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Alam A, van Zyl JS, Patel R, Jamil AK, Felius J, Carey SA, Gottlieb RL, Guerrero-Miranda CY, Kale P, Hall SA, Sam T. Three-year outcomes of de novo tacrolimus extended-release tablets (LCPT) compared to twice-daily tacrolimus in adult heart transplantation. Transpl Immunol 2024; 83:102009. [PMID: 38325525 DOI: 10.1016/j.trim.2024.102009] [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: 10/13/2023] [Revised: 01/31/2024] [Accepted: 02/03/2024] [Indexed: 02/09/2024]
Abstract
BACKGROUND Extended-release tacrolimus for prophylaxis of allograft rejection in heart transplant (HT) 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 (IR-) tacrolimus. We compared long-term efficacy and safety of LCPT to IR-tacrolimus applied de novo in adult OHT recipients. METHODS 25 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 3 years following transplant was compared between groups using non-inferiority analysis. RESULTS LCPT demonstrated non-inferiority to IR-tacrolimus, with a primary outcome risk reduction of 16% (90%CI, -37%, -1%, non-inferiority p = 0.002) up to 3 years following heart transplant. Up to 3-years post-transplant, 14 patients remained on once-daily LCPT and 10 patients were switched to IR-tacrolimus due to lack of insurance coverage. There were no significant differences in the rate of chronic kidney disease requiring dialysis, cytomegalovirus requiring treatment, cardiac allograft vasculopathy, and malignancy within 3 years following transplant. CONCLUSION LCPT is non-inferior in efficacy to IR-tacrolimus in heart transplantation with a similar safety profile. Narrowly-constrained FDA labels specific to kidney transplant remain a barrier to consistent access to many immunosuppressant medications for recipients of non-kidney solid organs. We recommend the FDA consider developing facile pathways for expanding the approved label of extended-release tacrolimus formulations to heart transplant recipients.
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Affiliation(s)
- Amit Alam
- Division of Cardiology, New York University, New York City, NY, USA
| | - Johanna S van Zyl
- Texas A&M Health Science Center, Dallas, TX, USA; Baylor Scott & White Research Institute, Baylor Scott & White Health, Dallas, TX, USA
| | - Raksha Patel
- Department of Pharmacy, Baylor University Medical Center, Dallas, TX, USA
| | - Aayla K Jamil
- Baylor Scott & White Research Institute, Baylor Scott & White Health, Dallas, TX, USA
| | - Joost Felius
- Baylor Scott & White Research Institute, Baylor Scott & White Health, Dallas, TX, USA
| | - Sandra A Carey
- Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Dallas, TX, USA
| | - Robert L Gottlieb
- Texas A&M Health Science Center, Dallas, TX, USA; Baylor Scott & White Research Institute, Baylor Scott & White Health, Dallas, TX, USA; Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Dallas, TX, USA; Baylor Scott & White Heart and Vascular Hospital, Dallas, TX, USA
| | - Cesar Y Guerrero-Miranda
- Texas A&M Health Science Center, Dallas, TX, USA; Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Dallas, TX, USA; Baylor Scott & White Heart and Vascular Hospital, Dallas, TX, USA
| | - Parag Kale
- Texas A&M Health Science Center, Dallas, TX, USA; Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Dallas, TX, USA; Baylor Scott & White Heart and Vascular Hospital, Dallas, TX, USA
| | - Shelley A Hall
- Texas A&M Health Science Center, Dallas, TX, USA; Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Dallas, TX, USA; Baylor Scott & White Heart and Vascular Hospital, Dallas, TX, USA
| | - Teena Sam
- Department of Pharmacy, Baylor University Medical Center, Dallas, TX, 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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Aziz F, Jorgenson M, Garg N, Parajuli S, Mohamed M, Raza F, Mandelbrot D, Djamali A, Dhingra R. New Approaches to Cardiovascular Disease and Its Management in Kidney Transplant Recipients. Transplantation 2022; 106:1143-1158. [PMID: 34856598 DOI: 10.1097/tp.0000000000003990] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Cardiovascular events, including ischemic heart disease, heart failure, and arrhythmia, are common complications after kidney transplantation and continue to be leading causes of graft loss. Kidney transplant recipients have both traditional and transplant-specific risk factors for cardiovascular disease. In the general population, modification of cardiovascular risk factors is the best strategy to reduce cardiovascular events; however, studies evaluating the impact of risk modification strategies on cardiovascular outcomes among kidney transplant recipients are limited. Furthermore, there is only minimal guidance on appropriate cardiovascular screening and monitoring in this unique patient population. This review focuses on the limited scientific evidence that addresses cardiovascular events in kidney transplant recipients. Additionally, we focus on clinical management of specific cardiovascular entities that are more prevalent among kidney transplant recipients (ie, pulmonary hypertension, valvular diseases, diastolic dysfunction) and the use of newer evolving drug classes for treatment of heart failure within this cohort of patients. We note that there are no consensus documents describing optimal diagnostic, monitoring, or management strategies to reduce cardiovascular events after kidney transplantation; however, we outline quality initiatives and research recommendations for the assessment and management of cardiovascular-specific risk factors that could improve outcomes.
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Affiliation(s)
- Fahad Aziz
- Division of Nephrology, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Margaret Jorgenson
- Department of Pharmacology, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Neetika Garg
- Division of Nephrology, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Sandesh Parajuli
- Division of Nephrology, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Maha Mohamed
- Division of Nephrology, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Farhan Raza
- Cardiovascular Division, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Didier Mandelbrot
- Division of Nephrology, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Arjang Djamali
- Division of Nephrology, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI
- Division of Transplantation, Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Ravi Dhingra
- Cardiovascular Division, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI
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Effect of MMF Immunosuppression Based on CNI Reduction on CNI-Related Renal Damage after Lung Transplantation. JOURNAL OF HEALTHCARE ENGINEERING 2022; 2022:8099684. [PMID: 35126949 PMCID: PMC8808151 DOI: 10.1155/2022/8099684] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 12/14/2021] [Accepted: 12/30/2021] [Indexed: 01/31/2023]
Abstract
In this paper, numerous effects of immunosuppressive regimen of mycophenolate mofetil (MMF) on CNI-related renal damage after lung transplantation are evaluated thoroughly. For this purpose, 110 lung transplant recipients who were treated in our hospital from March 2016 to January 2018 were randomly selected. All patients took prednisone acetate tablets or rapamycin at the same time or not at the same time. MMF is 1 g every time, twice a day, and adjusted according to the re-examination. According to the different drugs taken by 110 patients, they were divided into cyclosporine A group and tacrolimus group. Among them, 92 patients in cyclosporine A group took cyclosporine A; 18 patients in tacrolimus group took tacrolimus. The clinical data of age and gender of the two groups were collected, To observe and compare the occurrence of CNI-related renal damage in lung transplant recipients and different immunosuppressants. The CNI dosage of tacrolimus group and cyclosporine A group was compared before and after MMF. The changes of serum creatinine level and serum creatinine clearance rate were measured before MMF administration and 30, 60, and 90 days after MMF administration, to observe the complications of CNI-related renal damage after lung transplantation. Experimental results showed that there were 16 cases (14.55%) of CNI-related renal damage in lung transplant recipients and different immunosuppressants, including 10 cases (11.36%) in males, 6 cases (27.27%) in females, 11 cases (12.09%) in tacrolimus group, and 5 cases (26.32%) in cyclosporine A group. There was no significant difference between the two groups (P > 0.05). Compared with MMF before and after administration, CNI dosage of cyclosporine A group and tacrolimus group decreased significantly (P < 0.01). Compared with MMF before administration, serum creatinine level decreased and serum creatinine clearance rate increased significantly (P < 0.05). In the follow-up, 16 patients with CNI-related renal damage were found to be immune rejection before the adjustment of immunosuppression program, no complications such as immune rejection, myelosuppression, and infection occurred within 15 months after the adjustment of immunosuppression program, blood glucose increased in 3 patients within 2 years after operation, blood lipid increased in 1 patient, urea increased in 1 patient, and uric acid increased in 1 patient. MMF immunosuppressive therapy based on CNI reduction is a safe and effective immunosuppressive therapy, which can significantly reduce immune rejection, improve renal function, and play an important role in improving CNI-related renal damage after lung transplantation.
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Choi DK, Patel S, Muran C, Khamo N, Patel R, Fayyaz N, West-Thielke P. Prior Authorization Burden on the Use of LCP-Tacrolimus in Abdominal Solid Organ Transplant Recipients. Ann Pharmacother 2021; 56:856-857. [PMID: 34612712 DOI: 10.1177/10600280211050641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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6
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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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7
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Jorgenson MR, Descourouez JL, Brady BL, Chandran MM, Do V, Kim M, Laub MR, Lichvar A, Park JM, Szczepanik A, Alloway RR. A call for transplant stewardship: The need for expanded evidence-based evaluation of induction and biologic-based cost-saving strategies in kidney transplantation and beyond. Clin Transplant 2021; 35:e14372. [PMID: 34033140 DOI: 10.1111/ctr.14372] [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] [Received: 03/17/2021] [Revised: 05/15/2021] [Accepted: 05/19/2021] [Indexed: 12/14/2022]
Abstract
Rising expenditures threaten healthcare sustainability. While transplant programs are typically considered profitable, transplant medications are expensive and frequently targeted for cost savings. This review aims to summarize available literature supporting cost-containment strategies used in solid organ transplant. Despite widespread use of these tactics, we found the available evidence to be fairly low quality. Strategies mainly focus on induction, particularly rabbit antithymocyte globulin (rATG), given its significant cost and the lack of consensus surrounding dosing. While there is higher-quality evidence for high single-dose rATG, and dose-rounding protocols to reduce waste are likely low risk, more aggressive strategies, such as dosing rATG by CD3+ target-attainment or on ideal-body-weight, have less robust support and did not always attain similar efficacy outcomes. Extrapolation of induction dosing strategies to rejection treatment is not supported by any currently available literature. Cost-saving strategies for supportive therapies, such as IVIG and rituximab also have minimal literature support. Deferral of high-cost agents to the outpatient arena is associated with minimal risk and increases reimbursement, although may increase complexity and cost-burden for patients and infusion centers. The available evidence highlights the need for evaluation of unique patient-specific clinical scenarios and optimization of therapies, rather than simple blanket application of cost-saving initiatives in the transplant population.
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Affiliation(s)
- Margaret R Jorgenson
- Department of Pharmacy, University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | - Jillian L Descourouez
- Department of Pharmacy, University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | - Bethany L Brady
- Department of Pharmacy, Indiana University Health University Hospital, Indianapolis, IN, USA
| | - Mary M Chandran
- Department of Pharmacy, Children's Hospital of Colorado, Aurora, CO, USA
| | - Vincent Do
- Department of Pharmacy, Yale New Haven Hospital, New Haven, CT, USA
| | - Miae Kim
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Melissa R Laub
- Department of Pharmacy, Augusta University Medical Center, Augusta, GA, USA
| | - Alicia Lichvar
- Department of Pharmacy Practice and Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Jeong M Park
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI, USA
| | - Amanda Szczepanik
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, MD, USA
| | - Rita R Alloway
- Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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