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Karaterzi S, Tönshoff B, Ahlenstiel-Grunow T, Baghai M, Beck B, Büscher A, Eifler L, Giese T, Lezius S, Müller C, Oh J, Zapf A, Weber LT, Pape L. A multi-center interventional study to assess pharmacokinetics, effectiveness, and tolerability of prolonged-release tacrolimus after pediatric kidney transplantation: study protocol for a prospective, open-label, randomized, two-phase, two-sequence, single dose, crossover, phase III b trial. FRONTIERS IN NEPHROLOGY 2024; 4:1331510. [PMID: 38444519 PMCID: PMC10912931 DOI: 10.3389/fneph.2024.1331510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 01/25/2024] [Indexed: 03/07/2024]
Abstract
Background Tacrolimus, a calcineurin inhibitor (CNI), is currently the first-line immunosuppressive agent in kidney transplantation. The therapeutic index of tacrolimus is narrow due to due to the substantial impact of minor variations in drug concentration or exposure on clinical outcomes (i.e., nephrotoxicity), and it has a highly variable intra- and inter-individual bioavailability. Non-adherence to immunosuppressants is associated with rejection after kidney transplantation, which is the main cause of long-term graft loss. Once-daily formulations have been shown to significantly improve adherence compared to twice-daily dosing. Envarsus®, the once-daily prolonged-release formulation of tacrolimus, offers the same therapeutic efficacy as the conventional twice-daily immediate-release tacrolimus formulation (Prograf®) with improved bioavailability, a more consistent pharmacokinetic profile, and a reduced peak to trough, which may reduce CNI-related toxicity. Envarsus® has been approved as an immunosuppressive therapy in adults following kidney or liver transplantation but has not yet been approved in children. The objective of this study is to evaluate the pharmacokinetic profile, efficacy, and tolerability of Envarsus® in children and adolescents aged ≥ 8 and ≤ 18 years to assess its potential role as an additional option for immunosuppressive therapy in children after kidney transplantation. Methods/design The study is designed as a randomized, prospective crossover trial. Each patient undergoes two treatment sequences: sequence 1 includes 4 weeks of Envarsus® and sequence 2 includes 4 weeks of Prograf®. Patients are randomized to either group A (sequence 1, followed by sequence 2) or group B (sequence 2, followed by sequence 1). The primary objective is to assess equivalency between total exposure (of tacrolimus area under the curve concentration (AUC0-24)), immediate-release tacrolimus (Prograf®) therapy, and prolonged-release tacrolimus (Envarsus®) using a daily dose conversion factor of 0.7 for prolonged- versus immediate-release tacrolimus. Secondary objectives are the assessment of pharmacodynamics, pharmacogenetics, adherence, gut microbiome analyses, adverse events (including tacrolimus toxicity and biopsy-proven rejections), biopsy-proven rejections, difference in estimated glomerular filtration rate (eGFR), and occurrence of donor-specific antibodies (DSAs). Discussion This study will test the hypothesis that once-daily prolonged-release tacrolimus (Envarsus®) is bioequivalent to twice-daily intermediate-release tacrolimus after pediatric kidney transplantation and may reduce toxicity and facilitate medication adherence. This novel concept may optimize immunosuppressive therapy for more stable graft function and increased graft survival by avoiding T-cell mediated and/or antibody-mediated rejection due to improved adherence. In addition, the study will provide data on the pharmacodynamics and pharmacogenetics of prolonged-release tacrolimus in children and adolescents. Clinical Trial Registration EUDRA-CT 2019-003710-13 and ClinicalTrial.gov, identifier NCT06057545.
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Affiliation(s)
- Sinem Karaterzi
- Department of Pediatrics II, University Hospital of Essen, Essen, Germany
| | - Burkhard Tönshoff
- Department of Pediatrics I, University Children’s Hospital Heidelberg, Heidelberg, Germany
| | | | - Maral Baghai
- Department of Pediatrics I, University Children’s Hospital Heidelberg, Heidelberg, Germany
- Structural and Computational Biology Unit, European Molecular Biology Laboratory, Heidelberg, Germany
| | - Bodo Beck
- Institute of Human Genetics, University Hospital of Cologne, Cologne, Germany
| | - Anja Büscher
- Department of Pediatrics II, University Hospital of Essen, Essen, Germany
| | - Lisa Eifler
- Children’s and Adolescents’ Hospital, Pediatric Nephrology, University Hospital of Cologne, Cologne, Germany
| | - Thomas Giese
- Department of Immunology, University Hospital Heidelberg, Heidelberg, Germany
| | - Susanne Lezius
- Institute of Medical Biometry and Epidemiology, University Hospital Eppendorf, Hamburg, Germany
| | - Carsten Müller
- Pharmacology at the Laboratory Diagnostics Centre, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Jun Oh
- Department of Pediatric Nephrology and Gastroenterology, University Hospital Eppendorf, Hamburg, Germany
| | - Antonia Zapf
- Institute of Medical Biometry and Epidemiology, University Hospital Eppendorf, Hamburg, Germany
| | - Lutz T. Weber
- Children’s and Adolescents’ Hospital, Pediatric Nephrology, University Hospital of Cologne, Cologne, Germany
| | - Lars Pape
- Department of Pediatrics II, University Hospital of Essen, Essen, Germany
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2
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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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3
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Henkel L, Jehn U, Thölking G, Reuter S. Tacrolimus-why pharmacokinetics matter in the clinic. FRONTIERS IN TRANSPLANTATION 2023; 2:1160752. [PMID: 38993881 PMCID: PMC11235362 DOI: 10.3389/frtra.2023.1160752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 08/07/2023] [Indexed: 07/13/2024]
Abstract
The calcineurin inhibitor (CNI) Tacrolimus (Tac) is the most prescribed immunosuppressant drug after solid organ transplantation. After renal transplantation (RTx) approximately 95% of recipients are discharged with a Tac-based immunosuppressive regime. Despite the high immunosuppressive efficacy, its adverse effects, narrow therapeutic window and high intra- and interpatient variability (IPV) in pharmacokinetics require therapeutic drug monitoring (TDM), which makes treatment with Tac a major challenge for physicians. The C/D ratio (full blood trough level normalized by daily dose) is able to classify patients receiving Tac into two major metabolism groups, which were significantly associated with the clinical outcomes of patients after renal or liver transplantation. Therefore, the C/D ratio is a simple but effective tool to identify patients at risk of an unfavorable outcome. This review highlights the challenges of Tac-based immunosuppressive therapy faced by transplant physicians in their daily routine, the underlying causes and pharmacokinetics (including genetics, interactions, and differences between available Tac formulations), and the latest data on potential solutions to optimize treatment of high-risk patients.
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Affiliation(s)
- Lino Henkel
- Department of Medicine D, University of Münster, Münster, Germany
| | - Ulrich Jehn
- Department of Medicine D, University of Münster, Münster, Germany
| | - Gerold Thölking
- Department of Medicine D, University of Münster, Münster, Germany
- Department of Internal Medicine and Nephrology, University Hospital of Münster Marienhospital Steinfurt, Steinfurt, Germany
| | - Stefan Reuter
- Department of Medicine D, University of Münster, Münster, Germany
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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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5
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Soliman T, Gyoeri G, Salat A, Mejzlík V, Berlakovich G. A Multi-Centre Non-Interventional Study to Assess the Tolerability and Effectiveness of Extended-Release Tacrolimus (LCPT) in De Novo Liver Transplant Patients. J Clin Med 2023; 12:jcm12072537. [PMID: 37048621 PMCID: PMC10094891 DOI: 10.3390/jcm12072537] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 02/27/2023] [Accepted: 03/24/2023] [Indexed: 03/30/2023] Open
Abstract
Background: Available tacrolimus formulations exhibit substantial inter- and intra-individual variability in absorption and metabolism. The present non-interventional cohort study aimed to assess the tolerability and effectiveness of the once-daily tacrolimus formulation, LCPT, in hepatic allograft recipients in real life. Materials and methods: This study was conducted in Austria and the Czech Republic between July 2016 and August 2019. Patients aged ≥ 18 years old received LCPT per the approved label and local clinical routine. All the participants provided informed consent. Patients newly treated with tacrolimus (de novo) directly after transplantation were observed for six months. The relevant clinical variables were tacrolimus trough level (TL), total daily dose (TDD), number of dose adjustments, kidney and liver function, and tolerability. Results: Of the 70 analyzed patients, 72.9% were male and 85.7% were aged < 65 years old. The mean (SD) time to achieve tacrolimus target TL was 6.4 (4.6) days after 4.4 (4.0) dose adjustments; thereafter, TL remained stable throughout observation at approximately 8 ng/mL. The LCPT TDD at initiation was 8 mg and decreased by a median of 41.4% to 5 mg at 6 months. Liver function continuously improved, and kidney function remained stable. LCPT was well tolerated with 24 adverse events in eight patients (17 related to immunosuppression, mostly mild renal insufficiency, and hematological adverse events); two serious unrelated adverse events were reported (atrial flutter and liver dysfunction). Conclusions: TL was rapidly attained with few dose adaptations after LCPT initiation in de novo liver transplant patients. Liver function rapidly improved, whereas kidney function remained normal. LCPT was well-tolerated in this population.
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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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Tsakiridou G, O'Dwyer PJ, Margaritis A, Box KJ, Vertzoni M, Kalantzi L, Reppas C. On the usefulness of four in vitro methodologies in screening for product related differences in tacrolimus exposure after oral administration of amorphous solid dispersions with modified release characteristics in the fasted state. J Drug Deliv Sci Technol 2022. [DOI: 10.1016/j.jddst.2021.102990] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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8
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Herden U, Sterneck M, Buchholz BM, Achilles EG, Ott A, Fischer L. A single-center, open-label, randomized cross-over study to evaluate the pharmacokinetics and bioavailability of once-daily prolonged-release formulations of tacrolimus in de novo liver transplant recipients. Immun Inflamm Dis 2021; 9:1771-1780. [PMID: 34559956 PMCID: PMC8589356 DOI: 10.1002/iid3.537] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 09/06/2021] [Accepted: 09/09/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The narrow therapeutic window of tacrolimus (Tac) requires intense drug monitoring to achieve adequate efficacy while minimizing dose-related toxicities. Once-daily formulations of Tac (LCP-Tac and PR-Tac) have been recently designed for higher bioavailability and a more consistent exposure over time, as opposed to the twice-daily, administered immediate-release formulation of Tac (IR-Tac). METHODS This single-center, open-label, randomized cross-over pharmacokinetic (PK) study compares extended-release LCP-Tac with the prolonged-release formulation of tacrolimus (PR-Tac) in adult de novo liver transplant recipients. Eligible patients were screened and randomized 1:1 to the two treatment arms up to 30 days after liver transplantation. Patients were administered either LCP-Tac or PR-Tac for 14 days followed by another 14-day time interval of the other once-daily Tac medication. A 24hr-PK profile was obtained at the end of each time interval. RESULTS Nine patients (45%) completed the study resulting in a total of 18 Tac PK profiles. Overall, the profile of the mean concentrations indicated a flattened kinetic of LCP-Tac compared to PR-Tac, especially in the first 3 h after drug intake. The average cumulative dose per day to achieve equivalent trough levels was approximately 25% lower for LCP-Tac (8.7 mg) than for PR-Tac (11.7 mg). LCP-Tac resulted in a longer tmax and fewer peak-to-trough fluctuations compared to PR-Tac. CONCLUSION Despite methodological weaknesses that limit the conclusions, we have found a more consistent drug exposure for LCP-Tac in de novo LT recipients. LCP-Tac demonstrated a greater bioavailability compared to PR-Tac.
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Affiliation(s)
- Uta Herden
- Department of Visceral TransplantationUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Martina Sterneck
- Department of MedicineUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Bettina M. Buchholz
- Department of Visceral TransplantationUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Eike G. Achilles
- Department of Visceral TransplantationUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Armin Ott
- Institute of Medical Informatics, Statistics and EpidemiologyTechnische Universität MünchenMunichGermany
| | - Lutz Fischer
- Department of Visceral TransplantationUniversity Medical Center Hamburg‐EppendorfHamburgGermany
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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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10
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Henin E, Govoni M, Cella M, Laveille C, Piotti G. Therapeutic Drug Monitoring Strategies for Envarsus in De Novo Kidney Transplant Patients Using Population Modelling and Simulations. Adv Ther 2021; 38:5317-5332. [PMID: 34515977 DOI: 10.1007/s12325-021-01905-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 08/26/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Tacrolimus, the cornerstone of transplantation immunosuppression, is a narrow therapeutic index drug with a low and highly variable bioavailability. Therapeutic drug monitoring based on trough level assessment is mandatory in order to target a personalised exposure and avoid both rejection and toxicity. Population pharmacokinetic (POPPK) models might be a useful tool for improving early attainment of target range by guiding initial doses until steady state is reached and trough levels can be reliably used as surrogate marker of exposure. Here we present the first POPPK for predicting the initial doses of the once-daily prolonged release tacrolimus Envarsus (LCPT) in adult kidney recipients. METHODS The model was developed exploiting the data from a recent pharmacokinetic randomised clinical study, in which 69 de novo kidney recipients, 33 of whom treated with LCPT, underwent an intensive blood sampling strategy for tacrolimus including four complete pharmacokinetic profiles. RESULTS The complex and prolonged absorption of LCPT is well described by the three-phase model that incorporates body weight and CYP3A5 genotype as significant covariates accounting for a great proportion of the inter-patient variability: in particular, CYP3A5*1/*3 expressors had a 66% higher LCPT clearance. We have then generated by simulation a personalised dosing strategy based on the model that could improve the early attainment of therapeutic trough levels by almost doubling the proportion of patients within target range (69.3% compared to 36.1% with the standard body weight-based approach) on post-transplantation day 4 and significantly reduce the proportion of overexposed patients at risk of toxicity. CONCLUSIONS A POPPK model was successfully developed for LCPT in de novo kidney recipients. The model could guide a personalised dosing strategy early after transplantation. For the model to be translated into clinical practice, its beneficial impact of earlier attainment of therapeutic trough levels should be demonstrated on hard clinical outcomes in further studies.
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Affiliation(s)
| | - Mirco Govoni
- Global Clinical Development, Chiesi Farmaceutici S.p.A., Parma, Italy
| | - Massimo Cella
- Global Clinical Development, Chiesi Farmaceutici S.p.A., Parma, Italy
| | | | - Giovanni Piotti
- Global Clinical Development, Chiesi Farmaceutici S.p.A., Parma, Italy.
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Willuweit K, Frey A, Hörster A, Saner F, Herzer K. Real-World Administration of Once-Daily MeltDose ® Prolonged-Release Tacrolimus (LCPT) Allows for Dose Reduction of Tacrolimus and Stabilizes Graft Function Following Liver Transplantation. J Clin Med 2020; 10:jcm10010124. [PMID: 33396492 PMCID: PMC7795274 DOI: 10.3390/jcm10010124] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 12/28/2020] [Accepted: 12/28/2020] [Indexed: 01/16/2023] Open
Abstract
The calcineurin inhibitor tacrolimus is included in most immunosuppressive protocols after liver transplantation. This retrospective, observational 24-month study investigated the tolerability of once-daily MeltDose® prolonged-release tacrolimus (LCPT) after switching from twice-daily immediate-release tacrolimus (IR-Tac) in a real-world cohort of 150 patients with previous liver transplantation. No graft rejection or new safety signals were observed. Only 7.3% of patients discontinued LCPT due to side effects. In the overall patient population, median liver transaminases, total cholesterol, triglycerides, glucose, and HbA1c remained constant after switching to LCPT. Total cholesterol significantly decreased (p ≤ 0.002) in patients with initially elevated levels (>200 mg/dL). A total of 71.8% of 96 patients maintained a glomerular filtration rate > 60 mL/min/1.73 m2 throughout the study, while 44.7% of patients were classified as fast metabolizers and 55.3% as slow metabolizers. Median daily tacrolimus dose could be reduced by 50% in fast metabolizers and by 30% in slow metabolizers, while trough levels were maintained in the target range (4–6 ng/mL). In conclusion, our observational study confirmed previous evidence of good overall tolerability and a favorable outcome for the patients after switching from IR-Tac to LCPT after liver transplantation.
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Affiliation(s)
- Katharina Willuweit
- Department of Gastroenterology and Hepatology, University Hospital Essen, University of Duisburg-Essen, Hufelandstraße 55, 45147 Essen, Germany; (A.F.); (A.H.)
- Correspondence: (K.W.); (K.H.); Tel.: +49-2641-860 (K.H.)
| | - Alexandra Frey
- Department of Gastroenterology and Hepatology, University Hospital Essen, University of Duisburg-Essen, Hufelandstraße 55, 45147 Essen, Germany; (A.F.); (A.H.)
| | - Anne Hörster
- Department of Gastroenterology and Hepatology, University Hospital Essen, University of Duisburg-Essen, Hufelandstraße 55, 45147 Essen, Germany; (A.F.); (A.H.)
| | - Fuat Saner
- Department of General, Visceral and Transplant Surgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstraße 55, 45147 Essen, Germany;
| | - Kerstin Herzer
- Department of Gastroenterology and Hepatology, University Hospital Essen, University of Duisburg-Essen, Hufelandstraße 55, 45147 Essen, Germany; (A.F.); (A.H.)
- Knappschaftsklinik Bad Neuenahr, Georg-Kreuzberg-Straße 2-6, 53474 Bad Neuenahr, Germany
- Correspondence: (K.W.); (K.H.); Tel.: +49-2641-860 (K.H.)
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12
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Parodi EL, La Porta E, Russo R, Marsano L, Bellino D, Paoletti E, Massarino F, Sofia A, Garibotto G, Esposito P, Murugavel A, Cappadona F, Fontana I, Viazzi F, Picciotto D. Ten-Year Efficacy and Safety of Once-Daily Tacrolimus in Kidney Transplant: A Prospective Cohort Study. Transplant Proc 2020; 52:3112-3117. [PMID: 32680595 DOI: 10.1016/j.transproceed.2020.02.149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 02/09/2020] [Accepted: 02/15/2020] [Indexed: 02/07/2023]
Abstract
Tacrolimus is a cornerstone in the immunosuppressive therapy of kidney transplantation. The once-daily formulation of tacrolimus has been shown to improve adherence of patients without affecting short-term efficacy. However, long-term proof of once-daily tacrolimus efficacy and safety is still lacking. From January 2009 to November 2013, 170 clinically stable kidney transplant patients were offered to change from the ongoing twice-daily tacrolimus (TDT) formulation to a once-daily tacrolimus (ODT) regimen. Kidney transplant recipients agreeing to the change to be treated with an ODT regimen (n = 105, estimated glomerular filtration rate [eGFR] 57.1 ± 1.6 mL/min/1.73 m2) and patients continuing on a TDT formulation (n = 65, eGFR 52.0 ± 2.2 mL/min/1.73 m2) were prospectively followed (median follow-up time 10.4 and 12.6 years in the ODT and TDT groups, respectively, P = not significant). At the end of the follow-up, patients in both groups experienced similar eGFR (50.4 ± 2.2 vs 48.0 ± 2.7 mL/min/1.73 m2 in the ODT and TDT groups, respectively, P = not significant). No differences were observed in biopsy-proven acute rejection, overall graft survival, doubling of serum creatinine, and new onset of proteinuria. The 2 groups also had a comparable rate of death, sepsis, and neoplasia. In conclusion, ODT appears safe and effective in stable kidney graft recipients even 10 years after transplantation. These findings support the use of ODT as a primary tacrolimus formulation in patients with kidney transplantation.
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Affiliation(s)
- E L Parodi
- Clinica Nefrologica, Dialisi, Trapianto, IRCCS Ospedale Policlinico San Martino, Genova, Italy; University of Genoa, DiMI, Genova GE, Italy
| | - E La Porta
- Clinica Nefrologica, Dialisi, Trapianto, IRCCS Ospedale Policlinico San Martino, Genova, Italy; University of Genoa, DiMI, Genova GE, Italy
| | - R Russo
- Clinica Nefrologica, Dialisi, Trapianto, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - L Marsano
- Clinica Nefrologica, Dialisi, Trapianto, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - D Bellino
- Clinica Nefrologica, Dialisi, Trapianto, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - E Paoletti
- Clinica Nefrologica, Dialisi, Trapianto, IRCCS Ospedale Policlinico San Martino, Genova, Italy; University of Genoa, DiMI, Genova GE, Italy
| | - F Massarino
- Clinica Nefrologica, Dialisi, Trapianto, IRCCS Ospedale Policlinico San Martino, Genova, Italy; University of Genoa, DiMI, Genova GE, Italy
| | - A Sofia
- Clinica Nefrologica, Dialisi, Trapianto, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - G Garibotto
- Clinica Nefrologica, Dialisi, Trapianto, IRCCS Ospedale Policlinico San Martino, Genova, Italy; University of Genoa, DiMI, Genova GE, Italy.
| | - P Esposito
- Clinica Nefrologica, Dialisi, Trapianto, IRCCS Ospedale Policlinico San Martino, Genova, Italy; University of Genoa, DiMI, Genova GE, Italy
| | - A Murugavel
- Clinica Nefrologica, Dialisi, Trapianto, IRCCS Ospedale Policlinico San Martino, Genova, Italy; University of Genoa, DiMI, Genova GE, Italy
| | - F Cappadona
- Clinica Nefrologica, Dialisi, Trapianto, IRCCS Ospedale Policlinico San Martino, Genova, Italy; University of Genoa, DiMI, Genova GE, Italy
| | - I Fontana
- UOS Chirurgia del Trapianto di Rene, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - F Viazzi
- Clinica Nefrologica, Dialisi, Trapianto, IRCCS Ospedale Policlinico San Martino, Genova, Italy; University of Genoa, DiMI, Genova GE, Italy
| | - D Picciotto
- Clinica Nefrologica, Dialisi, Trapianto, IRCCS Ospedale Policlinico San Martino, Genova, Italy; University of Genoa, DiMI, Genova GE, Italy
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13
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Lange NW, Hedvat J, Tsapepas DS, Salerno DM. Managing the significant interaction between XR tacrolimus and fluconazole in kidney transplant recipients. Clin Transplant 2020; 34:e14001. [PMID: 32564404 DOI: 10.1111/ctr.14001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 05/27/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Nicholas W Lange
- Department of Pharmacy, NewYork-Presbyterian Hospital, New York, New York
| | - Jessica Hedvat
- Department of Pharmacy, NewYork-Presbyterian Hospital, New York, New York
| | - Demetra S Tsapepas
- Department of Transplant Surgery, New York-Presbyterian Hospital, New York, New York
| | - David M Salerno
- Department of Pharmacy, NewYork-Presbyterian Hospital, New York, New York
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14
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The Effect of Maintenance Treatment with Twice-Daily or Prolonged Once-Daily Tacrolimus Formulation on Visual Evoked Potentials in Stable Kidney Transplant Recipients. J Clin Med 2020; 9:jcm9061827. [PMID: 32545305 PMCID: PMC7355742 DOI: 10.3390/jcm9061827] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 06/05/2020] [Accepted: 06/09/2020] [Indexed: 12/18/2022] Open
Abstract
In kidney transplant recipients (KTRs), uraemia-induced central nervous system damage partly subsides, while the long-lasting exposure to tacrolimus may cause pathologic visual evoked potentials (VEP) findings, which have not been investigated yet. Thus, the aim of the present study was to assess the effect of tacrolimus maintenance treatment on bioelectrical function of optic nerves in stable KTRs. Sixty-five stable KTRs were enrolled, including 30 patients treated with twice-daily (Prograf) and 35 patients treated with prolonged once-daily (Advagraf) tacrolimus formulation. In all patients, pattern and flash VEP measurements were performed. Tacrolimus dosing and exposure were also analyzed. Overall, 129 eyes were analyzed. In pattern VEP, both (1°) and (15') latencies of P100 waves were significantly longer, whereas (1°) and (15') amplitudes were lower in the Advagraf group as compared with the Prograf group. Multivariate regression analyses revealed that the use of Advagraf (vs. Prograf) was independently associated with longer (1°) and (15') P100 latencies and lower corresponding amplitudes, whereas log tacrolimus daily dose was only related to amplitudes in a whole study group. In flash VEP, log tacrolimus trough level was associated with negative changes in P2 wave amplitude irrespective of tacrolimus formulation, whereas its association with P2 latency was observed only in the Prograf group. Both the type of tacrolimus formulation and drug exposure influenced the VEP parameters in stable KTRs.
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15
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von Einsiedel J, Thölking G, Wilms C, Vorona E, Bokemeyer A, Schmidt HH, Kabar I, Hüsing-Kabar A. Conversion from Standard-Release Tacrolimus to MeltDose ® Tacrolimus (LCPT) Improves Renal Function after Liver Transplantation. J Clin Med 2020; 9:jcm9061654. [PMID: 32492783 PMCID: PMC7356524 DOI: 10.3390/jcm9061654] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 05/23/2020] [Accepted: 05/28/2020] [Indexed: 12/22/2022] Open
Abstract
Renal impairment is a typical side effect of tacrolimus (Tac) treatment in liver transplant (LT) recipients. One strategy to avoid renal dysfunction is to increase the concentration/dose (C/D) ratio by improving drug bioavailability. LT recipients converted from standard-release Tac to MeltDose® Tac (LCPT), a novel technological formulation, were able to reduce the required Tac dose due to higher bioavailability. Hence, we hypothesize that such a conversion increases the C/D ratio, resulting in a preservation of renal function. In the intervention group, patients were switched from standard-release Tac to LCPT. Clinical data were collected for 12 months after conversion. Patients maintained on standard-release Tac were enrolled as a control group. Twelve months after conversion to LCPT, median C/D ratio had increased significantly by 50% (p < 0.001), with the first significant increase seen 3 months after conversion (p = 0.008). In contrast, C/D ratio in the control group was unchanged after 12 months (1.75 vs. 1.76; p = 0.847). Estimated glomerular filtration rate (eGFR) had already significantly deteriorated in the control group at 9 months (65.6 vs. 70.6 mL/min/1.73 m2 at study onset; p = 0.006). Notably, patients converted to LCPT already had significant recovery of mean eGFR 6 months after conversion (67.5 vs. 65.3 mL/min/1.73 m2 at study onset; p = 0.029). In summary, conversion of LT recipients to LCPT increased C/D ratio associated with renal function improvement.
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Affiliation(s)
- Johannes von Einsiedel
- Department of Medicine B, Gastroenterology and Hepatology, University Hospital Münster, 48149 Münster, Germany; (J.v.E.); (C.W.); (E.V.); (A.B.); (H.H.S.); (I.K.); (A.H.-K.)
| | - Gerold Thölking
- Department of Internal Medicine and Nephrology, University Hospital of Münster Marienhospital Steinfurt, 48565 Steinfurt, Germany
- Correspondence: ; Tel.: +49-2552-791226; Fax: +49-2552-791181
| | - Christian Wilms
- Department of Medicine B, Gastroenterology and Hepatology, University Hospital Münster, 48149 Münster, Germany; (J.v.E.); (C.W.); (E.V.); (A.B.); (H.H.S.); (I.K.); (A.H.-K.)
| | - Elena Vorona
- Department of Medicine B, Gastroenterology and Hepatology, University Hospital Münster, 48149 Münster, Germany; (J.v.E.); (C.W.); (E.V.); (A.B.); (H.H.S.); (I.K.); (A.H.-K.)
| | - Arne Bokemeyer
- Department of Medicine B, Gastroenterology and Hepatology, University Hospital Münster, 48149 Münster, Germany; (J.v.E.); (C.W.); (E.V.); (A.B.); (H.H.S.); (I.K.); (A.H.-K.)
| | - Hartmut H. Schmidt
- Department of Medicine B, Gastroenterology and Hepatology, University Hospital Münster, 48149 Münster, Germany; (J.v.E.); (C.W.); (E.V.); (A.B.); (H.H.S.); (I.K.); (A.H.-K.)
| | - Iyad Kabar
- Department of Medicine B, Gastroenterology and Hepatology, University Hospital Münster, 48149 Münster, Germany; (J.v.E.); (C.W.); (E.V.); (A.B.); (H.H.S.); (I.K.); (A.H.-K.)
| | - Anna Hüsing-Kabar
- Department of Medicine B, Gastroenterology and Hepatology, University Hospital Münster, 48149 Münster, Germany; (J.v.E.); (C.W.); (E.V.); (A.B.); (H.H.S.); (I.K.); (A.H.-K.)
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16
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Vadcharavivad S, Saengram W, Phupradit A, Poolsup N, Chancharoenthana W. Once-Daily versus Twice-Daily Tacrolimus in Kidney Transplantation: A Systematic Review and Meta-analysis of Observational Studies. Drugs 2020; 79:1947-1962. [PMID: 31713065 PMCID: PMC6900208 DOI: 10.1007/s40265-019-01217-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Tacrolimus is the most commonly prescribed medication in initial immunosuppressive regimens to prevent acute rejection in kidney transplant recipients (KTRs). Tacrolimus was originally available as an immediate-release formulation (IR-Tac) given twice daily. Extended-release tacrolimus (ER-Tac) given once daily was later developed with the expectation of improved medication adherence. Data from observational studies, which compared outcomes between ER-Tac and IR-Tac in different populations of KTRs including those who are unlikely to be enrolled in randomized clinical trials, have been reported. PURPOSE To evaluate the incidence of biopsy-proven acute rejection (BPAR) at 12 months together with other outcomes reported in observational studies among adult KTRs who received ER-Tac compared to IR-Tac. METHODS In accordance with the recommendations of the Cochrane Collaboration and the Meta-analysis of Observational Studies in Epidemiology, we systematically reviewed all observational studies that compared clinical outcomes between ER-Tac and IR-Tac in KTRs. The systematic searches were conducted on PubMed, EMBASE, Scopus, and Web of Science without language restriction. Reference lists were also searched and reviewed. Data were extracted for BPAR, graft survival, patient survival, estimated glomerular filtration rate (eGFR), serum creatinine (Scr), creatinine clearance (CrCl), at different times after kidney transplantation (KT). A meta-analysis was performed to integrate the results from the eligible studies. This study is registered with PROSPERO, number CRD42019135705. RESULTS From the 1401 articles screened, 10 observational studies in KTRs who received tacrolimus were included. The pooled results showed significantly lower BPAR with ER-Tac than with IR-Tac at 12 months post-KT (5 studies, n = 659; RR, 0.69; 95% CI 0.51-0.95; p = 0.02; I2 = 0%). No significant differences in BPAR at other time points after KT were found. Graft survival, patient survival, Scr, and eGFR were comparable between groups at different times over approximately 1 year after transplantation. CONCLUSIONS Based upon currently available evidence in observational studies, 30% lower risk of BPAR was observed in ER-Tac group compared with IR-Tac group at 12 months post-KT, while there was no significant difference in BPAR risk at any other studied time points. No differences in graft- and patient-survival rates and kidney function were found. Given the limitations of observational studies to make causal inference, as well as quality limitations among the included studies, caution should be exercised in interpreting these findings.
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Affiliation(s)
- Somratai Vadcharavivad
- Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, 10330, Thailand.
| | - Warangkana Saengram
- Pharmacy Department, Thammasat University Hospital, Pathumthani, 12120, Thailand
| | - Annop Phupradit
- Pharmacy Division, Ramathibodi Hospital, Mahidol University, Bangkok, 10400, Thailand
| | - Nalinee Poolsup
- Samrejvittaya School, Aranyaprathet, Sakaeo, 27120, Thailand
| | - Wiwat Chancharoenthana
- Immunology Unit, Department of Microbiology, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand
- Nephrology Research Unit, Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400, Thailand
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17
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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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18
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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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19
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MeltDose Technology vs Once-Daily Prolonged Release Tacrolimus in De Novo Liver Transplant Recipients. Transplant Proc 2019; 51:2971-2973. [DOI: 10.1016/j.transproceed.2019.03.084] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 02/19/2019] [Accepted: 03/12/2019] [Indexed: 11/21/2022]
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20
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Covvey JR, Mancl EE. Pharmaceutical care in transplantation: current challenges and future opportunities. Nanomedicine (Lond) 2019; 14:2651-2658. [PMID: 31610735 DOI: 10.2217/nnm-2019-0106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Jordan R Covvey
- Assistant Professor in Pharmacy Administration, Division of Pharmaceutical, Administrative & Social Sciences, Duquesne University School of Pharmacy, 600 Forbes Ave, 418 Mellon Hall, PA 15282, USA
| | - Erin E Mancl
- Medical Science Liaison, Mallinckrodt Pharmaceuticals, Somerset Center, 1425 US Route 206, NJ 07921, USA
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21
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Nowicka M, Górska M, Nowicka Z, Edyko K, Edyko P, Wiślicki S, Zawiasa-Bryszewska A, Strzelczyk J, Matych J, Kurnatowska I. Tacrolimus: Influence of the Posttransplant Concentration/Dose Ratio on Kidney Graft Function in a Two-Year Follow-Up. Kidney Blood Press Res 2019; 44:1075-1088. [PMID: 31522184 DOI: 10.1159/000502290] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 07/22/2019] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Tacrolimus (TAC) metabolism rate has the potential to impact graft function after kidney transplantation (KTx). We aimed to analyze the relationship between the early post-KTx TAC C/D ratio (blood trough concentration normalized by total daily dose) and kidney graft function in a 2-year follow-up. METHODS We retrospectively analyzed data from 101 post-KTx patients at 3, 6, 12, and 24 months after KTx to identify the C/D ratio cutoff value optimal for dividing patients into fast and slow TAC metabolizers. We investigated the relationship between their TAC metabolism rate and graft function. RESULTS Patients were divided based on the TAC C/D ratio at 6 months after KTx of 1.47 ng/mL * 1 mg. Fast metabolizers (C/D ratio <1.47 ng/mL * 1 mg) presented with significantly worse graft function throughout the whole study period (p < 0.05 at each timepoint) and were significantly less likely to develop good graft function (estimated glomerular filtration rate ≥45 mL/min/1.73 m2) than slow metabolizers. Our model based on donor and recipient age, recipient sex and slow/fast metabolism status allowed for identification of patients with compromised graft function in 2-year follow-up with 66.7% sensitivity and 94.6% specificity. CONCLUSION Estimating TAC C/D ratio at 6 months post-KTx might help identify patients at risk of developing deteriorated graft function in a 2-year follow-up.
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Affiliation(s)
- Maja Nowicka
- Department of Clinical Pharmacology, Medical University of Lodz, Lodz, Poland
| | - Monika Górska
- Department of Clinical Pharmacology, Medical University of Lodz, Lodz, Poland
| | - Zuzanna Nowicka
- Department of Clinical Pharmacology, Medical University of Lodz, Lodz, Poland.,Department of Biostatistics and Translational Medicine, Medical University of Lodz, Lodz, Poland
| | - Krzysztof Edyko
- Department of Clinical Pharmacology, Medical University of Lodz, Lodz, Poland
| | - Piotr Edyko
- Department of Urology and Kidney Transplantation, N Pirogov Provincial Specialist Hospital, Lodz, Poland
| | - Sebastian Wiślicki
- Clinical Department of Anesthesiology and Intensive Care and Pain Management, University Clinical Hospital No 1 N Barlicki in Lodz, Lodz, Poland
| | - Anna Zawiasa-Bryszewska
- Department of Clinical Pharmacology, Medical University of Lodz, Lodz, Poland.,Department of Nephrology, University Clinical Hospital No 1 N Barlicki in Lodz, Lodz, Poland
| | - Janusz Strzelczyk
- Department of General and Transplant Surgery, Medical University of Lodz, Lodz, Poland
| | - Józef Matych
- Department of Urology and Kidney Transplantation, N Pirogov Provincial Specialist Hospital, Lodz, Poland
| | - Ilona Kurnatowska
- Department of Clinical Pharmacology, Medical University of Lodz, Lodz, Poland, .,Department of Nephrology, University Clinical Hospital No 1 N Barlicki in Lodz, Lodz, Poland,
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22
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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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23
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Saengram W, Vadcharavivad S, Poolsup N, Chancharoenthana W. Extended release versus immediate release tacrolimus in kidney transplant recipients: a systematic review and meta-analysis. Eur J Clin Pharmacol 2018; 74:1249-1260. [PMID: 29961086 DOI: 10.1007/s00228-018-2512-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 06/22/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE To compare the estimated glomerular filtration rate (eGFR) at 12 months together with other outcomes among adult kidney transplant recipients (KTRs) who received extended release, once daily tacrolimus (ER-Tac) compared to those who received the immediate release, twice daily tacrolimus (IR-Tac) administration. METHODS In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement, we systematically reviewed all randomized controlled trials (RCTs) that compared clinical outcomes between ER-Tac versus IR-Tac in KTRs. The systematic searches were conducted on PubMed, EMBASE, Cochrane Register of Controlled Trials, Scopus, Web of Science, and CINAHL without language restriction. The trials registered and reference lists were also searched and reviewed. Data were extracted for eGFR, serum creatinine (Scr), creatinine clearance (CrCl), biopsy-proven acute rejection rate (BPAR), graft survival, and overall patient survival at different times over 24 months after kidney transplant (KT). A meta-analysis was performed to integrate the results from eligible studies. RESULTS From 1145 articles screened, 11 RCTs were included. The pooled results of included RCTs showed no significant difference of eGFR at 12 months between ER-Tac and IR-Tac groups (four trials, n = 1738; mean difference - 0.77 mL/min/1.73 m2, 95% CI: - 2.41 to 0.87; p = 0.56; I2 = 0%). Comparing between the two tacrolimus formulations, there were no significant differences of eGFR, CrCl, Scr, BPAR, graft survival, and patient survival at different times over 4 years after transplantation. CONCLUSIONS Based upon currently available evidences in KTRs, the impact on kidney allograft function appears to be comparable between ER-Tac and IR-Tac.
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Affiliation(s)
- Warangkana Saengram
- Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, 10330, Thailand
| | - Somratai Vadcharavivad
- Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, 10330, Thailand.
| | - Nalinee Poolsup
- Department of Pharmacy, Faculty of Pharmacy, Silpakorn University, Sanam Chandra Palace campus, Nakhon Pathom, 73000, Thailand
| | - Wiwat Chancharoenthana
- Division of Nephrology and Hypertension, Department of Medicine, Princess Chulabhorn College of Medical Sciences, and Comprehensive Center of Excellence in Organ Transplantation and Research, Chulabhorn Hospital, Chulabhorn Royal Academy, Bangkok, 10210, Thailand
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24
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Xu H, Liu L, Li X, Ma J, Liu R, Wang S. Extended tacrolimus release via the combination of lipid-based solid dispersion and HPMC hydrogel matrix tablets. Asian J Pharm Sci 2018; 14:445-454. [PMID: 32104473 PMCID: PMC7032121 DOI: 10.1016/j.ajps.2018.08.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 07/06/2018] [Accepted: 08/10/2018] [Indexed: 11/18/2022] Open
Abstract
The objective of this study is to evaluate the feasibility of obtaining extended release of tacrolimus by a novel combination of lipid-based solid dispersion and matrix-type extended release tablet techniques. Tacrolimus solid dispersion was prepared using glycerylbehenate (Compritol® ATO888) and Pluronic F127 as the carrier materials with hot-melt method, which was then blended with hydrogel matrix materials, such as HPMC and lactose, the powders were directly compressed into tablets. In vitro drug release tests were carried out to evaluate the performance of the solid dispersions and the tablets. The dissolution rate of tacrolimus was significantly improved by the lipid-based solid dispersion, and the incorporation of HPC into the solid dispersion obviously improved its stability after storage. Extended release tablets loaded with tacrolimus solid dispersion showed prolonged drug release patterns over 24 h, the release patterns of the tablets can be tailored by the compositions of the matrix materials, including the types and content of HPMCs. A modified processing method that directly mixed the melted solid dispersion with HPMC powders improved the uniformity of the solid dispersion inside the tablet matrix and release profile. The release data of the extended release tablet fitted well to the Korsmeyer–Peppas model with n value of 0.85, which suggested diffusion- and erosion-controlled release mechanism. The combination of lipid-based solid dispersion and HPMC hydrogel matrix may find wide applications in the extended release dosage forms of high potent, water-insoluble drugs.
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Affiliation(s)
- Hui Xu
- School of Pharmacy, Shenyang Pharmaceutical University, Benxi 117004, China
| | - Li Liu
- School of Pharmacy, Shenyang Pharmaceutical University, Benxi 117004, China
| | - Xuehui Li
- School of Pharmacy, Shenyang Pharmaceutical University, Benxi 117004, China
| | - Junyuan Ma
- School of Pharmaceutical Engineering, Shenyang Pharmaceutical University, Benxi 117004, China
| | - Rui Liu
- School of Pharmaceutical Engineering, Shenyang Pharmaceutical University, Benxi 117004, China
| | - Shaoning Wang
- School of Pharmaceutical Engineering, Shenyang Pharmaceutical University, Benxi 117004, China
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25
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Orally Disintegrating Tablets Containing Melt Extruded Amorphous Solid Dispersion of Tacrolimus for Dissolution Enhancement. Pharmaceutics 2018; 10:pharmaceutics10010035. [PMID: 29547585 PMCID: PMC5874848 DOI: 10.3390/pharmaceutics10010035] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 03/09/2018] [Accepted: 03/10/2018] [Indexed: 11/16/2022] Open
Abstract
In order to improve the aqueous solubility and dissolution of Tacrolimus (TAC), amorphous solid dispersions of TAC were prepared by hot melt extrusion with three hydrophilic polymers, Polyvinylpyrrolidone vinyl acetate (PVP VA64), Soluplus® and Hydroxypropyl Cellulose (HPC), at a drug loading of 10% w/w. Molecular modeling was used to determine the miscibility of the drug with the carrier polymers by calculating the Hansen Solubility Parameters. Powder X-ray diffraction and differential scanning calorimetry (DSC) studies of powdered solid dispersions revealed the conversion of crystalline TAC to amorphous form. Fourier transform Infrared (FTIR) spectroscopy results indicated formation of hydrogen bond between TAC and polymers leading to stabilization of TAC in amorphous form. The extrudates were found to be stable under accelerated storage conditions for 3 months with no re-crystallization, indicating that hot melt extrusion is suitable for producing stable amorphous solid dispersions of TAC in PVP VA64, Soluplus® and HPC. Stable solid dispersions of amorphous TAC exhibited higher dissolution rate, with the solid dispersions releasing more than 80% drug in 15 min compared to the crystalline drug giving 5% drug release in two hours. These stable solid dispersions were incorporated into orally-disintegrating tablets in which the solid dispersion retained its solubility, dissolution and stability advantage.
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26
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Patel K, Atkinson C, Tran D, Nadig SN. Nanotechnological Approaches to Immunosuppression and Tolerance Induction. CURRENT TRANSPLANTATION REPORTS 2017; 4:159-168. [PMID: 29057203 DOI: 10.1007/s40472-017-0146-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
PURPOSE OF REVIEW Several preclinical studies have engineered nanoparticles for immune regulation, and have shown promising results in the fields of autoimmunity and cancer. In solid organ transplantation, the use of nanoparticle-based immune regulation has only just begun to emerge but holds significant promise for the improvement of our current standard of care immunosuppressive regimens. In this review, we will shed light on the current status of nanoparticle-engineered immunotherapeutics, and the potential application of these technologies to the field of organ transplantation. Further we discuss different strategies for delivery and potential cellular targeting moieties that could be utilized to obviate the need for high dose systemic immunosuppressive regimens. RECENT FINDINGS Recent studies have shown the potential of immunosuppressive laden nanoparticles to increase bioavailability, drug release, and specifically target immune cell compartments as methods to provide recipient immunosuppressive sparing strategies. SUMMARY Nanoparticle centered immunosuppressive strategies hold the potential to usher in a new era in transplant recipient management and could hold the key to minimizing off-target effects of immunosuppressants, along with prolonging transplant survival.
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Affiliation(s)
- Kunal Patel
- Department of Surgery, Division of Transplantation, Lee Patterson Allen Transplant Immunobiology Laboratory, Medical University of South Carolina, Charleston, South Carolina, USA
- Department of Surgery, Division of Transplantation, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Carl Atkinson
- Department of Surgery, Division of Transplantation, Lee Patterson Allen Transplant Immunobiology Laboratory, Medical University of South Carolina, Charleston, South Carolina, USA
- Department of Surgery, Division of Transplantation, Medical University of South Carolina, Charleston, South Carolina, USA
- South Carolina Investigators in Transplantation, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Danh Tran
- Department of Surgery, Division of Transplantation, Lee Patterson Allen Transplant Immunobiology Laboratory, Medical University of South Carolina, Charleston, South Carolina, USA
- Department of Surgery, Division of Transplantation, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Satish N Nadig
- Department of Surgery, Division of Transplantation, Lee Patterson Allen Transplant Immunobiology Laboratory, Medical University of South Carolina, Charleston, South Carolina, USA
- Department of Surgery, Division of Transplantation, Medical University of South Carolina, Charleston, South Carolina, USA
- South Carolina Investigators in Transplantation, Medical University of South Carolina, Charleston, South Carolina, USA
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27
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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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28
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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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29
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In vitro and in silico characterisation of Tacrolimus released under biorelevant conditions. Int J Pharm 2016; 515:271-280. [PMID: 27737809 DOI: 10.1016/j.ijpharm.2016.10.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Revised: 10/06/2016] [Accepted: 10/08/2016] [Indexed: 11/22/2022]
Abstract
This work aims to better understand the in vivo behaviour of modified release (MR) formulations (Envarsus® tablets and Advagraf® capsules) using in vitro properties of tacrolimus and in silico simulations. The in silico concentration profiles of tacrolimus released from the MR formulations were predicted after building a three compartments PK model with GastroPlus™, and using the experimentally determined in vitro physico-chemical properties as input parameters. In vitro-in vivo correlations (IVIVC) were obtained after deconvolution of in vivo data from a clinical trial. The IVIVC showed that the in vitro dissolution was faster than the in vivo deconvoluted dissolution for Advagraf®, while the in vitro dissolution was slightly slower than the in vivo deconvoluted dissolution for Envarsus®. Population PK simulation showed that variability in the simulation was lower for Envarsus® compared to Advagraf®. The in silico predicted preferential absorption sites were the proximal and distal tract for Advagraf® and Envarsus®, respectively. The integration of experimental in vitro solubility, permeability and biorelevant dissolution data allowed to generate in silico tacrolimus concentrations for two different MR formulations. This permitted to compare the two formulations in a single PK profile, in a simulated population PK study and with respect to their absorption sites.
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30
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Horwedel TA, Brennan DC. Extended-release tacrolimus tablets for preventing organ transplant rejection. Expert Opin Orphan Drugs 2016. [DOI: 10.1080/21678707.2016.1218330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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31
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Piotti G, Cremaschi E, Maggiore U. Once-daily prolonged-release tacrolimus formulations for kidney transplantation: what the nephrologist needs to know. J Nephrol 2016; 30:53-61. [DOI: 10.1007/s40620-016-0316-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Accepted: 05/02/2016] [Indexed: 12/30/2022]
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32
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Clinical Pharmacokinetics of Once-Daily Tacrolimus in Solid-Organ Transplant Patients. Clin Pharmacokinet 2015; 54:993-1025. [DOI: 10.1007/s40262-015-0282-2] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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33
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Revollo J. Update on the clinical utility of once-daily tacrolimus in the management of transplantation. DRUG DESIGN DEVELOPMENT AND THERAPY 2015; 9:2581-3. [PMID: 26005334 PMCID: PMC4428359 DOI: 10.2147/dddt.s84301] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Jane Revollo
- Department of Pharmacy, Jackson Memorial Hospital, University of Miami Leonard M Miller School of Medicine Miami, FL, USA
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