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Barriga-Rodríguez P, Falcón-Cubillo M, Mejías-Trueba M, Ciudad-Gutiérrez P, Guisado-Gil AB, Gómez-Bravo MÁ, Porras-López M, Gil-Navarro MV, Herrera-Hidalgo L. Pharmacokinetics of Different Tacrolimus Formulations in the Early Post-Liver Transplant Period: A Scoping Review. Pharmaceutics 2025; 17:619. [PMID: 40430910 PMCID: PMC12114635 DOI: 10.3390/pharmaceutics17050619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2025] [Revised: 04/30/2025] [Accepted: 05/02/2025] [Indexed: 05/29/2025] Open
Abstract
Background: Tacrolimus (TAC) is the cornerstone of immunosuppression after liver transplantation (LT). TAC has a narrow therapeutic index and high inter- and intra-individual pharmacokinetic (PK) variability, requiring dose individualization. This variability is more noticeable in the early post-LT period. Objectives: This study aimed to compare the PK of different TAC formulations in the early post-LT period and describe the main PK characteristics and plasma levels obtained with each TAC formulation used. Methods: The search was conducted in MEDLINE (PubMed) and EMBASE in accordance with PRISMA-ScR guidelines. The main inclusion criteria were clinical trials and observational studies focusing on the PK parameters of TAC in LT recipients during the first month post-transplant. Results: A total of 2169 articles were identified, of which 23 met the inclusion criteria. Various PK parameters were analyzed after LT for the different TAC formulations: intravenous (iv) and oral forms, such as immediate-release (IRT), prolonged-release (PRT), and extended-release (LCPT) formulations. PK variability was higher in the initial days after LT, with different TAC exposure between formulations. IV TAC allows the rapid attainment of therapeutic levels, but it has fallen into disuse. Regarding oral formulations, IRT reaches target levels faster than PRT and LCPT. PRT and LCPT exposure seem more stable during the first month post-LT than when using IRT. Conclusions: TAC formulations exhibit relevant differences in their PK profile in the early post-LT period. PK differences might influence the dose regimen and the time to achieve PK targets. Given these variations, therapeutic drug monitoring (TDM) is essential for optimizing treatment.
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Affiliation(s)
- Paloma Barriga-Rodríguez
- Department of Pharmacy, Virgen del Rocío University Hospital, 41013 Seville, Spain; (P.B.-R.); (M.F.-C.); (P.C.-G.); (A.B.G.-G.); (M.V.G.-N.); (L.H.-H.)
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital, Consejo Superior de Investigaciones Científicas (CSIC), University of Seville, 41013 Seville, Spain
| | - Marta Falcón-Cubillo
- Department of Pharmacy, Virgen del Rocío University Hospital, 41013 Seville, Spain; (P.B.-R.); (M.F.-C.); (P.C.-G.); (A.B.G.-G.); (M.V.G.-N.); (L.H.-H.)
| | - Marta Mejías-Trueba
- Department of Pharmacy, Virgen del Rocío University Hospital, 41013 Seville, Spain; (P.B.-R.); (M.F.-C.); (P.C.-G.); (A.B.G.-G.); (M.V.G.-N.); (L.H.-H.)
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital, Consejo Superior de Investigaciones Científicas (CSIC), University of Seville, 41013 Seville, Spain
| | - Pablo Ciudad-Gutiérrez
- Department of Pharmacy, Virgen del Rocío University Hospital, 41013 Seville, Spain; (P.B.-R.); (M.F.-C.); (P.C.-G.); (A.B.G.-G.); (M.V.G.-N.); (L.H.-H.)
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital, Consejo Superior de Investigaciones Científicas (CSIC), University of Seville, 41013 Seville, Spain
| | - Ana Belén Guisado-Gil
- Department of Pharmacy, Virgen del Rocío University Hospital, 41013 Seville, Spain; (P.B.-R.); (M.F.-C.); (P.C.-G.); (A.B.G.-G.); (M.V.G.-N.); (L.H.-H.)
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital, Consejo Superior de Investigaciones Científicas (CSIC), University of Seville, 41013 Seville, Spain
| | - Miguel Ángel Gómez-Bravo
- Department of Hepatobiliary-Pancreatic Surgery, General and Digestive Surgery Service, Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital, Consejo Superior de Investigaciones Científicas (CSIC), University of Seville, 41013 Seville, Spain;
| | - Manuel Porras-López
- Department of Intensive Care, Virgen del Rocío University Hospital, 41013 Seville, Spain;
| | - María Victoria Gil-Navarro
- Department of Pharmacy, Virgen del Rocío University Hospital, 41013 Seville, Spain; (P.B.-R.); (M.F.-C.); (P.C.-G.); (A.B.G.-G.); (M.V.G.-N.); (L.H.-H.)
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital, Consejo Superior de Investigaciones Científicas (CSIC), University of Seville, 41013 Seville, Spain
| | - Laura Herrera-Hidalgo
- Department of Pharmacy, Virgen del Rocío University Hospital, 41013 Seville, Spain; (P.B.-R.); (M.F.-C.); (P.C.-G.); (A.B.G.-G.); (M.V.G.-N.); (L.H.-H.)
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital, Consejo Superior de Investigaciones Científicas (CSIC), University of Seville, 41013 Seville, Spain
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Tharanon V, Iamrahong P, Tuamsem J, Choochaeam K, Auamnoy T, Sobhonslidsuk A. Hemoglobin and total bilirubin may affect tacrolimus clearance in liver transplant patient following the early postoperative period: a case report. J Med Case Rep 2024; 18:408. [PMID: 39232822 PMCID: PMC11375944 DOI: 10.1186/s13256-024-04753-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Accepted: 08/09/2024] [Indexed: 09/06/2024] Open
Abstract
BACKGROUND Tacrolimus is a potent calcineurin inhibitor (CNI) that is principally used as a first-line immunosuppressant for the prophylaxis of allograft rejection in liver transplantation (LT) patients. In clinical practice, prescribing the optimal tacrolimus dosage is complicated by its narrow therapeutic index and high pharmacokinetic variability. Thus, performing therapeutic drug monitoring (TDM) of only tacrolimus may not provide optimal drug levels. However, other influential clinical factors affecting tacrolimus levels, such as hemoglobin (Hb), hematocrit, and total bilirubin (TBIL), should be considered while adjusting tacrolimus levels. This case report aims to introduce clinicians and their teams to taking the pharmacokinetic prediction equation into consideration for a better understanding of tacrolimus dosage adjustment during the early postoperative LT. CASE PRESENTATION In this case report, an 18-year-old male patient of Thai ethnicity was admitted for orthotropic liver transplantation, and tacrolimus was prescribed as a cornerstone immunosuppressive agent. In the immediate postoperative period, which is the most challenging period in liver transplantation, the population pharmacokinetics predictive equation was clinically used to assist in dosage adjustment of tacrolimus by considering the significant clinical factors in this case. Hemoglobin and total bilirubin levels were deemed significant clinical factors affecting the oral clearance (CL/F) of tacrolimus. First, a decrease in the Hb concentration increases the free drug concentration and therefore increases the CL/F of tacrolimus. Second, an elevated TBIL decreases the biliary excretion of tacrolimus, resulting in a decrease in the CL/F of tacrolimus. Thus, dose optimization of tacrolimus would be accurate when taking the pharmacokinetic prediction equation into consideration. Moreover, the results may contribute to a better understanding of tacrolimus pharmacokinetic variability in each transplant patient during the immediate postoperative course. CONCLUSIONS Hemoglobin and total bilirubin were significant clinical factors influencing the oral clearance of tacrolimus early after liver transplantation. A decrease in the hemoglobin concentration would increase the free drug concentration and therefore increase the oral clearance of tacrolimus. An elevated total bilirubin decreases the biliary excretion of tacrolimus, resulting in a decrease in the oral clearance of tacrolimus.
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Affiliation(s)
- Vichapat Tharanon
- Clinical Pharmacy section, Department of Pharmacy, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
| | - Pansa Iamrahong
- Clinical Pharmacy section, Department of Pharmacy, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Jutamas Tuamsem
- Clinical Pharmacy section, Department of Pharmacy, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Kunvadee Choochaeam
- Clinical Pharmacy section, Department of Pharmacy, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Titinun Auamnoy
- Division of Social Pharmacy and Pharmacy Administration, Faculty of Pharmaceutical Sciences, Burapha University, ChonBuri, Thailand
| | - Abhasnee Sobhonslidsuk
- Division of Gastroenterology and Hepatology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Oteo I, Lukas JC, Leal N, Suarez E, Valdivieso A, Gastaca M, Ortiz de Urbina J, Calvo R. Tacrolimus pharmacokinetics in the early post-liver transplantation period and clinical applicability via Bayesian prediction. Eur J Clin Pharmacol 2012; 69:65-74. [DOI: 10.1007/s00228-012-1300-z] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2011] [Accepted: 04/19/2012] [Indexed: 10/28/2022]
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