Data from ASTCOFF, a phase 3B pharmacokinetic clinical trial (NCT02339246), demonstrated that the unique pharmacokinetic curve of LCPT may allow for a therapeutic monitoring window that extends for 3 hours before or after the 24-hour monitoring target. Furthermore, important tools to help clinicians interpret these levels, such as formulas to estimate the 24-hour trough level if an alternative monitoring time is used, were constructed from these data. These study results give treating clinicians access to data that allow them to safely use and monitor LCPT in their patients and expand the body of evidence surrounding differentiation and practical application of the novel LCPT tacrolimus formulation.
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Affiliation(s)
| | - Nicolae Leca
- University of Washington Medical Center, Seattle, WA, USA
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Eficacia y seguridad del uso de novo y precoz de tacrolimus de liberación prolongada en el trasplante cardiaco. Rev Esp Cardiol 2018. [DOI: 10.1016/j.recesp.2017.03.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Szempruch KR, Westreich KD, Toledo AH. Early Use of Tacrolimus Extended-Release in a Pediatric Kidney Transplant Recipient. EXP CLIN TRANSPLANT 2017; 19:865-867. [PMID: 29206086 DOI: 10.6002/ect.2017.0195] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Tacrolimus extended-release pharmacokinetics and its once-daily formulation provide beneficial properties, and its use has been evaluated in the adult kidney transplant population. Here, we report a case of successful conversion from tacrolimus immediate-release capsules to tacrolimus extended-release tablets in a pediatric kidney transplant recipient.
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Affiliation(s)
- Kristen R Szempruch
- From the Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, North Carolina, USA
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Trofe-Clark J, Brennan DC, West-Thielke P, Milone MC, Lim MA, Neubauer R, Nigro V, Bloom RD. Results of ASERTAA, a Randomized Prospective Crossover Pharmacogenetic Study of Immediate-Release Versus Extended-Release Tacrolimus in African American Kidney Transplant Recipients. Am J Kidney Dis 2017; 71:315-326. [PMID: 29162334 DOI: 10.1053/j.ajkd.2017.07.018] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 07/20/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND Differences in tacrolimus dosing across ancestries is partly attributable to polymorphisms in CYP3A5 genes that encode tacrolimus-metabolizing cytochrome P450 3A5 enzymes. The CYP3A5*1 allele, preponderant in African Americans, is associated with rapid metabolism, subtherapeutic concentrations, and higher dose requirements for tacrolimus, all contributing to worse outcomes. Little is known about the relationship between CYP3A5 genotype and the tacrolimus pharmacokinetic area under the curve (AUC) profile in African Americans or whether pharmacogenetic differences exist between conventional twice-daily, rapidly absorbed, immediate-release tacrolimus (IR-Tac) and once-daily extended-release tacrolimus (LifeCycle Pharma Tac [LCPT]) with a delayed absorption profile. STUDY DESIGN Randomized prospective crossover study. SETTING & PARTICIPANTS 50 African American maintenance kidney recipients on stable IR-Tac dosing. INTERVENTION Recipients were randomly assigned to continue IR-Tac on days 1 to 7 and then switch to LCPT on day 8 or receive LCPT on days 1 to 7 and then switch to IR-Tac on day 8. The LCPT dose was 85% of the IR-Tac total daily dose. OUTCOMES Tacrolimus 24-hour AUC (AUC0-24), peak and trough concentrations (Cmax and Cmin), time to peak concentration, and bioavailability of LCPT versus IR-Tac, according to CYP3A5 genotype. MEASUREMENTS CYP3A5 genotype, 24-hour tacrolimus pharmacokinetic profiles. RESULTS ∼80% of participants carried the CYP3A5*1 allele (CYP3A5 expressers). There were no significant differences in AUC0-24 or Cmin between CYP3A5 expressers and nonexpressers during administration of either IR-Tac or LCPT. With IR-Tac, tacrolimus Cmax was 33% higher in CYP3A5 expressers compared with nonexpressers (P=0.04): With LCPT, this difference was 11% (P=0.4). LIMITATIONS This was primarily a pharmacogenetic study rather than an efficacy study; the follow-up period was too short to capture clinical outcomes. CONCLUSIONS Achieving therapeutic tacrolimus trough concentrations with IR-Tac in most African Americans results in significantly higher peak concentrations, potentially magnifying the risk for toxicity and adverse outcomes. This pharmacogenetic effect is attenuated by delayed tacrolimus absorption with LCPT. TRIAL REGISTRATION Registered at ClinicalTrials.gov, with study number NCT01962922.
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Affiliation(s)
- Jennifer Trofe-Clark
- Department of Pharmacy Services, Hospital of the University of Pennsylvania, Philadelphia, PA; Renal Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | | | - Michael C Milone
- Perelman School of Medicine, University of Pennsylvania, Penn Institute for Immunology, Philadelphia, PA
| | - Mary Ann Lim
- Renal Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Robin Neubauer
- Renal Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | - Roy D Bloom
- Renal Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
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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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González-Vílchez F, Lambert JL, Rangel D, Almenar L, de la Fuente JL, Palomo J, Díaz Molina B, Lage E, Sánchez Lázaro I, Vázquez de Prada JA. Efficacy and Safety of de Novo and Early Use of Extended-release Tacrolimus in Heart Transplantation. ACTA ACUST UNITED AC 2017; 71:18-25. [PMID: 28545984 DOI: 10.1016/j.rec.2017.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Accepted: 03/14/2017] [Indexed: 11/26/2022]
Abstract
INTRODUCTION AND OBJECTIVES The extended-release formulation of tacrolimus (ERT) allows once-daily dosage, thus simplifying the immunosuppressive regimen. This study aimed to describe the safety and efficacy of the de novo and early use of ERT in heart transplantation. METHODS This was an observational, retrospective, multicenter study comparing the safety and efficacy of the de novo use of ERT (ERT group [n=94]), standard-release tacrolimus (SRT group [n=42]) and early conversion (EC) from SRT to ERT (EC group [n=44]). Extended-release tacrolimus was used between 2007 and 2012. One-year incidence rates of acute rejection, infection, and cytomegalovirus infection were analyzed. Safety parameters were also evaluated. RESULTS There were no significant between-group differences in the daily dose or trough levels of tacrolimus during the first year after transplantation. The rejection incidence rates were 1.05 (95%CI, 0.51-1.54), 1.39 (95%CI, 1.00-1.78), and 1.11 (95%CI, 0.58-1.65) episodes per patient-years in the SRT group, ERT group, and EC group, respectively (P=.48). The infection incidence rates were 0.75 (95%CI, 0.60-0.86), 0.62 (95%CI, 0.52-0.71), and 0.55 (95%CI, 0.40-0.68) in the SRT group, ERT group, and EC group, respectively (P=.46). Cytomegalovirus infection occurred in 23.8%, 20.2%, and 18.2% of the patients, respectively (P=.86). No significant between-group differences were found in laboratory tests or in allograft function. There was 1 death in the SRT group and 2 in the ERT group. CONCLUSIONS Both de novo and early use of ERT seem to have similar safety and efficacy profiles to conventional SRT-based immunosuppression.
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Affiliation(s)
- Francisco González-Vílchez
- Unidad de Insuficiencia Cardiaca Avanzada y Trasplante Cardiaco, Servicio de Cardiología, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain.
| | - José Luis Lambert
- Unidad de Insuficiencia Cardiaca Avanzada y Trasplante Cardiaco, Servicio de Cardiología, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - Diego Rangel
- Unidad de Insuficiencia Cardiaca Avanzada y Trasplante Cardiaco, Servicio de Cardiología, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Luis Almenar
- Unidad de Insuficiencia Cardiaca Avanzada y Trasplante Cardiaco, Servicio de Cardiología, Hospital Universitario La Fe, Valencia, Spain
| | - José Luis de la Fuente
- Unidad de Insuficiencia Cardiaca Avanzada y Trasplante Cardiaco, Servicio de Cardiología, Hospital Universitario Clínico de Valladolid, Valladolid, Spain
| | - Jesús Palomo
- Unidad de Insuficiencia Cardiaca Avanzada y Trasplante Cardiaco, Servicio de Cardiología, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Beatriz Díaz Molina
- Unidad de Insuficiencia Cardiaca Avanzada y Trasplante Cardiaco, Servicio de Cardiología, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - Ernesto Lage
- Unidad de Insuficiencia Cardiaca Avanzada y Trasplante Cardiaco, Servicio de Cardiología, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Ignacio Sánchez Lázaro
- Unidad de Insuficiencia Cardiaca Avanzada y Trasplante Cardiaco, Servicio de Cardiología, Hospital Universitario La Fe, Valencia, Spain
| | - José A Vázquez de Prada
- Unidad de Insuficiencia Cardiaca Avanzada y Trasplante Cardiaco, Servicio de Cardiología, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain
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Wong TC, Lo CM, Fung JY. Emerging drugs for prevention of T-cell mediated rejection in liver and kidney transplantation. Expert Opin Emerg Drugs 2017; 22:123-136. [PMID: 28503959 DOI: 10.1080/14728214.2017.1330884] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Acute and chronic graft rejection continues to be an important problem after solid organ transplantation. With the introduction of potent immunosuppressive agents such as calcineurin inhibitors, the risk of rejection has been significantly reduced. However, the adverse effects of life-long immunosuppression remain a concern, and there exist a fine balance between over-immunosuppression and risk of rejection. Areas covered: In this review, the current standard of care in immunosuppressive therapy, including the use of steroids, calcineurin inhibitors, mycophenolate prodrugs and mammalian target of rapamycin inhibitors, will be discussed. Newer immunosuppressive agents showing promising early data after liver and kidney transplantation will also be explored. Expert Opinion: Currently, calcineurin inhibitors continue to be a vital component of immunosuppressive therapy after solid organ transplantation. Although minimization and avoidance strategies have been developed, the ultimate goal of inducing tolerance remains elusive. Newer emerging agents should have potent and specific immunosuppressive activity, with minimal associated side effects. An individualized approach should be adopted to tailor immunosuppression according to the different needs of recipients.
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Affiliation(s)
- Tiffany Cl Wong
- a Department of Surgery, Department of Medicine , Queen Mary Hospital, The University of Hong Kong , Hong Kong , Hong Kong S.A.R
| | - Chung-Mau Lo
- a Department of Surgery, Department of Medicine , Queen Mary Hospital, The University of Hong Kong , Hong Kong , Hong Kong S.A.R
| | - James Yy Fung
- a Department of Surgery, Department of Medicine , Queen Mary Hospital, The University of Hong Kong , Hong Kong , Hong Kong S.A.R
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Tremblay S, Nigro V, Weinberg J, Woodle ES, Alloway RR. A Steady-State Head-to-Head Pharmacokinetic Comparison of All FK-506 (Tacrolimus) Formulations (ASTCOFF): An Open-Label, Prospective, Randomized, Two-Arm, Three-Period Crossover Study. Am J Transplant 2017; 17:432-442. [PMID: 27340950 PMCID: PMC5297985 DOI: 10.1111/ajt.13935] [Citation(s) in RCA: 96] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 06/08/2016] [Accepted: 06/18/2016] [Indexed: 02/06/2023]
Abstract
This two-sequence, three-period crossover study is the first pharmacokinetic (PK) study to compare all three innovator formulations of tacrolimus (twice-daily immediate-release tacrolimus capsules [IR-Tac]; once-daily extended-release tacrolimus capsules [ER-Tac]; novel once-daily tacrolimus tablets [LCPT]). Stable renal transplant patients were dosed with each drug for 7 days, and blood samples were obtained over 24 h. Thirty subjects were included in the PK analysis set. A conversion factor of 1:1:0.80 for IR-Tac:ER-Tac:LCPT was used; no dose adjustments were permitted during the study. The median (interquartile range) total daily dose was 6.0 (4.0-8.0) mg for IR-Tac and ER-Tac and 4.8 (3.3-6.3) for LCPT. Significantly higher exposure on a per milligram basis, lower intraday fluctuation and prolonged time (Tmax ) to peak concentration (Cmax ) were found for LCPT versus IR-Tac or ER-Tac. ER-Tac showed no differences versus IR-Tac in exposure, Cmax , Tmax or fluctuation. The observed exposure of IR-Tac was used to normalize exposure for LCPT and ER-Tac, resulting in the following recommended total daily dose conversion rates: IR-Tac:ER-Tac, +8%; IR-Tac:LCPT, -30%; ER-Tac:LCPT, -36%. After exposure normalization, Cmax was ~17% lower for LCPT than for IR-Tac or ER-Tac; Cmin was ~6% lower for LCPT compared with IR-Tac and 3% higher compared with ER-Tac.
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Affiliation(s)
- S. Tremblay
- Department of Internal MedicineDivision of Nephrology and HypertensionUniversity of Cincinnati College of MedicineCincinnatiOH
| | - V. Nigro
- Veloxis Pharmaceuticals, Inc.EdisonNJ
| | | | - E. S. Woodle
- Department of SurgeryDivision of TransplantationUniversity of Cincinnati College of MedicineCincinnatiOH
| | - R. R. Alloway
- Department of Internal MedicineDivision of Nephrology and HypertensionUniversity of Cincinnati College of MedicineCincinnatiOH
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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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Baraldo M. Meltdose Tacrolimus Pharmacokinetics. Transplant Proc 2017; 48:420-3. [PMID: 27109969 DOI: 10.1016/j.transproceed.2016.02.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Revised: 01/31/2016] [Accepted: 02/02/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Nonadherence to immunosuppressive therapy contributes to the loss of grafts. One of the problem is the fractioning of immunosuppressive dose. In fact, it was demonstrated that a single daily dose (QD) is associated with an increased adherence to therapy compared with twice daily dosing (BID). Tacrolimus (TAC), calcineurin inhibitor, is one of immunosuppression pillar in organ transplantation and its action is strongly correlated with blood concentration and therefore the therapeutic drug monitoring is recommended in the guidelines. However, one of the critical points of TAC is the poor and variable bioavailability that influences immunosuppression, and is also responsible for adverse effects. METHODS MeltDose® Technology is a new technology to improve efficacy and/or reduce side effects. This new technology applied to TAC (Envarsus® or LCP-TAC) has achieved 4 main objectives: (1) improved bioavailability, (2) reduced dose fractioning to one tablet per day, (3) limited variability concentrations of TAC, and (4) lower doses of TAC will be administered. RESULTS We analyzed the pharmacokinetic profile, efficacy, and security of Envarsus®.
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Affiliation(s)
- M Baraldo
- Department of Experimental and Clinical Medicine, Medical School, University of Udine; SOC Institute of Clinical Pharmacology, University-Hospital S. Maria della Misercordia, Udine, Italy.
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50
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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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