1
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Kuypers D, Weekers L, Blogg M, Anaokar S, del Pilar Repetur C, De Meyer V, Kanaan N. Efficacy of Prolonged-release Tacrolimus After Conversion From Immediate-release Tacrolimus in Kidney Transplantation: A Retrospective Analysis of Long-term Outcomes From the ADMIRAD Study. Transplant Direct 2023; 9:e1465. [PMID: 36935873 PMCID: PMC10019145 DOI: 10.1097/txd.0000000000001465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 02/12/2023] [Indexed: 03/17/2023] Open
Abstract
Prolonged-release tacrolimus (PRT) may offer improved outcomes after kidney transplantation compared with immediate-release tacrolimus (IRT). However, data on outcomes beyond 5-y posttransplantation are lacking. Methods A retrospective, noninterventional chart review study examined long-term graft survival in adult kidney transplant participants in the Adherence Measurement in Stable Renal Transplant Patients Following Conversion From Prograf to Advagraf (ADMIRAD) clinical trial at 4 Belgian sites. Patients were randomized to receive once-daily PRT or twice-daily IRT for 6 mo, followed by treatment as per real-world clinical practice. Data were collected retrospectively from randomization day until December 31, 2018. Primary endpoints included efficacy failure, defined as a composite endpoint of graft loss, biopsy-confirmed acute rejection, and graft dysfunction. Secondary endpoints included overall patient survival and course of kidney function. Results This analysis included 78.5% of patients from ADMIRAD (n = 108 PRT; n = 64 IRT). The Kaplan-Meier survival rate without efficacy failure from randomization to year 5 was 0.741 (95% confidence interval [CI]: 0.647, 0.813) for the PRT group (n = 80), and 0.667 (95% CI: 0.536, 0.768) for the IRT group (n = 42) and remained higher for PRT throughout 10 y follow-up (P = 0.041). The Kaplan-Meier estimate of overall survival from the time of last transplant was 0.981 (95% CI: 0.928, 0.995) and 0.880 (95% CI: 0.802, 0.928) at 5 and 10 y in the PRT group. Kidney function parameters and tacrolimus trough levels remained stable over the follow-up period. Conclusions Patients in the ADMIRAD study who received PRT for up to 10 y had improved long-term outcomes compared with patients receiving IRT, with a consistent effect on both graft and patient survival.
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Affiliation(s)
- Dirk Kuypers
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
- Department of Microbiology, Immunology and Transplantation, University of Leuven, Leuven, Belgium
| | - Laurent Weekers
- Department of Nephrology, Centre Hospitalier Universitaire de Liège, Liège, Belgium
| | - Martin Blogg
- Astellas Pharma Europe, Addlestone, United Kingdom
| | | | | | - Vicky De Meyer
- Division of Nephrology, Vrije Universiteit Brussel, Brussels, Belgium
| | - Nada Kanaan
- Division of Nephrology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
- Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
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2
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Lai EF, Nguyen HT, Famure O, Li Y, Kim SJ. Tacrolimus Formulation, Exposure Variability, and Outcomes in Kidney Transplant Recipients. Prog Transplant 2023; 33:34-42. [PMID: 36562176 PMCID: PMC9968997 DOI: 10.1177/15269248221145044] [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] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Few studies have compared within-patient variability measures of tacrolimus trough levels by formulation and assessed within-patient variability on outcomes of kidney transplant recipients. RESEARCH QUESTIONS (1) To compare within-patient variability of trough levels when converting from twice-daily to once-daily tacrolimus using standard deviation, coefficient of variation, and intrapatient variability percent. (2) To use the 3 measures of variability to examine the relationship between tacrolimus once-daily within-patient variability and total graft failure (i.e., return to chronic dialysis, pre-emptive retransplant, death with graft function). DESIGN In this observational cohort study, within-patient variability of trough levels pre- and post-conversion from twice-daily to once-daily tacrolimus were compared using Wilcoxon matched-pairs signed-rank test. Graft outcomes were analyzed using Kaplan-Meier curves and multivariable Cox proportional hazards models. RESULTS In 463 patients, within-patient variability differences pre- and post-conversion of median standard deviation, coefficient of variation, and intrapatient variability percent were -0.16 (P = 0.09), -0.01 (P = 0.52), and -1.41 (P = 0.32), respectively. Post-conversion, every 1 unit increase in within-patient variability standard deviation and intrapatient variability percent and every 0.1 unit increase in the coefficient of variation was associated with an increased hazard ratio [1.19 (P = 0.004), 1.02 (P = 0.030), 1.13 (P = 0.001), respectively] of total graft failure. Post-conversion, within-patient variability above cohort medians using standard deviation and coefficient of variation had a significantly higher risk of total graft failure. DISCUSSION Under a program-wide conversion, no significant difference was observed in within-patient variability post-conversion from twice-daily to once-daily tacrolimus using the three measures of variability. High within-patient variability was associated with adverse transplant outcomes post-conversion.
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Affiliation(s)
- Elaine F Lai
- Ajmera Transplant Center, 33540Toronto General Hospital, University Health Network, Toronto, Canada
| | - Huong Thao Nguyen
- Ajmera Transplant Center, 33540Toronto General Hospital, University Health Network, Toronto, Canada
| | - Olusegun Famure
- Ajmera Transplant Center, 33540Toronto General Hospital, University Health Network, Toronto, Canada.,Division of Nephrology and the Kidney Transplant Program, Toronto General Hospital, 7989University Health Network, Toronto, Canada
| | - Yanhong Li
- Ajmera Transplant Center, 33540Toronto General Hospital, University Health Network, Toronto, Canada.,Division of Nephrology and the Kidney Transplant Program, Toronto General Hospital, 7989University Health Network, Toronto, Canada
| | - S Joseph Kim
- Ajmera Transplant Center, 33540Toronto General Hospital, University Health Network, Toronto, Canada.,Division of Nephrology and the Kidney Transplant Program, Toronto General Hospital, 7989University Health Network, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, Faculty of Medicine, 33540University of Toronto, Toronto, Canada
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3
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Ruijter BN, Tushuizen ME, Moes DJAR, Klerk BMD, Hoek BV. Tacrolimus 4-hour monitoring in liver transplant patients is non-inferior to trough monitoring: The randomized controlled FK04 trial. Clin Transplant 2022; 36:e14829. [PMID: 36193575 PMCID: PMC10078353 DOI: 10.1111/ctr.14829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 08/22/2022] [Accepted: 09/10/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND After liver transplantation (LT), tacrolimus and ciclosporin treatment can lead to, partially concentration-dependent, chronic kidney disease. Monitoring ciclosporin with two-hour levels reduced overexposure and led to better renal function than trough-monitoring (C0). For tacrolimus, a 4-hour level (C4) can give a reasonable approximation of total drug exposure. We evaluated whether monitoring tacrolimus in stable patients after LT by C4 was superior to C0 regarding renal function, rejection and metabolic parameters. METHODS This open label randomized controlled trial compared C4 monitoring of tacrolimus BID (Prograft) to trough (C0) monitoring in stable LT recipients. The target range for C4 of 7.8-16 ng/ml was calculated to be comparable with target C0 of 4-8 ng/ml. Primary endpoint was the effect on renal function and secondary endpoints were the occurrence of treated biopsy-proven acute rejection, blood pressure and metabolic parameters, during 3 months of follow-up. RESULTS Fifty patients were randomized to C0 (n = 25) or C4 (n = 25) monitoring. There was no difference in renal function between the C0 and the C4 group (p = .98 and p = .13 for CG and MDRD at 3 months). Also, the amount of proteinuria was similar (p = .59). None of the patients suffered from graft loss or was treated for rejection. Metabolic parameters did not differ between the two groups. CONCLUSION Tacrolimus 4-hour monitoring in stable LT patients is not superior to trough monitoring, regarding the effect on renal function, but is safe for use to facilitate tacrolimus monitoring in an afternoon outpatient clinic.
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Affiliation(s)
- Bastian N Ruijter
- Department of Gastroenterology and Hepatology and Transplantation Center, Leiden University Medical Center, Leiden, The Netherlands
| | - Maarten E Tushuizen
- Department of Gastroenterology and Hepatology and Transplantation Center, Leiden University Medical Center, Leiden, The Netherlands
| | - Dirk J A R Moes
- Department of Clinical Pharmacology and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Babs M de Klerk
- Department of Gastroenterology and Hepatology and Transplantation Center, Leiden University Medical Center, Leiden, The Netherlands
| | - Bart van Hoek
- Department of Gastroenterology and Hepatology and Transplantation Center, Leiden University Medical Center, Leiden, The Netherlands
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4
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Tiankanon K, Kerr SJ, Thongthip S, Udomkarnjananun S, Sodsai P, Vorasittha A, Panumatrassamee K, Takkavatakarn K, Tungsanga K, Eiam-Ong S, Praditpornsilpa K, Avihingsanon Y, Townamchai N. Tacrolimus dose adjustment is not necessary in dose to dose conversion from a twice daily to a prolonged release once daily dose form. Sci Rep 2022; 12:10051. [PMID: 35710816 PMCID: PMC9203451 DOI: 10.1038/s41598-022-14317-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 06/06/2022] [Indexed: 11/09/2022] Open
Abstract
Twice daily TAC (BID TAC) and prolonged released once daily dose tacrolimus (OD TAC) have different pharmacokinetic (PK) profiles in kidney transplant (KT) recipients. Precise dose adjustment recommendations when converting from BID TAC to OD TAC remain inconclusive. A single center, PK study was conducted in stable KT recipients taking constant doses of TAC, mycophenolic acid, and prednisolone. The area under the concentration-time curve (AUC) 0-24 and Ctrough were measured before and 4 weeks after 1:1 conversion from BID TAC to OD TAC without subsequent dose adjustment. A 90% confidence interval (CI) of geometric mean ratio (GMR) of OD TAC/BID TAC within the range of 0.9-1.11 was utilized to indicate equivalence of the narrow therapeutic index drugs. The roles of CYP3A5 genotypic polymorphism on PK parameters were also assessed. There were 20 patients with median time since transplantation of 18 months. The mean of CKD-EPI eGFR was 60.7 ± 16.43 mL/min/1.73 m2. The median total daily TAC dose of 0.058 mg/kg/day. The geometric means (%CV) of AUC0-24 of OD and BID TAC were 205.16 (36.4%) and 210.3 (32.5%) ng/mL × h, respectively, with a GMR of 0.98 (90%CI 0.91-1.04). The geometric means (%CV) of Ctrough of OD TAC and BID TAC were 5.43 (33.1%) and 6.09 (34.6%) ng/mL, respectively. The GMR of Ctrough was 0.89 (90%CI 0.82-0.98), which was below 0.9. The newly calculated target Ctrough level of OD TAC was 4.8-6.2 ng/mL. The best abbreviated AUC0-24 was AUC = 0.97(C0) + 5.79(C6) + 18.97(C12) - 4.26. The GMR AUC0-24 was within the range of 0.9-1.11 irrespective of CYP3A5 genotypic polymorphism while the GMR of Ctrough was below 0.9 only in the CYP3A5 expressor patients. The 1:1 conversion from BID TAC to OD TAC without subsequent dose adjustment provided similar AUC0-24 regardless of CYP3A5 genotypic polymorphism. However, the Ctrough was lower in the CYP3A5 expressor group. Therefore, it is not necessary to routinely increase the OD TAC dose after conversion.Trial registration: Thai Clinical Trials Registry (TCTR20210715002).
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Affiliation(s)
- Kanitha Tiankanon
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Stephen J Kerr
- Biostatistics Excellence Centre, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Siriwan Thongthip
- Maha Chakri Sirindhorn Clinical Research Center, Chulalongkorn University, Bangkok, Thailand
| | - Suwasin Udomkarnjananun
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand.,Excellence Center for Solid Organ Transplantation, King Chulalongkorn Memorial Hospital, Bangkok, Thailand.,Renal Immunology and Renal Transplant Research Unit, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Pimpayao Sodsai
- Center of Excellence in Immunology and Immune-Mediated Diseases, Department of Microbiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Athaya Vorasittha
- Excellence Center for Solid Organ Transplantation, King Chulalongkorn Memorial Hospital, Bangkok, Thailand.,Department of Surgery, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Kamol Panumatrassamee
- Division of Urology, Department of Surgery, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Kullaya Takkavatakarn
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Kriang Tungsanga
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Somchai Eiam-Ong
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Kearkiat Praditpornsilpa
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Yingyos Avihingsanon
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand.,Excellence Center for Solid Organ Transplantation, King Chulalongkorn Memorial Hospital, Bangkok, Thailand.,Renal Immunology and Renal Transplant Research Unit, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Natavudh Townamchai
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand. .,Excellence Center for Solid Organ Transplantation, King Chulalongkorn Memorial Hospital, Bangkok, Thailand. .,Renal Immunology and Renal Transplant Research Unit, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
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5
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Godinas L, Dobbels F, Hulst L, Verbeeck I, De Coninck I, Berrevoets P, Schaevers V, Yserbyt J, Dupont LJ, Verleden SE, Vanaudenaerde BM, Ceulemans LJ, Van Raemdonck DE, Neyrinck A, Verleden GM, Vos R. Once daily tacrolimus conversion in lung transplantation: A prospective study on safety and medication adherence. J Heart Lung Transplant 2021; 40:467-477. [PMID: 33840608 DOI: 10.1016/j.healun.2021.02.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 02/17/2021] [Accepted: 02/24/2021] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Lung transplantation (LTx) requires a calcineurin inhibitor-based immunosuppressive regimen. A once daily (QD) tacrolimus regimen was developed to increase medication adherence. However, data concerning its safety and efficacy in LTx are lacking. METHODS In this prospective study, stable LTx patients were consecutively converted from twice daily (BID) tacrolimus to QD tacrolimus on a 1 mg:1 mg basis. Trough level (Cmin), renal function, cholesterol, fasting glucose, potassium and lung function were monitored six months before and up to one year after conversion. Adherence and its barriers were assessed by self-reported questionnaires (Basel Assessment of Adherence to Immunosuppressive Medications Scale (BAASIS) and Identification of Medication Adherence Barriers questionnaire (IMAB)) and blood-based assays (mean Cmin and coefficient of variation (CV)). RESULTS We included 372 patients, in whom we observed a decrease in tacrolimus Cmin of 18.5% (p < 0.0001) post-conversion, requiring subsequent daily dose adaptations in both cystic fibrosis (CF) (n = 72) and non-CF patients (n = 300). We observed a small decrease in eGFR one year post-conversion (p = 0.024). No significant changes in blood creatinine, potassium, fasting glucose, cholesterol or rate of lung function decline were observed. In a subgroup of 166 patients, significantly fewer patients missed doses (8.4% vs. 19.3%, p = 0.016) or had irregular intake post-conversion (19.3% vs. 32.5%, p = 0.019). Mean Cmin and CV, as well as the total number of barriers, also decreased significantly post-conversion. CONCLUSIONS In LTx, conversion from BID to QD tacrolimus (1 mg:1 mg) requires close monitoring of tacrolimus Cmin. QD tacrolimus after transplantation is safe with respect to renal function, metabolic parameters and allograft function and improves LTx recipient adherence.
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Affiliation(s)
- Laurent Godinas
- Department of Respiratory Diseases, Lung Transplantation Group, UZ Leuven, Campus Gasthuisberg, Leuven, Belgium; Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department CHROMETA, KU Leuven, Leuven, Belgium.
| | - Fabienne Dobbels
- Academic Center for Nursing and Midwifery, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Leni Hulst
- Department of Respiratory Diseases, Lung Transplantation Group, UZ Leuven, Campus Gasthuisberg, Leuven, Belgium
| | - Ive Verbeeck
- Academic Center for Nursing and Midwifery, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Ines De Coninck
- Academic Center for Nursing and Midwifery, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Pieter Berrevoets
- Academic Center for Nursing and Midwifery, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Veronique Schaevers
- Department of Respiratory Diseases, Lung Transplantation Group, UZ Leuven, Campus Gasthuisberg, Leuven, Belgium
| | - Jonas Yserbyt
- Department of Respiratory Diseases, Lung Transplantation Group, UZ Leuven, Campus Gasthuisberg, Leuven, Belgium; Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department CHROMETA, KU Leuven, Leuven, Belgium
| | - Lieven J Dupont
- Department of Respiratory Diseases, Lung Transplantation Group, UZ Leuven, Campus Gasthuisberg, Leuven, Belgium; Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department CHROMETA, KU Leuven, Leuven, Belgium
| | - Stijn E Verleden
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department CHROMETA, KU Leuven, Leuven, Belgium
| | - Bart M Vanaudenaerde
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department CHROMETA, KU Leuven, Leuven, Belgium
| | - Laurens J Ceulemans
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department CHROMETA, KU Leuven, Leuven, Belgium; Department of Thoracic Surgery, Lung transplantation group, UZ Leuven, Campus Gasthuisberg, Leuven, Belgium
| | - Dirk E Van Raemdonck
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department CHROMETA, KU Leuven, Leuven, Belgium; Department of Thoracic Surgery, Lung transplantation group, UZ Leuven, Campus Gasthuisberg, Leuven, Belgium
| | - Arne Neyrinck
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department CHROMETA, KU Leuven, Leuven, Belgium; Department of Anesthesiology, Lung transplantation group, UZ Leuven, Campus Gasthuisberg, Leuven, Belgium
| | - Geert M Verleden
- Department of Respiratory Diseases, Lung Transplantation Group, UZ Leuven, Campus Gasthuisberg, Leuven, Belgium; Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department CHROMETA, KU Leuven, Leuven, Belgium
| | - Robin Vos
- Department of Respiratory Diseases, Lung Transplantation Group, UZ Leuven, Campus Gasthuisberg, Leuven, Belgium; Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department CHROMETA, KU Leuven, Leuven, Belgium
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6
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Hugo C, Weihprecht H, Banas B, Schröppel B, Jank S, Arns W, Schenker P, Rath T, Hergesell O, Feldkamp T, Hermann B, Schiffer M. Renal Function and Patient-Reported Outcomes in Stable Kidney Transplant Patients Following Conversion From Twice-Daily Immediate-Release Tacrolimus to Once-Daily Prolonged-Release Tacrolimus: A 12-Month Observational Study in Routine Clinical Practice in Germany (ADAGIO). Transplant Proc 2021; 53:1484-1493. [PMID: 33610306 DOI: 10.1016/j.transproceed.2021.01.034] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 01/08/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION This 12-month, noninterventional study on routine clinical practice in Germany evaluated renal function in stable kidney transplant recipients converted from immediate-release tacrolimus (IR-T) to prolonged-release tacrolimus (PR-T). METHODS Renal function was assessed in 183 patients by estimated glomerular filtration rate using the modification of diet in renal disease-4 formula. Self-reported gastrointestinal health-related quality of life, adherence, satisfaction with PR-T, suspected rejection episodes, and safety were also assessed at conversion and at 3, 6, and 12 months. RESULTS Conversion from IR-T to PR-T resulted in stable kidney function over 12 months, with a difference in estimated glomerular filtration rate between the first and final visits of 0.1 mL/min/1.73 m2 (95% confidence interval, -1.6, 1.8). Eight patients experienced an acute rejection episode (4.4%). At each assessment, gastrointestinal health-related quality of life was low and adherence was high. Most patients reported that they were very satisfied (69.8%) or satisfied (28.1%) with PR-T at the final visit. Among patients reporting a preference, 78.4% preferred PR-T, 2.2% preferred IR-T, and 19.4% reported no preference. The safety profile of PR-T was consistent with that previously described. CONCLUSION Conversion of stable kidney transplant recipients from IR-T to PR-T provided stable kidney and graft function over 12 months (Verband Forschender Arzneimittelhersteller--registered study: NIS ADV-02).
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Affiliation(s)
- Christian Hugo
- Division of Nephrology, Medizinische Klinik und Poliklinik III, Technische Universität Dresden, Dresden, Germany
| | - Horst Weihprecht
- Department of Internal Medicine, Division of Nephrology, University Hospital Augsburg, Augsburg, Germany.
| | - Bernhard Banas
- Department of Nephrology, University Hospital Regensburg, Regensburg, Germany
| | | | - Sabine Jank
- Department of Nephrology, Transplantation KfH-Kidney Center, Nuremberg, Germany
| | - Wolfgang Arns
- Cologne Merheim Medical Center, Cologne General Hospital, Cologne, Germany
| | - Peter Schenker
- Department of Surgery, University Hospital Knappschaftskrankenhaus Bochum, Ruhr-University Bochum, Bochum, Germany
| | - Thomas Rath
- Department of Nephrology and Transplantation, Westpfalz-Klinikum, Kaiserslautern, Germany
| | - Olaf Hergesell
- Nephrologisches Zentrum Villingen-Schwenningen, Villingen-Schwenningen, Erlangen, Germany
| | - Thorsten Feldkamp
- Department of Internal Medicine IV, Universitätsklinikum Schleswig Holstein, Kiel, Germany
| | | | - Mario Schiffer
- Department of Nephrology and Hypertension, Universitätsklinikum Erlangen, Germany
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7
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van Gelder T, Etsouli O, Moes DJ, Swen JJ. Comparison of the Impact of Pharmacogenetic Variability on the PK of Slow Release and Immediate Release Tacrolimus Formulations. Genes (Basel) 2020; 11:genes11101205. [PMID: 33076474 PMCID: PMC7602647 DOI: 10.3390/genes11101205] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 10/10/2020] [Accepted: 10/14/2020] [Indexed: 12/18/2022] Open
Abstract
Tacrolimus-modified release formulations allow for once-daily dosing, and adherence is better compared to the twice-daily immediate release formulation. When patients are switched from one formulation to another, variable changes in drug concentrations are observed. Current data suggest that the changes in drug exposure are larger in patients who express the CYP3A5 enzyme (CYP3A5 *1/*3 or *1/*1) compared to nonexpressers (CYP3A5*3/*3). Possibly, these differences are due to the fact that in the upper region of the small intestine CYP3A activity is higher, and that this expression of CYP3A decreases towards the more distal parts of the gut. Modified release formulations may therefore be subject to a less presystemic metabolism. However, the full implications of pharmacogenetic variants affecting the expression and function of drug transporters in the gut wall and of enzymes involved in phase I and phase II metabolism on the different formulations are incompletely understood, and additional studies are required. Conclusions: In all patients in whom the formulation of tacrolimus is changed, drug levels need to be checked to avoid clinically relevant under- or overexposure. In patients with the CYP3A5 expresser genotype, this recommendation is even more important, as changes in drug exposure can be expected.
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8
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Impacts of High Intra- and Inter-Individual Variability in Tacrolimus Pharmacokinetics and Fast Tacrolimus Metabolism on Outcomes of Solid Organ Transplant Recipients. J Clin Med 2020; 9:jcm9072193. [PMID: 32664531 PMCID: PMC7408675 DOI: 10.3390/jcm9072193] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 07/09/2020] [Indexed: 12/14/2022] Open
Abstract
Tacrolimus is a first-line calcineurin inhibitor (CNI) and an integral part of the immunosuppressive strategy in solid organ transplantation. Being a dose-critical drug, tacrolimus has a narrow therapeutic index that necessitates periodic monitoring to maintain the drug’s efficacy and reduce the consequences of overexposure. Tacrolimus is characterized by substantial intra- and inter-individual pharmacokinetic variability. At steady state, the tacrolimus blood concentration to daily dose ratio (C/D ratio) has been described as a surrogate for the estimation of the individual metabolism rate, where a low C/D ratio reflects a higher rate of metabolism. Fast tacrolimus metabolism (low C/D ratio) is associated with the risk of poor outcomes after transplantation, including reduced allograft function and survival, higher allograft rejection, CNI nephrotoxicity, a faster decline in kidney function, reduced death-censored graft survival (DCGS), post-transplant lymphoproliferative disorders, dyslipidemia, hypertension, and cardiovascular events. In this article, we discuss the potential role of the C/D ratio in a noninvasive monitoring strategy for identifying patients at risk for potential adverse events post-transplant.
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9
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Kamińska D, Poznański P, Kuriata-Kordek M, Zielińska D, Mazanowska O, Kościelska-Kasprzak K, Krajewska M. Conversion From a Twice-Daily to a Once-Daily Tacrolimus Formulation in Kidney Transplant Recipients. Transplant Proc 2020; 52:2288-2293. [PMID: 32247597 DOI: 10.1016/j.transproceed.2020.02.109] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Accepted: 02/13/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND The aim of the study was to assess bioavailability aspects of tacrolimus formulations during conversion from twice-daily (TAC BID) to once-daily (TAC OD) formulation in 89 stable kidney transplant recipients. MATERIALS AND METHODS The study included 89 stable kidney transplant recipients transplanted between 1998 and 2008 (37 female, 52 male, aged 46.0 ± 12.4 years) and followed for 10 years. For a comprehensive comparison of the different tacrolimus formulations, dose-normalized trough levels (ng/mL/mg total daily dose, C/D ratio) and their variability were studied for 10 consecutive visits before and 6 months after conversion. RESULTS The mean trough level decreased significantly 14 days after conversion (16%, 5.77 ± 1.94 [5.6, 4.5-6.5] ng/mL, P < .001). There was no significant difference between the tacrolimus trough levels before and 3 months after conversion (6.92 ± 1.89 [6.8, 5.9-8.0] ng/mL, P = .548). The tacrolimus daily dose 3 months after conversion (4.56 ± 1.81 [4.5, 3.5-5.5] mg/d) was significantly higher than the dose before conversion (4.16 ± 1.80 [4.0, 3.0-5.0] mg/d, P = .006). The post-conversion mean TAC trough level (10 measures) (6.6 [6.2-7.0] ng/mL) was similar to preconversion level (6.8 [5.6-7.9] ng/mL, P = .203). C/D ratio as well as C/D intrapatient variability (CV%) did not change during conversion (C/D 1.68 [1.36-2.53] vs 1.74 [1.41 vs 2.31], P = .075; CV% 19.5 [16.4-26.6] vs 24.4 [17.5-28.3], P = .114). CONCLUSIONS Conversion from TAC BID to TAC OD is associated with a significant increase in tacrolimus dose during the first 3 months. In a long-term observation both formulations present similar dose-normalized trough levels and variability.
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Affiliation(s)
- Dorota Kamińska
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wroclaw, Poland.
| | - Paweł Poznański
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wroclaw, Poland
| | - Magdalena Kuriata-Kordek
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wroclaw, Poland
| | - Dorota Zielińska
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wroclaw, Poland
| | - Oktawia Mazanowska
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wroclaw, Poland
| | | | - Magdalena Krajewska
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wroclaw, Poland
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10
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Stifft F, Vandermeer F, Neef C, van Kuijk S, Christiaans MHL. A limited sampling strategy to estimate exposure of once-daily modified release tacrolimus in renal transplant recipients using linear regression analysis and comparison with Bayesian population pharmacokinetics in different cohorts. Eur J Clin Pharmacol 2020; 76:685-693. [DOI: 10.1007/s00228-019-02814-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 12/05/2019] [Indexed: 11/30/2022]
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11
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Fleming JN, Posadas Salas MA, Taber DJ. Dosing Requirements of Extended-Release Tacrolimus (Astagraf XL) in African American Kidney Transplant Recipients Converted from Immediate-Release Tacrolimus (AAAKTRS). Ther Drug Monit 2020; 42:415-420. [PMID: 31913864 DOI: 10.1097/ftd.0000000000000722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The formal recommendation for converting twice-daily tacrolimus immediate release (IR) to once-daily tacrolimus extended release (ER) is a 1:1 dose conversion. However, more recent clinical analysis has shown that this may not be true; some patients may require a higher dose. In addition, de novo dosing tacrolimus ER has revealed that African Americans require approximately 20%-30% higher doses than Caucasians to achieve similar levels. As a result, this study sought to identify the appropriate dose conversion in the African American kidney transplant population, a population at high risk of rejection. METHODS This was a single-center, prospective, open-label study comparing the difference in dose-normalized trough and total daily dose necessary to reach steady-state therapeutic goal, after conversion from tacrolimus IR to tacrolimus ER, in 25 African American kidney transplant recipients. RESULTS After conversion to tacrolimus ER, there was a significant decrease in dose-normalized trough (C0) (0.44 versus 0.59, P = 0.03). Statistically significant differences were seen in both total daily and weight-based doses, when reported as actual values (15 versus 10 mg and 0.16 versus 0.11 mg/kg, respectively), as well as when standardized to achieve a target tacrolimus C0 of 8 ng/mL (18.1 versus 13.6 mg and 0.17 versus 0.15 mg/kg, respectively). The median standardized dose conversion required was 1.3 [1.0, 1.4], for the overall population. There were no instances of biopsy-proven acute rejection, allograft loss, or study drug discontinuation. CONCLUSIONS This single-center, open-label conversion study demonstrated that there was a statistically and clinically significant decrease in dose-normalized trough after conversion from tacrolimus IR to tacrolimus ER in an African American kidney transplant population and that a 1:1 dose conversion is unlikely to meet therapeutic goals.
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Affiliation(s)
- James N Fleming
- Department of Pharmacy Services, Medical University of South Carolina
| | - Maria A Posadas Salas
- Department of Medicine, Division of Nephrology and Hypertension, Medical University of South Carolina
| | - David J Taber
- Department of Pharmacy, Ralph H Johnson VAMC; and.,Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
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12
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Long-Term Kidney Transplant Outcomes: Role of Prolonged-Release Tacrolimus. Transplant Proc 2019; 52:102-110. [PMID: 31901329 DOI: 10.1016/j.transproceed.2019.11.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 11/02/2019] [Indexed: 01/08/2023]
Abstract
Tacrolimus has significantly improved outcomes for kidney transplant patients and remains the cornerstone of immunosuppressive therapy. While improvements in short-term outcomes in transplantation have been achieved in recent years, maintaining long-term graft survival remains a challenge in kidney transplantation. Minimizing risk factors for poor long-term kidney graft function and survival, and modifying tacrolimus regimens in the early and maintenance phases post-transplantation are essential to maintain long-term kidney transplant outcomes. Tacrolimus has a narrow therapeutic window, resulting in a tightly defined range of optimal drug exposure. Underimmunosuppression is associated with long-term risks, such as the development of donor-specific antibodies and antibody-mediated rejection, with a high possibility of a decline in kidney function and progression to graft failure. Conversely, prolonged overimmunosuppression carries a risk of drug-related adverse events. This review provides an overview of the differences in the formulation, delivery, and pharmacokinetic profiles between immediate- and prolonged-release tacrolimus and evaluates the effect of prolonged-release tacrolimus on the risk factors for poor outcomes in kidney transplantation. Recent evidence is used to provide guidance on target tacrolimus trough levels in the early and maintenance phases post-transplantation, with a view to improving long-term kidney graft function.
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13
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Nakazawa R, Yoshiike M, Nozawa S, Aida K, Katsuoka Y, Fujimoto E, Yazawa M, Kikuchi E, Shibagaki Y, Sasaki H. Clinically useful limited sampling strategy to estimate area under the concentration-time curve of once-daily tacrolimus in adult Japanese kidney transplant recipients. PLoS One 2019; 14:e0225878. [PMID: 31825991 PMCID: PMC6905578 DOI: 10.1371/journal.pone.0225878] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 11/14/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND An extended-release, once-daily, oral formulation of tacrolimus is currently used after kidney transplantation as a substitute for the conventional twice-daily formulation. The purpose of this study was to provide a limited sampling strategy with minimum and optimum sampling points to predict the tacrolimus area under the concentration-time curve (AUC) after administration of once-daily tacrolimus in de novo adult kidney transplant patients. METHODS A total of 36 adult Japanese kidney transplant patients receiving once-daily tacrolimus were included: 31 were allocated to a study group to develop limited sampling strategy (LSS) model equations based on multiple stepwise linear regression analysis, and 5 were allocated to a validation group to estimate the precision of the LSS equations developed by the study group. Twelve-hour AUC (AUC0-12) was calculated by the trapezoidal rule, and the relationship between individual concentration points and AUC0-12 were determined by multiple linear regression analysis. The coefficient of determination (R2) was used to assess the goodness-of-fit of the regression models. Three error indices (mean error, mean absolute error, and root mean squared prediction error) were calculated to evaluate predictive bias, accuracy, and precision, respectively. Quality of the statistical models was compared with Akaike's information criterion (AIC). RESULTS A four-point model using C0, C2, C4 and C6 gave the best fit to predict AUC0-12 (R2 = 0.978). In the three- and two-point models, the best fits were at time points C2, C4, and C6 (R2 = 0.973), and C2 and C6 (R2 = 0.962), respectively. All three models reliably estimated tacrolimus AUC0-12, consistent with evaluations by the three error indices and Akaike's information criterion. Practically, the two-point model with C2 and C6 was considered to be the best combination, providing a highly accurate prediction and the lowest blood sampling frequency. CONCLUSIONS The two-point model with C2 and C6 may be valuable in reducing the burden on patients, as well as medical costs, for once-daily tacrolimus monitoring.
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Affiliation(s)
- Ryuto Nakazawa
- Department of Urology, St. Marianna University School of Medicine, Kawasaki, Japan
- * E-mail:
| | - Miki Yoshiike
- Department of Urology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Shiari Nozawa
- Department of Urology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Koichiro Aida
- Department of Urology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Yuichi Katsuoka
- Department of Urology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Eisuke Fujimoto
- Department of Urology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Masahiko Yazawa
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Eiji Kikuchi
- Department of Urology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Yugo Shibagaki
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Hideo Sasaki
- Department of Urology, St. Marianna University School of Medicine, Kawasaki, Japan
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14
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Rummo O, Carmellini M, Kamar N, Durrbach A, Mousson C, Caputo F, Mathe Z, Christiaans MHL, Kuypers DRJ, Klempnauer J, Anaokar S, Hurst M, Kazeem G, Undre N, Lehner F. Long-term, prolonged-release tacrolimus-based immunosuppression in de novo kidney transplant recipients: 5-year prospective follow-up of the ADHERE study patients. Transpl Int 2019; 33:161-173. [PMID: 31536654 DOI: 10.1111/tri.13527] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 04/10/2019] [Accepted: 09/17/2019] [Indexed: 12/29/2022]
Abstract
The objectives of this study were to assess long-term graft survival, patient survival, renal function, and acute rejections in de novo kidney transplant recipients, treated with once-daily prolonged-release tacrolimus-based therapy. The study was a 5-year non-interventional prospective follow-up of patients from the ADHERE study, a Phase IV 12-month open-label assessment of patients randomized to receive prolonged-release tacrolimus in combination with mycophenolate mofetil (MMF) (Arm 1) or sirolimus (Arm 2). From 838 patients in the randomized study, 587 were included in the long-term follow-up, of whom 510 completed the study at year 5. At 1 year post-transplant, graft and patient survival rates were 93.0% and 97.8%, respectively, and at 5 years were 84.0% and 90.8%, respectively. Cox proportional hazards analysis showed no association between graft loss, initial randomized treatment arm, donor age, donor type, or sex. The 5-year acute rejection-free survival rate was 77.4%, and biopsy-confirmed acute rejection-free survival rate was 86.0%. Renal function remained stable over the follow-up period: mean ± SD eGFR 4-variable modification diet in renal disease formula (MDRD4) was 52.3 ± 21.6 ml/min/1.73 m2 at 6 months and 52.5 ± 23.0 ml/min/1.73 m2 at 5 years post-transplant. These findings support the role of long-term once-daily prolonged-release tacrolimus-based immunosuppression, in combination with sirolimus or MMF, for renal transplant recipients in routine clinical practice.
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Affiliation(s)
- Oleg Rummo
- Republican Scientific and Practical Center (RSPC) for Organ and Tissue Transplantation, Minsk, Belarus
| | - Mario Carmellini
- Department of Medical, Surgical and Neuroscience, Policlinico Santa Maria alle Scotte, University of Siena, Siena, Italy
| | - Nassim Kamar
- Department of Nephrology and Organ Transplantation, CHU Rangueil, Université Paul Sabatier Toulouse, Toulouse Cedex 9, France
| | - Antoine Durrbach
- Nephrology Service, Centre Hospitalier de Bicetre, Le Kremlin Bicetre, France.,UMRS1197, INSERM, Villejuif, France.,University Paris Sud, Orsay, France
| | - Christiane Mousson
- Department of Nephrology-Transplantation, University Hospital Dijon, Dijon, France
| | - Flavia Caputo
- UOC Nephrology 2, Dialysis and Transplantation, ARNAS Civico Palermo, Palermo, Italy
| | - Zoltan Mathe
- Transplantation and Surgery Clinic, Semmelweis University, Budapest, Hungary
| | - Maarten H L Christiaans
- Department of Internal Medicine/Division of Nephrology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Dirk R J Kuypers
- Department of Nephrology, and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Jürgen Klempnauer
- General, Visceral and Transplantation Surgery, Hannover Medical School, Hannover, Germany
| | | | | | - Gbenga Kazeem
- Astellas Pharma Europe Ltd, Chertsey, UK.,BENKAZ Consulting Ltd, Cambridge, UK
| | | | - Frank Lehner
- General, Visceral and Transplantation Surgery, Hannover Medical School, Hannover, Germany
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15
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Rubik J, Debray D, Kelly D, Iserin F, Webb NJA, Czubkowski P, Vondrak K, Sellier-Leclerc AL, Rivet C, Riva S, Tönshoff B, D'Antiga L, Marks SD, Reding R, Kazeem G, Undre N. Efficacy and safety of prolonged-release tacrolimus in stable pediatric allograft recipients converted from immediate-release tacrolimus - a Phase 2, open-label, single-arm, one-way crossover study. Transpl Int 2019; 32:1182-1193. [PMID: 31325368 PMCID: PMC6852421 DOI: 10.1111/tri.13479] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 01/21/2019] [Accepted: 07/11/2019] [Indexed: 12/11/2022]
Abstract
There are limited clinical data regarding prolonged‐release tacrolimus (PR‐T) use in pediatric transplant recipients. This Phase 2 study assessed the efficacy and safety of PR‐T in stable pediatric kidney, liver, and heart transplant recipients (aged ≥5 to ≤16 years) over 1 year following conversion from immediate‐release tacrolimus (IR‐T), on a 1:1 mg total‐daily‐dose basis. Endpoints included the incidence of acute rejection (AR), a composite endpoint of efficacy failure (death, graft loss, biopsy‐confirmed AR, and unknown outcome), and safety. Tacrolimus dose and whole‐blood trough levels (target 3.5–15 ng/ml) were also evaluated. Overall, 79 patients (kidney, n = 48; liver, n = 29; heart, n = 2) were assessed. Following conversion, tacrolimus dose and trough levels remained stable; however, 7.6–17.7% of patients across follow‐up visits had trough levels below the target range. Two (2.5%) patients had AR, and 3 (3.8%) had efficacy failure. No graft loss or deaths were reported. No new safety signals were identified. Drug‐related treatment‐emergent adverse events occurred in 28 patients (35.4%); most were mild, and all resolved. This study suggests that IR‐T to PR‐T conversion is effective and well tolerated over 1 year in pediatric transplant recipients and highlights the importance of therapeutic drug monitoring to maintain target tacrolimus trough levels.
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Affiliation(s)
- Jacek Rubik
- Department of Nephrology, Kidney Transplantation and Hypertension, The Children's Memorial Health Institute, Warsaw, Poland
| | - Dominique Debray
- Pediatric Hepatology Unit, APHP-Hôpital Universitaire Necker, Paris, France
| | - Deirdre Kelly
- The Liver Unit, Birmingham Women's & Children's Hospital, Birmingham, UK
| | - Franck Iserin
- Pediatric Cardiology Unit, APHP-Hôpital Universitaire Necker, Paris, France
| | - Nicholas J A Webb
- Department of Pediatric Nephrology, NIHR/Wellcome Trust Manchester Clinical Research Facility, Manchester Academic Health Science Centre, Royal Manchester Children's Hospital, University of Manchester, Manchester, UK
| | - Piotr Czubkowski
- Department of Gastroenterology, Hepatology, Nutritional Disturbances and Pediatrics, The Children's Memorial Health Institute, Warsaw, Poland
| | - Karel Vondrak
- Department of Pediatrics, Second School of Medicine, University Hospital Motol, Charles University, Prague, Czech Republic
| | - Anne-Laure Sellier-Leclerc
- Department of Nephrology, Rheumatology, and Dermatology, Center for Rare Diseases, Civil Hospice of Lyon, 'Woman-Mother-Child' Hospital, Bron Cedex, France
| | - Christine Rivet
- Pediatric Hepatology, Gastroenterology and Transplantation, Civil Hospice of Lyon, Lyon, France
| | - Silvia Riva
- Department of Pediatrics, ISMETT-IRCCS, Palermo, Italy
| | - Burkhard Tönshoff
- Department of Pediatrics I, University Children's Hospital Heidelberg, Heidelberg, Germany
| | - Lorenzo D'Antiga
- Pediatric Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Stephen D Marks
- Department of Pediatric Nephrology, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Raymond Reding
- Unité de Chirurgie et Transplantation Pédiatrique, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Gbenga Kazeem
- BENKAZ Consulting Ltd, Cambridge, UK.,Astellas Pharma Europe Ltd, Chertsey, UK
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16
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A non-randomized trial of conversion from ciclosporin and tacrolimus to tacrolimus MR4 in stable long-term kidney transplant recipients: Graft function and influences of ABCB1 genotypes. PLoS One 2019; 14:e0218709. [PMID: 31266056 PMCID: PMC6606311 DOI: 10.1371/journal.pone.0218709] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 06/06/2019] [Indexed: 12/23/2022] Open
Abstract
In this non-randomized extension study of a randomized controlled trial we converted 87 stable long-term kidney transplant recipients (KTR) from either ciclosporin (CSA, n = 28) or tacrolimus (TAC, n = 59) to TAC modified release (TAC MR4) to study the characteristics of TAC trough levels after conversion with the primary endpoint graft function after 12 months. TAC MR4 consumption was calculated by level-to-dose ([ng/mL]/[mg/d]) and concentration-to-dose ([mg/kg])/d) ratios. Influences of ABCB1 single nucleotide polymorphisms (2677G>T/A, 1236C>T, 3435C>T) on TAC metabolism were studied. Graft function of KTR converted from CSA to TAC MR4 significantly declined over 12 months, and remained unchanged after conversion from TAC to TAC MR4. Conversion from CSA to TAC MR4 resulted in supra therapeutic- and conversion from TAC to TAC MR4 in low trough levels. We could not find associations of ABCB1 genotypes and TAC MR4 trough levels. Adverse events and errors with TAC/TAC MR4 intake were common. In stable long-term KTR conversion from TAC to TAC MR4 is feasible. For conversion from CSA we suggest a rate of 1:40 for a rough estimation of TAC MR4 target doses.
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17
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González-Vílchez F, Delgado JF, Palomo J, Mirabet S, Díaz-Molina B, Almenar L, Arizón JM, Rangel-Sousa D, Pérez-Villa F, Garrido IP, de la Fuente L, Gómez-Bueno M, Sanz ML, Crespo-Leiro MG. Conversion From Immediate-Release Tacrolimus to Prolonged-Release Tacrolimus in Stable Heart Transplant Patients: A Retrospective Study. Transplant Proc 2019; 51:1994-2001. [PMID: 31227301 DOI: 10.1016/j.transproceed.2019.04.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 04/17/2019] [Accepted: 04/25/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Lifelong adherence with post-transplant immunosuppression is challenging, with nonadherence associated with greater acute rejection (AR) risk. METHODS This retrospective study evaluated conversion from immediate-release tacrolimus (IRT) to prolonged-release tacrolimus (PRT), between January 2008 and December 2012 in stable adult heart transplant recipients. Cumulative incidence rate (IR) of AR and infection pre- and postconversion, safety, tacrolimus dose and trough levels, concomitant immunosuppression, and PRT discontinuation were analyzed (intention-to-treat population). RESULTS Overall, 467 patients (mean age, 59.3 [SD, 13.3] years) converted to PRT at 5.1 (SD, 4.9) years post transplant and were followed for 3.4 (SD, 1.5) years. During the 6 months post conversion, 5 patients (1.1%; 95% CI, 0.35%-2.48%) had an AR episode and IR was 2.2/100 patient-years (95% CI, 0.91-5.26). Incidence of rejection preconversion varied by time from transplant to conversion. Infection IR was similar post- and preconversion (9.2/100 patient-years [95% CI, 7.4-11.3] vs 10.6/100 patient-years [95% CI, 8.8-12.3], respectively; P = .20). Safety variables remained similar post conversion. The IR of mortality/graft loss was 2.3/100 patient-years (95% CI, 1.7-3.1). CONCLUSIONS Conversion from IRT to PRT in heart transplant recipients in Spain was associated with no new safety concerns and appropriate immunosuppressive effectiveness.
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Affiliation(s)
- Francisco González-Vílchez
- Registro Español de Transplante Cardiaco, Sección de Insuficiencia Cardiaca, Sociedad Española de Cardiología, Madrid, Spain; Unidad de Transplante Cardiaco, Servicio de Cardiología, Hospital Universitario Marqués de Valdecilla, Santander, Spain.
| | - Juan F Delgado
- Hospital Universitario 12 de Octubre, CIBERCV, UCM, Madrid, Spain
| | - Jesús Palomo
- Hospital Universitario Gregorio Marañón, Madrid, Spain
| | | | | | - Luis Almenar
- Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | | | | | | | - Iris P Garrido
- Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Luis de la Fuente
- Hospital Universitario Clínico de Valladolid, CIBERCV, Valladolid, Spain
| | | | - María L Sanz
- Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - María G Crespo-Leiro
- Unidad de Insuficiencia Cardiaca Avanzada y Transplante Cardiaco, Servicio de Cardiologia, Instituto de Investigación Biomédica de A Coruña (INIBIC), Complexo Hospitalario Universitario de A Coruña (CHUAC), Sergas, Universidade da Coruña (UDC), CIBERCV, As Xubias, A Coruña, Spain
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18
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Ho B, Bhagat H, Schwartz JJ, Atiemo K, Daud A, Kang R, Montag SE, Zhao L, Lee E, Skaro AI, Ladner DP. Real-World Study of Once-Daily, Extended-Release Tacrolimus Versus Twice-Daily, Immediate-Release Tacrolimus in Kidney Transplantation: Clinical Outcomes and Healthcare Resource Utilization. Adv Ther 2019; 36:1465-1479. [PMID: 30941724 PMCID: PMC6824361 DOI: 10.1007/s12325-019-00904-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Real-world data with extended-release tacrolimus (ER-T) are lacking in the USA. This study examined clinical outcomes and healthcare resource utilization in kidney transplant patients receiving ER-T in clinical practice. METHODS This was a retrospective, single-center analysis (February-June 2016) using data from Northwestern University's Enterprise Data Warehouse. Adult patients receiving a kidney transplant in the preceding 4 years, treated de novo or converted to ER-T from immediate-release tacrolimus (IR-T) within 10 days post-transplantation, and maintained on ER-T (at least 3 months) were included. Patients were matched for demographic and clinical characteristics with IR-T-treated control patients. Endpoints included clinical outcomes and healthcare resource utilization up to 1 year post-transplantation. RESULTS A total of 19 ER-T-treated patients were matched with 55 IR-T-treated patients. No ER-T-treated patients experienced biopsy-confirmed acute rejection (BCAR) or graft failure versus 3 (5.5%) and 3 (5.5%) IR-T-treated patients, respectively. Mean estimated glomerular filtration rate (eGFR), the number of all-cause outpatient visits, readmissions, and all-cause hospitalization days were comparable between groups. Tacrolimus trough levels, days to target level (6-10 ng/mL), and number of required dose adjustments were also similar. CONCLUSION Real-world clinical outcomes and healthcare resource utilization were similar with ER-T and IR-T. Larger studies will need to investigate the trend toward fewer BCAR events, and increased graft survival with ER-T. FUNDING Astellas Pharma Global Development, Inc. Plain language summary available for this article.
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Affiliation(s)
- Bing Ho
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Northwestern University, 676 N. St. Clair Street, 19th Floor, Chicago, IL, 60611, USA
| | - Hardik Bhagat
- Medical Affairs, Americas, Astellas Pharma Global Development, Inc., 1 Astellas Way, Northbrook, IL, 60062, USA
| | - Jason J Schwartz
- Medical Affairs, Americas, Astellas Pharma Global Development, Inc., 1 Astellas Way, Northbrook, IL, 60062, USA
| | - Kofi Atiemo
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Northwestern University, 676 N. St. Clair Street, 19th Floor, Chicago, IL, 60611, USA
| | - Amna Daud
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Northwestern University, 676 N. St. Clair Street, 19th Floor, Chicago, IL, 60611, USA
| | - Raymond Kang
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Northwestern University, 676 N. St. Clair Street, 19th Floor, Chicago, IL, 60611, USA
| | - Samantha E Montag
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Northwestern University, 676 N. St. Clair Street, 19th Floor, Chicago, IL, 60611, USA
- Department of Preventive Medicine, Northwestern University, 680 N. Lake Shore Drive, Suite 1400, Chicago, IL, 60611, USA
| | - Lihui Zhao
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Northwestern University, 676 N. St. Clair Street, 19th Floor, Chicago, IL, 60611, USA
- Department of Preventive Medicine, Northwestern University, 680 N. Lake Shore Drive, Suite 1400, Chicago, IL, 60611, USA
| | - Edward Lee
- Medical Affairs, Americas, Astellas Pharma Global Development, Inc., 1 Astellas Way, Northbrook, IL, 60062, USA
| | - Anton I Skaro
- Department of Surgery, Schulich School of Medicine and Dentistry, Western University, St. Joseph's Hospital, 268 Grosvenor Street, Rm. E3-117, London, ON, N6A 4V2, Canada
| | - Daniela P Ladner
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Northwestern University, 676 N. St. Clair Street, 19th Floor, Chicago, IL, 60611, USA.
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Rubik J, Debray D, Iserin F, Vondrak K, Sellier-Leclerc AL, Kelly D, Czubkowski P, Webb NJA, Riva S, D'Antiga L, Marks SD, Rivet C, Tönshoff B, Kazeem G, Undre N. Comparative pharmacokinetics of tacrolimus in stable pediatric allograft recipients converted from immediate-release tacrolimus to prolonged-release tacrolimus formulation. Pediatr Transplant 2019; 23:e13391. [PMID: 30932313 DOI: 10.1111/petr.13391] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 01/18/2019] [Accepted: 02/01/2019] [Indexed: 01/28/2023]
Abstract
This study was a Phase II, open-label, multicenter, single-arm, cross-over study comparing the pharmacokinetics (PK) of tacrolimus in stable pediatric kidney, liver, or heart allograft recipients converted from immediate-release tacrolimus (IR-T) to prolonged-release tacrolimus (PR-T). In Days -30 to -1 of screening period, patients received their IR-T-based regimen; during Days 1-7, patients received study IR-T (same dose as screening). On Day 7, the first 24-hours PK profile was taken; patients were then converted to PR-T (1 mg:1 mg), with a second 24-hours PK profile taken on Day 14. The primary end-point was tacrolimus area under the blood concentration-time curve over 24 hours (AUC24 ); secondary end-points were maximum concentration Cmax and concentration at 24 hours C24 . The predefined similarity interval for confidence intervals (CIs) of least squares mean (LSM) ratios was 80%-125%. The PK analysis set comprised 74 pediatric transplant recipients (kidney, n = 45; liver, n = 28; heart, n = 1). PR-T:IR-T LSM ratio (90% CI) was similar overall for AUC24 , max , and C24 , and for kidney and liver recipients for AUC24 (LSM ratio, kidney 91.8%; liver 104.1%) and C24 (kidney 90.5%; liver 89.9%). Linear relationship was similar between AUC24 and C24 , and between PR-T and IR-T (rho 0.89 and 0.84, respectively), suggesting that stable pediatric transplant recipients can be converted from IR-T to PR-T at the same total daily dose, using the same therapeutic drug monitoring method.
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Affiliation(s)
- Jacek Rubik
- Department of Nephrology, Kidney Transplantation and Hypertension, The Children's Memorial Health Institute, Warsaw, Poland
| | - Dominique Debray
- Pediatric Hepatology Unit, APHP-University Hospital Necker Enfants Malades, Paris, France
| | - Franck Iserin
- Department of Pediatric Cardiology, University Hospital Necker Enfants Malades, Paris, France
| | - Karel Vondrak
- Department of Pediatrics, University Hospital Motol, Second School of Medicine, Charles University, Prague, Czech Republic
| | - Anne-Laure Sellier-Leclerc
- Department of Nephrology, Rheumatology, and Dermatology, Center for Rare Diseases, Civil Hospice of Lyon, "Woman-Mother-Child" Hospital, Bron, France
| | - Deirdre Kelly
- The Liver Unit, Birmingham Women's and Children's Hospital, Birmingham, UK
| | - Piotr Czubkowski
- Department of Gastroenterology, Hepatology, Nutritional Disorders and Pediatrics, The Children's Memorial Health Institute, Warsaw, Poland
| | - Nicholas J A Webb
- Department of Paediatric Nephrology and NIHR/Wellcome Trust Manchester Clinical Research Facility, University of Manchester, Manchester Academic Health Science Centre, Royal Manchester Children's Hospital, Manchester, UK
| | - Silvia Riva
- Department of Pediatrics, ISMETT-IRCCS, Palermo, Italy
| | - Lorenzo D'Antiga
- Pediatric Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Stephen D Marks
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Christine Rivet
- Pediatric Hepatology, Gastroenterology and Transplantation, Civil Hospice of Lyon, Lyon, France
| | - Burkhard Tönshoff
- Department of Pediatrics I, University Children's Hospital Heidelberg, Heidelberg, Germany
| | - Gbenga Kazeem
- Astellas Pharma Europe Ltd, Chertsey, UK.,BENKAZ Consulting Ltd, Cambridge, UK
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20
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Franco A, Más-Serrano P, Balibrea N, Rodriguez D, Javaloyes A, Díaz M, Gascón I, Ramon-Lopez A, Perez-Contreras J, Selva J, Nalda-Molina R. Envarsus, a novelty for transplant nephrologists: Observational retrospective study. Nefrologia 2019; 39:506-512. [PMID: 30850218 DOI: 10.1016/j.nefro.2018.11.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 11/06/2018] [Accepted: 11/09/2018] [Indexed: 11/29/2022] Open
Abstract
The aim of this study was to evaluate the trough concentrations (Cptrough) and the tacrolimus dosage regimen after the conversion of Prograf or Advagraf to Envarsus (new pharmaceutical form with MeltDose technology that improves the absorption of fat-soluble drugs) in patients with stable renal transplantation, and their renal function. We selected stable renal transplant patients who were converted to Envarsus. Two periods were defined: Baseline and Conversion (Envarsus) and they were stratified according to the pharmaceutical form used in the Baseline period. Sixty-one patients were included (24 with Advagraf and 37 with Prograf), with an average age of 52years. The mean post-transplant time at the time of conversion to Envarsus was 76.3months and the mean follow-up in the Baseline and Conversion period was 10.1months and 11.6months, respectively. In the Prograf and Envarsus group, the Cptrough medians were 6.6 vs 6.4 ng/mL (P=.636), with a mean daily dose that decreased significantly from 3mg to 2mg (P<.001), respectively, maintaining the filtration rate. The median Cptrough values in the Advagraf and Envarsus groups were 5.7ng/mL and 6.3ng/mL (P=.07), with a median daily dose of 7mg and 4mg (P<.001), respectively, and the same renal function. In stable renal transplant patients, the conversion from Advagraf to Envarsus has allowed the dose of tacrolimus to be reduced by 42.9% and, in the case of Prograf, by 33.3%, maintaining similar Cptrough values, without renal function being altered.
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Affiliation(s)
- Antonio Franco
- Servicio de Nefrología, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL-Fundación FISABIO), Hospital General Universitario de Alicante, Alicante, España.
| | - Patricio Más-Serrano
- Servicio de Farmacia, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL-Fundación FISABIO), Hospital General Universitario de Alicante, Alicante, España; Área de Farmacia y Tecnología Farmacéutica, Departamento de Ingeniería, Universidad Miguel Hernández de Elche; Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL-Fundación FISABIO), Elche, Alicante, España
| | - Noelia Balibrea
- Servicio de Nefrología, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL-Fundación FISABIO), Hospital General Universitario de Alicante, Alicante, España
| | - David Rodriguez
- Servicio de Nefrología, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL-Fundación FISABIO), Hospital General Universitario de Alicante, Alicante, España
| | - Aurora Javaloyes
- Servicio de Farmacia, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL-Fundación FISABIO), Hospital General Universitario de Alicante, Alicante, España
| | - Marcos Díaz
- Servicio de Farmacia, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL-Fundación FISABIO), Hospital General Universitario de Alicante, Alicante, España
| | - Isabel Gascón
- Servicio de Farmacia, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL-Fundación FISABIO), Hospital General Universitario de Alicante, Alicante, España
| | - Amelia Ramon-Lopez
- Área de Farmacia y Tecnología Farmacéutica, Departamento de Ingeniería, Universidad Miguel Hernández de Elche; Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL-Fundación FISABIO), Elche, Alicante, España
| | - Javier Perez-Contreras
- Servicio de Nefrología, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL-Fundación FISABIO), Hospital General Universitario de Alicante, Alicante, España
| | - Juan Selva
- Servicio de Farmacia, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL-Fundación FISABIO), Hospital General Universitario de Alicante, Alicante, España; Área de Farmacia y Tecnología Farmacéutica, Departamento de Ingeniería, Universidad Miguel Hernández de Elche; Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL-Fundación FISABIO), Elche, Alicante, España
| | - Ricardo Nalda-Molina
- Área de Farmacia y Tecnología Farmacéutica, Departamento de Ingeniería, Universidad Miguel Hernández de Elche; Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL-Fundación FISABIO), Elche, Alicante, España
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21
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Schwartz JJ, Wilson S, Shi F, Elsouda D, Undre N, Kumar MSA. Prolonged-Release vs Immediate-Release Tacrolimus Capsules in Black vs White Kidney Transplant Patients: A Post Hoc Analysis of Phase III Data. Transplant Proc 2018; 50:3283-3295. [PMID: 30577198 DOI: 10.1016/j.transproceed.2018.08.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Revised: 07/27/2018] [Accepted: 08/16/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Black kidney transplant patients experience inferior outcomes compared with other ethnicities. Because scrutiny is required when immunosuppressant drugs are used in such at-risk populations, we report the first large-scale clinical efficacy data assessing prolonged-release tacrolimus (PR-T) in black de novo kidney transplant patients. METHODS AND MATERIALS We used logistic regression and proportionate hazards to compare a composite outcome measure (biopsy-proven acute rejection, graft loss, mortality, and loss to follow-up) in black and white patients in treatment groups longer than 24 weeks, from 3 large Phase III randomized controlled trials. Secondary endpoints included tacrolimus trough concentration, dose, and estimated glomerular filtration rate. RESULTS The study included 2162 patients whose treatments belonged to two categories (immediate-release tacrolimus: 77 black patients, 721 white patients; and PR-T: 87 black patients, 1277 white patients). Despite demographic factors generally predictive of worse outcomes, efficacy failure among black patients who received PR-T was non-inferior to that among white patients who received either therapy. Compared with immediate-release tacrolimus, black patients who received PR-T achieved stable tacrolimus concentrations 2.5 times faster (21 vs 56 days, P = .04), and more achieved stable target concentrations (76.7% vs 69.3%). Treatment-emergent adverse events were consistent with those reported separately in pivotal trials. CONCLUSIONS Overall, black patients who received PR-T achieved non-inferior outcomes compared to white patients, despite higher pretransplant risk among black patients. Moreover, PR-T improved the time to achieve, and the likelihood of reaching, stable therapeutic concentrations among black patients, suggesting that PR-T could improve the consistency of tacrolimus exposure in this patient population.
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Affiliation(s)
- J J Schwartz
- Medical Affairs, Astellas Pharma Global Development, Inc, Northbrook, Illinois.
| | - S Wilson
- Medical Affairs, Astellas Pharma Global Development, Inc, Northbrook, Illinois
| | - F Shi
- Medical Affairs, Astellas Pharma Global Development, Inc, Northbrook, Illinois
| | - D Elsouda
- Medical Affairs, Astellas Pharma Global Development, Inc, Northbrook, Illinois
| | - N Undre
- Medical Affairs, Astellas Pharma Global Development, Inc, Chertsey, United Kingdom
| | - M S A Kumar
- Medical Affairs, Astellas Pharma Global Development, Inc, Northbrook, Illinois
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Conversion from Twice-Daily Prograf ® to Once-Daily Advagraf ® in Multi-ethnic Asian Adult Renal Transplant Recipients With or Without Concomitant Use of Diltiazem: Impact of CYP3A5 and MDR1 Genetic Polymorphisms on Tacrolimus Exposure. Eur J Drug Metab Pharmacokinet 2018; 44:481-492. [PMID: 30471066 DOI: 10.1007/s13318-018-0531-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND OBJECTIVES Tacrolimus is the mainstay of immunosuppression in renal transplantation. Given that once-daily administration improves patient compliance, 1:1 dose conversion from twice-daily Prograf® to once-daily Advagraf® is recommended. Although cytochrome P450 (CYP) 3A5 and multi-drug resistance 1 (MDR1) polymorphisms influence tacrolimus concentrations, it is unknown if these impact on conversion. This study investigated the change in the pharmacokinetics of tacrolimus after conversion from Prograf® to Advagraf® and examined the impact of CYP3A5 and MDR1 C3435T polymorphisms on those pharmacokinetics. METHODS A prospective open-label pharmacokinetic study of 1:1 conversion from Prograf® to Advagraf® with or without diltiazem was conducted on 26 stable renal transplant recipients. Blood samples were collected over 24 h during each phase, tacrolimus concentrations were assayed, and noncompartmental pharmacokinetic analysis was performed. All participants were genotyped for CYP3A5*3 and MDR1 C3435T. RESULTS After conversion, without diltiazem, the area under the concentration-time curve at steady state from 0 to 24 h after dose administration (AUCss, 0-24) was significantly reduced [median 224 (range 172-366) vs. 184 (104-347) ng·h/mL, p = 0.006, n = 26]. A decrease in tacrolimus exposure (median 21%) was only evident among CYP3A5 expressors [227 (172-366) vs. 180 (104-347) ng·h/mL, p = 0.014, n = 18], not among non-expressors [215 (197-290) vs. 217 (129-281) ng·h/mL, p = 0.263, n = 8]. In contrast, among CYP3A5 expressors receiving diltiazem, AUCss, 0-24 did not change significantly upon conversion [229 (170-296) vs. 221 (123-342) ng·h/mL, p = 0.575, n = 10]. An independent effect was not evident for MDR1 C3435T polymorphism. CONCLUSION The high prevalence of CYP3A5 polymorphism among Asians may lead to a significant reduction in tacrolimus exposure with 1:1 dose conversion of Prograf® to Advagraf®. These results advocate for CYP3A5 determination prior to conversion, and suggest that 1:1.25 conversion should be used for CYP3A5 expressors and 1:1 conversion for other patients.
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23
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Advancing Transplantation: New Questions, New Possibilities in Kidney and Liver Transplantation. Transplantation 2018; 101 Suppl 2S:S1-S41. [PMID: 28125449 DOI: 10.1097/tp.0000000000001563] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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24
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Garaix F, Stern M, Lamy FX, Dubel L, Kamar N. Tacrolimus Granules for Oral Suspension as Post-Transplant Immunosuppression in Routine Medical Practice in France: The OPTIMOD Study. Ann Transplant 2018; 23:561-571. [PMID: 30093607 PMCID: PMC6248292 DOI: 10.12659/aot.908522] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background Different pharmaceutical forms of oral tacrolimus allow tailored administration. The granular formulation facilitates accurate dose adjustment of tacrolimus according to patient characteristics, such as weight, or potential concomitant drug interactions. Currently, there are no data describing the use of tacrolimus granules in transplant recipients in France. Material/Methods OPTIMOD was a 6-month prospective, observational multicenter study that aimed to describe patient characteristics and conditions of use of tacrolimus granules. The 25 participating centers enrolled patients at time of tacrolimus granules initiation and were to collect patient and treatment data at initiation and after 6 months of follow-up. All analyses were descriptive. Results Of 61 patients included, 55.7% were children (mainly kidney graft recipients) and 44.3% were adults (mostly lung graft recipients). Overall, 24.6% of patients (all children) initiated tacrolimus granules immediately post-transplant; the remaining 75.4% converted to tacrolimus granules from ciclosporin or immediate-release tacrolimus hard capsules. The main reasons for initiating tacrolimus granules, irrespective of whether first- or second-line therapy, were to offset potential drug–drug interactions in adults by adjusting dose, and to adapt to the particular needs of children as patients. Most patients (78.7%) underwent ≥1 dose modification during follow-up. Eleven rejection episodes occurred during follow-up, of which none led to graft loss. The adverse-event profile of the tacrolimus granules was similar to that of other tacrolimus formulations and 7 treatment-related adverse events were recorded. Conclusions Results suggest that tacrolimus granules are well tolerated and effective in preventing transplant rejection when administered in routine practice in France.
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Affiliation(s)
- Florentine Garaix
- Department of Paediatric Nephrology, Hôpital La Timone, Marseille, France
| | - Marc Stern
- Department of Pulmonology, Hôpital Foch, Suresnes, France
| | | | - Laurence Dubel
- Department of Scientific and Medical Affairs Transplantation, Astellas France, Levallois-Perret Cedex, France
| | - Nassim Kamar
- Department of Nephrology, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
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Adherence to and Acceptance of Once-Daily Tacrolimus After Kidney and Liver Transplant: Results From OSIRIS, a French Observational Study. Transplantation 2018; 100:2099-2106. [PMID: 27653227 DOI: 10.1097/tp.0000000000001307] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Adherence to immunosuppressive treatments is a major concern in transplanted patients. METHODS This 6-month French observational, longitudinal, prospective study aimed to assess patient adherence to and acceptance of once-daily tacrolimus (Advagraf) initiation in kidney and liver transplant recipients. Data from 1106 patients initiating once-daily tacrolimus during posttransplant follow-up were analyzed. Adherence and acceptance were assessed using self-administered questionnaires at inclusion and at 3 and 6 months. RESULTS Mean age was 52.4 ± 13.2 years, 61.5% were men. For 94.9% of patients, once-daily tacrolimus was prescribed after switching from twice-daily tacrolimus. At inclusion, 20.9% of patients reported good treatment adherence, 72.0% minor nonadherence, and 7.1% were nonadherent. Mean general acceptance score (range, 0-100) was 77.7 (±24.7). At 3 months, adherence was improved in 21.1%, unchanged in 69.2%, and worsened in 9.7% of patients. Mean general acceptance score was 75.4 (±26.5). General acceptance score was improved in 28.0%, unchanged in 39.4%, and worsened in 32.7% of patients. At 6 months, similar changes in adherence and acceptance were observed. Higher general acceptance score at month 3 was significantly associated with better adherence at month 6. CONCLUSIONS Conversion to once-daily tacrolimus led to an improved rate of adherence at month 3 in more than 20% of patients and a worsened rate of adherence in less than 10% of patients.
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26
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Sukkha S, Chindavijak B, Montakantikul P, Ingsathit A, Nosoongnoen W, Sumethkul V. Trough level from twice daily to once daily tacrolimus in early conversion kidney transplant recipients: a prospective study. Int J Clin Pharm 2017; 39:1298-1303. [PMID: 29101615 DOI: 10.1007/s11096-017-0549-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 10/21/2017] [Indexed: 02/05/2023]
Abstract
Background Early conversion from twice-daily tacrolimus (TAC-BID) to once-daily tacrolimus (TAC-OD) provides a greater benefit of reducing under-exposure of TAC-OD during the first period after transplantation. Information regarding the conversion dose among Asian kidney transplant recipients is still limited. Objective This study aimed to compare the trough levels (Cmin) of TAC-BID (Prograf®) and TAC-OD (Advagraf®). The values were obtained from early conversion intervention by 1:1 milligram per-milligram. Setting A university-based hospital. Method This study employed a single-center, open-label, prospective and single-armed design. Fifteen de novo standard risk kidney transplant recipients were enrolled. Fourteen days after transplantation, the Cmin of TAC-BID (pre-conversion Cmin) was determined. Subsequently, TAC-BID was converted to TAC-OD with a similar dose. The Cmin of TAC-OD was first measured at a steady state (immediate post-conversion Cmin) and compared. All enrolled patients received therapeutic monitoring at the first and second months. Main outcome measure Pre-conversion Cmin of TAC-BID and immediate post-conversion Cmin of TAC-OD. Results The immediate post-conversion Cmin was found to be 23% lowered than the pre-conversion Cmin. However, the Cmin of TAC-OD was found to be similar to the pre-conversion Cmin compared during the follow-up period. Renal function was found to be stable in all patients over 2 months. Conclusion Early conversion therapy was associated with a significantly lower immediate post-conversion Cmin but comparable Cmin throughout the follow-up period. The "one to one conversion ratio" from TAC-BID to TAC-OD could be performed among Asian de novo kidney transplant recipients at an early period after transplantation.
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Affiliation(s)
- Sayamon Sukkha
- Division of Clinical Pharmacy, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, 447 Sri Ayutthaya Road, Rajathevi, Bangkok, 10400, Thailand
| | - Busba Chindavijak
- Division of Clinical Pharmacy, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, 447 Sri Ayutthaya Road, Rajathevi, Bangkok, 10400, Thailand
| | - Preecha Montakantikul
- Division of Clinical Pharmacy, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, 447 Sri Ayutthaya Road, Rajathevi, Bangkok, 10400, Thailand
| | - Atiporn Ingsathit
- Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Rajathevi, Bangkok, 10400, Thailand
| | - Wichit Nosoongnoen
- Division of Clinical Pharmacy, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, 447 Sri Ayutthaya Road, Rajathevi, Bangkok, 10400, Thailand.
| | - Vasant Sumethkul
- Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Rajathevi, Bangkok, 10400, Thailand
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27
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Trofe-Clark J, Brennan DC, West-Thielke P, Milone MC, Lim MA, Neubauer R, Nigro V, Bloom RD. Results of ASERTAA, a Randomized Prospective Crossover Pharmacogenetic Study of Immediate-Release Versus Extended-Release Tacrolimus in African American Kidney Transplant Recipients. Am J Kidney Dis 2017; 71:315-326. [PMID: 29162334 DOI: 10.1053/j.ajkd.2017.07.018] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 07/20/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND Differences in tacrolimus dosing across ancestries is partly attributable to polymorphisms in CYP3A5 genes that encode tacrolimus-metabolizing cytochrome P450 3A5 enzymes. The CYP3A5*1 allele, preponderant in African Americans, is associated with rapid metabolism, subtherapeutic concentrations, and higher dose requirements for tacrolimus, all contributing to worse outcomes. Little is known about the relationship between CYP3A5 genotype and the tacrolimus pharmacokinetic area under the curve (AUC) profile in African Americans or whether pharmacogenetic differences exist between conventional twice-daily, rapidly absorbed, immediate-release tacrolimus (IR-Tac) and once-daily extended-release tacrolimus (LifeCycle Pharma Tac [LCPT]) with a delayed absorption profile. STUDY DESIGN Randomized prospective crossover study. SETTING & PARTICIPANTS 50 African American maintenance kidney recipients on stable IR-Tac dosing. INTERVENTION Recipients were randomly assigned to continue IR-Tac on days 1 to 7 and then switch to LCPT on day 8 or receive LCPT on days 1 to 7 and then switch to IR-Tac on day 8. The LCPT dose was 85% of the IR-Tac total daily dose. OUTCOMES Tacrolimus 24-hour AUC (AUC0-24), peak and trough concentrations (Cmax and Cmin), time to peak concentration, and bioavailability of LCPT versus IR-Tac, according to CYP3A5 genotype. MEASUREMENTS CYP3A5 genotype, 24-hour tacrolimus pharmacokinetic profiles. RESULTS ∼80% of participants carried the CYP3A5*1 allele (CYP3A5 expressers). There were no significant differences in AUC0-24 or Cmin between CYP3A5 expressers and nonexpressers during administration of either IR-Tac or LCPT. With IR-Tac, tacrolimus Cmax was 33% higher in CYP3A5 expressers compared with nonexpressers (P=0.04): With LCPT, this difference was 11% (P=0.4). LIMITATIONS This was primarily a pharmacogenetic study rather than an efficacy study; the follow-up period was too short to capture clinical outcomes. CONCLUSIONS Achieving therapeutic tacrolimus trough concentrations with IR-Tac in most African Americans results in significantly higher peak concentrations, potentially magnifying the risk for toxicity and adverse outcomes. This pharmacogenetic effect is attenuated by delayed tacrolimus absorption with LCPT. TRIAL REGISTRATION Registered at ClinicalTrials.gov, with study number NCT01962922.
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Affiliation(s)
- Jennifer Trofe-Clark
- Department of Pharmacy Services, Hospital of the University of Pennsylvania, Philadelphia, PA; Renal Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | | | - Michael C Milone
- Perelman School of Medicine, University of Pennsylvania, Penn Institute for Immunology, Philadelphia, PA
| | - Mary Ann Lim
- Renal Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Robin Neubauer
- Renal Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | - Roy D Bloom
- Renal Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
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28
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Efficacy of Prolonged- and Immediate-release Tacrolimus in Kidney Transplantation: A Pooled Analysis of Two Large, Randomized, Controlled Trials. Transplant Proc 2017; 49:2040-2049. [DOI: 10.1016/j.transproceed.2017.07.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 07/30/2017] [Indexed: 11/18/2022]
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29
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Tremblay S, Alloway RR. Clinical Evaluation of Modified Release and Immediate Release Tacrolimus Formulations. AAPS JOURNAL 2017; 19:1332-1347. [PMID: 28717926 DOI: 10.1208/s12248-017-0119-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 06/27/2017] [Indexed: 12/21/2022]
Abstract
The science of drug delivery has evolved considerably and has led to the development of multiple sustained release formulations. Each of these formulations can present particular challenges in terms of clinical evaluation and necessitate careful study to identify their optimal use in practice. Tacrolimus is an immunosuppressive agent that is widely used in organ transplant recipients. However, it is poorly soluble, has an unpredictable pharmacokinetic profile subject to important genetic polymorphisms and drug-drug interactions, and has a narrow therapeutic index. For these reasons, it represents an agent that could benefit from modified release formulations to overcome these limitations. The objective of this review is to discuss the clinical evaluation of immediate and modified release tacrolimus formulations in renal transplant recipients. Clinical trials from early development of immediate release tacrolimus to formulation-specific post-marketing trials of modified release tacrolimus formulations are reviewed with an emphasis on key elements relating to trial design end endpoint assessment. Particular elements that can be addressed with formulation alterations, such as pharmacokinetics, pharmacogenomics, and toxicity and corresponding clinical evaluations are discussed. In addition, current knowledge gaps in the clinical evaluation of immediate and modified release tacrolimus formulations are discussed to highlight potential avenues for the future development of different tacrolimus formulations with outcomes relevant to the regulators, the transplant community, and to transplant recipients. This review shows that new formulations may alter tacrolimus bioavailability, alleviate certain adverse events while potentially enhancing patient convenience.
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Affiliation(s)
- Simon Tremblay
- Department of Surgery, Division of Transplantation, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML0519, Cincinnati, OH, 45267, USA. .,Department of Environmental Health, Division of Epidemiology, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML0519, Cincinnati, OH, 45267, USA.
| | - Rita R Alloway
- Department of Internal Medicine, Division of Nephrology, Kidney C.A.R.E Program, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Impact of Conversion From Advagraf to Twice-Daily Generic Tacrolimus in Kidney Transplant Recipients: A Single-Center Study—A 3-Year Follow-Up. Transplant Direct 2017; 3:e175. [PMID: 28706978 PMCID: PMC5498016 DOI: 10.1097/txd.0000000000000696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 04/25/2017] [Accepted: 05/02/2017] [Indexed: 11/30/2022] Open
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Diwan TS, Lichvar AB, Leino AD, Vinks AA, Christians U, Shields AR, Cardi MA, Fukuda T, Mizuno T, Kaiser T, Woodle ES, Alloway RR. Pharmacokinetic and pharmacogenetic analysis of immunosuppressive agents after laparoscopic sleeve gastrectomy. Clin Transplant 2017; 31. [PMID: 28342282 DOI: 10.1111/ctr.12975] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2017] [Indexed: 01/15/2023]
Abstract
BACKGROUND Severe obesity has been shown to limit access to renal transplantation in patients with end-stage renal disease (ESRD). Laparoscopic sleeve gastrectomy (LSG) has been performed in the ESRD population to assist in achieving waitlist and transplant eligibility. Little is known about how LSG impacts the bioequivalence of tacrolimus products and immunosuppression pharmacokinetics. METHODS This was a prospective, open-label, single-dose, crossover, two-period pharmacokinetic (PK) study. The purpose of this study was to assess single-dose PK of immediate-release tacrolimus (IR-TAC), extended-release tacrolimus (ER-TAC), and mycophenolic acid (MPA) in adult ESRD patients post-LSG. RESULTS Twenty-three subjects were included in the 24-hour PK assessments. The ratio of geometric means between ER-TAC and IR-TAC was 103.5% (90% CI; 89.6%-119.6%) for AUC0-24 and 92.5% (90% CI; 80.4%-106.4%) for Cmax . PK parameters were similar between ER-TAC and IR-TAC, except for Cmin (P=.004) and Cmax (P=.04). MPA AUC0-24 was similar when given with either ER-TAC or IR-TAC (P=.32). Patients expressing CYP3A5*1 genotypes had lower tacrolimus AUC0-24 values vs those with CYP3A5*3/*3 (IR-TACP<.001; ER-TACP=.008). Genotype did not impact MPA PK. CONCLUSION Dose modification of immunosuppressants post-LSG may not be necessary aside from standard therapeutic drug monitoring.
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Affiliation(s)
- Tayyab S Diwan
- Division of Transplantation, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Alicia B Lichvar
- Division of Transplantation, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Abbie D Leino
- Division of Transplantation, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Alexander A Vinks
- Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Uwe Christians
- Department of Anesthesiology, iC42 Clinical Research and Development, University of Colorado Denver, Aurora, CO, USA
| | - Adele R Shields
- Division of Transplantation, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA.,The Christ Hospital, Cincinnati, OH, USA
| | | | - Tsuyoshi Fukuda
- Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Tomoyuki Mizuno
- Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Tiffany Kaiser
- Division of Digestive Diseases, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - E Steve Woodle
- Division of Transplantation, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Rita R Alloway
- Division of Nephrology, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Tremblay S, Nigro V, Weinberg J, Woodle ES, Alloway RR. A Steady-State Head-to-Head Pharmacokinetic Comparison of All FK-506 (Tacrolimus) Formulations (ASTCOFF): An Open-Label, Prospective, Randomized, Two-Arm, Three-Period Crossover Study. Am J Transplant 2017; 17:432-442. [PMID: 27340950 PMCID: PMC5297985 DOI: 10.1111/ajt.13935] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 06/08/2016] [Accepted: 06/18/2016] [Indexed: 02/06/2023]
Abstract
This two-sequence, three-period crossover study is the first pharmacokinetic (PK) study to compare all three innovator formulations of tacrolimus (twice-daily immediate-release tacrolimus capsules [IR-Tac]; once-daily extended-release tacrolimus capsules [ER-Tac]; novel once-daily tacrolimus tablets [LCPT]). Stable renal transplant patients were dosed with each drug for 7 days, and blood samples were obtained over 24 h. Thirty subjects were included in the PK analysis set. A conversion factor of 1:1:0.80 for IR-Tac:ER-Tac:LCPT was used; no dose adjustments were permitted during the study. The median (interquartile range) total daily dose was 6.0 (4.0-8.0) mg for IR-Tac and ER-Tac and 4.8 (3.3-6.3) for LCPT. Significantly higher exposure on a per milligram basis, lower intraday fluctuation and prolonged time (Tmax ) to peak concentration (Cmax ) were found for LCPT versus IR-Tac or ER-Tac. ER-Tac showed no differences versus IR-Tac in exposure, Cmax , Tmax or fluctuation. The observed exposure of IR-Tac was used to normalize exposure for LCPT and ER-Tac, resulting in the following recommended total daily dose conversion rates: IR-Tac:ER-Tac, +8%; IR-Tac:LCPT, -30%; ER-Tac:LCPT, -36%. After exposure normalization, Cmax was ~17% lower for LCPT than for IR-Tac or ER-Tac; Cmin was ~6% lower for LCPT compared with IR-Tac and 3% higher compared with ER-Tac.
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Affiliation(s)
- S. Tremblay
- Department of Internal MedicineDivision of Nephrology and HypertensionUniversity of Cincinnati College of MedicineCincinnatiOH
| | - V. Nigro
- Veloxis Pharmaceuticals, Inc.EdisonNJ
| | | | - E. S. Woodle
- Department of SurgeryDivision of TransplantationUniversity of Cincinnati College of MedicineCincinnatiOH
| | - R. R. Alloway
- Department of Internal MedicineDivision of Nephrology and HypertensionUniversity of Cincinnati College of MedicineCincinnatiOH
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Takahashi Y, Shishido S, Hyodo Y, Yonekura T, Nihei H, Itabashi Y, Muramatsu M, Hamasaki Y, Kawamura T, Aikawa A. Pharmacokinetic Profile of Twice- and Once-daily Tacrolimus in Pediatric Kidney Transplant Recipients. Transplant Proc 2017; 49:37-40. [PMID: 28104153 DOI: 10.1016/j.transproceed.2016.11.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND The aim of this study was to assess the differences in pharmacokinetic (PK) profiles after the 1:1 ratio-based conversion from a twice-daily to a once-daily tacrolimus formulation (TD-TAC and OD-TAC, respectively) in pediatric recipients of kidney transplants. METHODS TD-TAC was initially administered to 29 pediatric patients who underwent kidney transplantations between April 2010 and September 2015 and were then subsequently switched to OD-TAC. The switch dose ratio was 1:1, and the 24-hour complete PK parameter assessment was performed before and after the regimen was changed from TD-TAC to OD-TAC. RESULTS The mean total daily dose at baseline was 5.5 ± 2.9 mg (0.18 ± 0.10 mg/kg body weight). Consecutive PK studies revealed no significant difference in the mean time to achieve maximum concentrations and the area under the concentration-time curve from 0 to 24 hours (AUC0-24) of both drug formulations. However, the mean trough concentration (Cmin) and the maximum concentration of OD-TAC were 22% and 6% lower and higher, respectively, than those of TD-TAC. Therefore, a better correlation was observed between the AUC0-24 and Cmin of OD-TAC than between those of TD-TAC. CONCLUSIONS After the change from TD-TAC to OD-TAC, the AUC0-24 values were equivalent despite a 22% reduction in Cmin. Cmin may therefore be an excellent predictor in the therapeutic drug monitoring of OD-TAC because of its superior correlation with AUC0-24.
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Affiliation(s)
- Y Takahashi
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan; Department of Pediatric Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | - S Shishido
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan; Department of Pediatric Nephrology, Toho University Faculty of Medicine, Tokyo, Japan.
| | - Y Hyodo
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | - T Yonekura
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | - H Nihei
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Y Itabashi
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | - M Muramatsu
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Y Hamasaki
- Department of Pediatric Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | - T Kawamura
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | - A Aikawa
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
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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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Barreto P, Malheiro J, Vieira P, Pedroso S, Almeida M, Martins LS, Dias L, Henriques AC, Cabrita A. Conversion From Twice-Daily to Once-Daily Tacrolimus in Stable Kidney Graft Recipients. Transplant Proc 2016; 48:2276-2279. [PMID: 27742278 DOI: 10.1016/j.transproceed.2016.06.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Immunosuppression has a pivotal role in kidney transplantation. The new prolonged-release formulation of tacrolimus was developed to provide a more convenient once-daily dosing to improve patient adherence. METHODS We selected 60 stable kidney transplant recipients who underwent tacrolimus conversion in our unit. Conversion was made on a 1 mg:1 mg basis in 66.7% of patients (n = 40) and on a 1 mg:1.1 mg basis in the remaining 33.3% (n = 20). Clinical and analytical data at conversion and postconversion was analyzed retrospectively to evaluate the efficacy and safety of conversion from tacrolimus twice-daily to once-daily formulation. RESULTS A significant reduction in tacrolimus blood levels requiring an increase in tacrolimus daily dose was observed postconversion. Postconversion tacrolimus blood level reduction >25% was significantly higher in the conversion group 1 mg:1 mg basis (P = .004). In patients converted 1 mg:1 mg, female sex and higher tacrolimus level at conversion were significant risk factors for a reduction >25% in tacrolimus blood levels after conversion. No significant change was detected between mean glomerular filtration rate at conversion (57 mL/min) and at 3, 6, and 9 months postconversion. CONCLUSIONS Once-daily tacrolimus at similar doses to the twice-daily formulation is an efficient and safe treatment option. Conversion made on 1 mg:1.1 mg basis seems advantageous at least in some patients.
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Affiliation(s)
- P Barreto
- Nephrology Department, Centro Hospitalar do Porto, Porto, Portugal; Nephrology Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal.
| | - J Malheiro
- Nephrology Department, Centro Hospitalar do Porto, Porto, Portugal
| | - P Vieira
- Nephrology Department, Centro Hospitalar do Porto, Porto, Portugal; Nephrology Department, Centro Hospitalar do Funchal, Funchal, Portugal
| | - S Pedroso
- Nephrology Department, Centro Hospitalar do Porto, Porto, Portugal
| | - M Almeida
- Nephrology Department, Centro Hospitalar do Porto, Porto, Portugal
| | - L S Martins
- Nephrology Department, Centro Hospitalar do Porto, Porto, Portugal
| | - L Dias
- Nephrology Department, Centro Hospitalar do Porto, Porto, Portugal
| | - A C Henriques
- Nephrology Department, Centro Hospitalar do Porto, Porto, Portugal
| | - A Cabrita
- Nephrology Department, Centro Hospitalar do Porto, Porto, Portugal
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Pharmacokinetic study of once-daily formulation of tacrolimus (Advagraf) in stable Chinese kidney transplant recipients. Int J Organ Transplant Med 2016. [DOI: 10.1016/j.hkjn.2016.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Effect of Breakfast on the Exposure of the Once-Daily Tacrolimus Formulation in Stable Kidney Transplant Recipients. Ther Drug Monit 2016; 38:456-62. [DOI: 10.1097/ftd.0000000000000311] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Tanzi MG, Undre N, Keirns J, Fitzsimmons WE, Brown M, First MR. Pharmacokinetics of prolonged-release tacrolimus and implications for use in solid organ transplant recipients. Clin Transplant 2016; 30:901-11. [PMID: 27220013 DOI: 10.1111/ctr.12763] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2016] [Indexed: 11/26/2022]
Abstract
Prolonged-release tacrolimus was developed as a once-daily formulation with ethylcellulose as the excipient, resulting in slower release and reduction in peak concentration (Cmax ) for a given dose compared with immediate-release tacrolimus, which is administered twice daily. This manuscript reviews pharmacokinetic information on prolonged-release tacrolimus in healthy subjects, in transplant recipients converted from immediate-release tacrolimus, and in de novo kidney and liver transplant recipients. As with the immediate-release formulation, prolonged-release tacrolimus shows a strong correlation between trough concentration (Cmin ) and area under the 24-hour time-concentration curve (AUC24 ), indicating that trough whole blood concentrations provide an accurate measure of drug exposure. We present the pharmacokinetic similarities and differences between the two formulations, so that prescribing physicians will have a better understanding of therapeutic drug monitoring in patients receiving prolonged-release tacrolimus.
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Affiliation(s)
- Maria G Tanzi
- Astellas Pharma Global Development, Northbrook, IL, USA
| | | | - James Keirns
- Astellas Pharma Global Development, Northbrook, IL, USA
| | | | | | - M Roy First
- Transplant Genomics Inc., Brookline, MA, USA
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De Meyer M, Haufroid V, Kanaan N, Darius T, Buemi A, De Pauw L, Eddour DC, Wallemacq P, Mourad M. Pharmacogenetic-based strategy using de novo tacrolimus once daily after kidney transplantation: prospective pilot study. Pharmacogenomics 2016; 17:1019-27. [DOI: 10.2217/pgs-2016-0005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Aim: The once daily tacrolimus formulation (Tac-OD) has been associated with better patient adherence and low variability in exposure. Patients carrying the CYP3A5*1 allele show accelerated clearance of Tac. Authors prospectively evaluate a simplified strategy for Tac-OD administration. Patients & methods: After grafting, 151 patients were divided into four groups and received a daily dose calculated according to CYP3A5 genotypes and unchanged for the first 3 days: CYP3A5*3/*3: 0.20 mg/kg/day, CYP3A5*3/*3: 0.25 mg/kg/day, CYP3A5*1/*3: 0.30 mg/kg/day and CYP3A5*1/*1: 0.35 mg/kg/day. The dose was adaptated on day 4 and remained unchanged a further three days and so on. Results: On day 3, median Cmin fell within the therapeutic range in all study groups. CYP3A5 expressors require significantly higher Tac-OD throughout the follow-up period to achieve a comparable Cmin. Conclusion: This simplified strategy does not hamper treatment efficacy.
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Affiliation(s)
- Martine De Meyer
- Department of Surgery, Surgery & Abdominal Transplantation Division, Université catholique de Louvain, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Vincent Haufroid
- Department of Clinical Chemistry, Université catholique de Louvain, Cliniques universitaires Saint-Luc, Brussels, Belgium
- Louvain Centre for Toxicology & Applied Pharmacology (LTAP), Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, Brussels, Belgium
| | - Nada Kanaan
- Department of Nephrology, Université catholique de Louvain, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Tom Darius
- Department of Surgery, Surgery & Abdominal Transplantation Division, Université catholique de Louvain, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Antoine Buemi
- Department of Surgery, Surgery & Abdominal Transplantation Division, Université catholique de Louvain, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Luc De Pauw
- Department of Surgery, Surgery & Abdominal Transplantation Division, Université catholique de Louvain, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Djamila Chaïb Eddour
- Department of Surgery, Surgery & Abdominal Transplantation Division, Université catholique de Louvain, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Pierre Wallemacq
- Department of Clinical Chemistry, Université catholique de Louvain, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Michel Mourad
- Department of Surgery, Surgery & Abdominal Transplantation Division, Université catholique de Louvain, Cliniques universitaires Saint-Luc, Brussels, Belgium
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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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Patel N, Cook A, Greenhalgh E, Rech MA, Rusinak J, Heinrich L. Overview of extended release tacrolimus in solid organ transplantation. World J Transplant 2016; 6:144-154. [PMID: 27011912 PMCID: PMC4801790 DOI: 10.5500/wjt.v6.i1.144] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Revised: 10/28/2015] [Accepted: 01/04/2016] [Indexed: 02/05/2023] Open
Abstract
Tacrolimus (Prograf©, Astellas Pharma Europe Ltd, Staines, United Kingdom; referred to as tacrolimus-BID) is an immunosuppressive agent to prevent and treat allograft rejection in kidney transplant recipients in combination with mycophenolate mofetil, corticosteroids, with or without basiliximab induction. The drug has also been studied in liver, heart and lung transplant; however, these are currently off-label indications. An extended release tacrolimus formulation (Advagraf©, Astagraf XL©) allows for once-daily dosing, with the potential to improve adherence. Extended release tacrolimus has similar absorption, distribution, metabolism and excretion to tacrolimus-BID. Phase I pharmacokinetic trials comparing extended release tacrolimus and tacrolimus-BID have demonstrated a decreased maximum concentration (Cmax) and delayed time to maximum concentration (tmax) with the extended release formulation; however, AUC0-24 was comparable between formulations. Overall extended release tacrolimus has a very similar safety and efficacy profile to tacrolimus-BID. It is not recommended in the use of liver transplant patient’s due to the increased risk of mortality in female recipients. There has been minimal data regarding the use of extended release tacrolimus in heart and lung transplant recipients. With the current data available for all organ groups the extended release tacrolimus should be dosed in a 1:1 fashion, the exception may be the cystic fibrosis population where their initial dose may need to be higher.
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Effects of CYP3A5 Genetic Polymorphism on the Pharmacokinetics of Tacrolimus in Renal Transplant Recipients. Transplant Proc 2016; 48:81-7. [DOI: 10.1016/j.transproceed.2016.01.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Accepted: 01/04/2016] [Indexed: 11/17/2022]
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Muduma G, Shupo FC, Dam S, Hawken NA, Aballéa S, Odeyemi I, Toumi M. Patient survey to identify reasons for non-adherence and elicitation of quality of life concepts associated with immunosuppressant therapy in kidney transplant recipients. Patient Prefer Adherence 2016; 10:27-36. [PMID: 26834463 PMCID: PMC4716768 DOI: 10.2147/ppa.s96086] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Renal transplantation (RT) is considered the treatment of choice for end-stage renal disease compared to dialysis, offering better health-related quality of life (HRQoL) and higher survival rates. However, immunosuppressants are essential for the long-term survival of kidney grafts and patients' non-adherence to their medication leads to poor outcomes. Immunosuppressants can also significantly alter patients' HRQoL because of their side effects and the complex chronic medication regimen they represent. PURPOSE To elicit key concepts related to adherence to immunosuppressant therapy (IT) and reasons for non-adherence in terms of patient reported outcomes, side effects, and the impact of the medication on HRQoL in RT population, including patient preference of once daily over twice-daily immunosuppressive regimen. Results were used to develop an IT-specific conceptual framework and provide suggestions for improving patients' adherence to IT. MATERIALS AND METHODS Interviews were conducted with three clinical experts to determine key concepts related to RT and immunosuppressants. Thirty-seven participants in four focus groups were asked to cite important concepts related to adherence and impact of IT on HRQoL and to rate them. Qualitative analysis was conducted to code participants' responses. RESULTS Non-adherence among participants where admitted was unintentional. The reason for this included forgetfulness, interference with lifestyle, being asleep at the time the medication should be taken, change in routine, and impact of side effects. Overall, participants reported that the evening dose was more problematic to remember and that the exclusion of this dose could make them more adherent. Participants also reported that IT impacted on their HRQoL in a number of ways including: placing restrictions on their lifestyle, causing anxiety, or impairing their ability to work. CONCLUSION This study provides qualitative evidence about the barriers to IT adherence and the components of HRQoL that are important from the perspective of RT patients. The developed conceptual framework of IT-HRQoL in RT transplants, including social, psychological, and work life domains, can be used to inform the development of a new IT-specific measure of HRQoL in RT patients for use in head-to-head clinical trials or observational studies. Despite limitations associated with the number and the age range of patients recruited, this study suggests that a change in the regimen from twice-daily to once daily among other measures could improve their adherence to IT and their HRQoL by placing less restrictions on their lifestyles.
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Affiliation(s)
| | | | | | | | | | | | - Mondher Toumi
- Public Health (EA 3279), Faculty of Medicine, Aix-Marseille University, Marseille, France
- Correspondence: Mondher Toumi, Public Health (EA 3279), Faculty of Medicine, Aix-Marseille University, 27 bd Jean Moulin, 13385 Marseille Cedex 05, France, Tel/Fax +33 4 9139 6500, Email
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Conversion from twice-daily to once-daily tacrolimus does not reduce intrapatient variability in tacrolimus exposure. Ther Drug Monit 2015; 37:262-9. [PMID: 25265255 DOI: 10.1097/ftd.0000000000000136] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Intrapatient variability (IPV) in tacrolimus exposure is associated with renal allograft failure. The aim of this study was to investigate whether conversion from the twice-daily tacrolimus formulation (Tac-TD) to a once-daily formulation (Tac-OD) leads to a lower IPV in tacrolimus exposure. METHODS Two hundred forty-seven stable renal transplant recipients were converted from Tac-TD to Tac-OD (Advagraf) on a 1:1-mg total daily dose basis. After conversion, patients were followed for 12 months and tacrolimus predose whole-blood concentrations (C0), serum creatinine, estimated glomerular filtration rate, and proteinuria were measured. These parameters were compared with those collected at all outpatient visits in the 12-month period (±3 months) before conversion (Tac-TD period). The IPV was calculated based on the dose-adjusted tacrolimus C0. RESULTS The Tac-OD formulation provided an excellent graft survival (100%), a low acute rejection rate (0.8%), and good tolerability. Renal function remained stable: estimated glomerular filtration rate 48 (16-90) versus 46 (12-90) mL/min (P = 0.15) before and after conversion, respectively. After conversion to Tac-OD, mean C0 was significantly lower, decreasing from 5.7 ± 1.5 to 5.0 ± 1.5 ng/mL, corresponding to a 12% reduction (P < 0.01). Both drugs had similar IPVs (Tac-TD: 17.3% ± 1.6% versus Tac-OD: 16.4% ± 1.6%, P = 0.31). CONCLUSIONS Although conversion from Tac-TD to Tac-OD significantly reduces tacrolimus exposure as measured by C0 and seems safe, it does not reduce IPV in tacrolimus exposure.
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Caillard S, Moulin B, Buron F, Mariat C, Audard V, Grimbert P, Marquet P. Advagraf(®) , a once-daily prolonged release tacrolimus formulation, in kidney transplantation: literature review and guidelines from a panel of experts. Transpl Int 2015; 29:860-9. [PMID: 26373896 DOI: 10.1111/tri.12674] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Revised: 02/18/2015] [Accepted: 08/20/2015] [Indexed: 12/01/2022]
Abstract
The efficacy and safety of tacrolimus twice-a-day (BID) and once-a-day (QD) formulations are similar. However, the available information regarding the initiation and management of tacrolimus QD is sparse and practical information is lacking. A panel of French experts extensively reviewed the available literature on tacrolimus pharmacokinetics, clinical efficacy, and safety in kidney transplantation and, based on their own day-to-day experience, provided the practitioners with practical guidelines for the daily use and management of tacrolimus QD in de novo initiation or early conversion.
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Affiliation(s)
- Sophie Caillard
- Nephrology and Transplant Department, Strasbourg University Hospital, Strasbourg, France
| | - Bruno Moulin
- Nephrology and Transplant Department, Strasbourg University Hospital, Strasbourg, France
| | - Fanny Buron
- Transplant, Nephrology and Immunology Department, Hospices Civils de Lyon, Edouard Herriot Hospital, Lyon, France
| | - Christophe Mariat
- Nephrology, Dialysis and Renal Transplants Department, North Hospital, Saint Etienne University Hospital, Saint Priest en Jarez, France
| | - Vincent Audard
- Nephrology and Transplant Department, Institut Francilien de Recherche en Néphrologie et Transplantation (IFRNT), Assistance Publique Hôpitaux de Paris, Henri-Mondor Hospital, Créteil, France
| | - Philippe Grimbert
- Nephrology and Transplant Department, Institut Francilien de Recherche en Néphrologie et Transplantation (IFRNT), Assistance Publique Hôpitaux de Paris, Henri-Mondor Hospital, Créteil, France
| | - Pierre Marquet
- CHU Limoges, UMR 850 INSERM, University of Limoges, Limoges, France
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Falconer SJ, Peagam WR, Oniscu GC. Early or Late Conversion From Tac-BD to Tac-BD in Renal Transplantation: When is the Right Time? Transplant Proc 2015; 47:1741-5. [PMID: 26293044 DOI: 10.1016/j.transproceed.2015.05.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 05/22/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND Increasing numbers of renal transplant recipients are converted from Prograf (Astellas Pharma, Tokyo, Japan) (tacrolimus twice daily [Tac-BD]) to Advagraf (Astellas) (tacrolimus once daily [Tac-QD]), but the optimal time for conversion is as yet unclear. This study aimed to investigate the correlation between the time of conversion from Tac-BD to Tac-QD after renal transplant and the dosing requirements, tacrolimus levels, renal function, and clinical outcomes. METHODS Since September 2008, 125 renal transplant patients were converted from Tac-BD to Tac-QD and followed up for 2 years after conversion. Patients were split into early (0 to 12 months) and late (>12 months) conversion groups. Demographics, Tac-QD dose, trough levels, graft function, and patient and graft outcome were prospectively collected. RESULTS Forty-four patients (35.2%) were converted early (3.82 ± 3.24 months), whereas 81 (64.8%) patients were converted late (77.35 ± 53.71 months). Tac-BD dose before conversion was higher in the early group (8.70 ± 6.34 vs 4.44 ± 2.15 mg) as was the initial Tac-QD dose (8.66 ± 6.20 vs 4.37 ± 2.04 mg, P < .0001), and remained higher for 18 months after conversion, as did the serum tacrolimus trough level levels. Renal function, acute rejection, and patient and graft survival were comparable between the groups. CONCLUSIONS Patients can be safely converted to Tac-QD within the first year post-transplantation, without adverse effects on clinical outcome, despite the higher doses and tacrolimus levels for the first 18 months.
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Affiliation(s)
- S J Falconer
- The Transplant Unit, The Royal Infirmary of Edinburgh/University of Edinburgh, Little France Crescent, Edinburgh, UK
| | - W R Peagam
- The Transplant Unit, The Royal Infirmary of Edinburgh/University of Edinburgh, Little France Crescent, Edinburgh, UK
| | - G C Oniscu
- The Transplant Unit, The Royal Infirmary of Edinburgh/University of Edinburgh, Little France Crescent, Edinburgh, UK.
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Medium-Term Renal Function in a Large Cohort of Stable Kidney Transplant Recipients Converted From Twice-Daily to Once-Daily Tacrolimus. Transplant Direct 2015; 1:e24. [PMID: 27500226 PMCID: PMC4946473 DOI: 10.1097/txd.0000000000000536] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND There is some evidence pointing toward better renal function in kidney transplant recipients (KTR) treated with once-daily tacrolimus (QD-TAC) vs. twice-daily tacrolimus (BID-TAC). METHODS This is an extension study of a 1-year, single arm prospective study of stable KTR who were converted from BID-TAC to QD-TAC (4.9 ± 4.0 years after transplantation) in Spanish routine clinical practice. Patient and graft survival, renal function, acute rejection episodes, and other analytic parameters were assessed at 24 and 36 months after conversion. RESULTS A total of 1798 KTR were included in the extension study. Tacrolimus doses at 36 months were significantly lower compared to those at time of conversion (-0.2 mg/day; P = 0.023). Blood levels were lower than baseline during all the study (P < 0.001). Graft and patient survival at 3 years after conversion were 93.9% and 95.1%, respectively. Compared with baseline, the mean estimated glomerular filtration rate (eGFR) remained very stable at all timepoints (56.7 ± 19.8 vs 58.1 ± 24.6 mL/min per 1.73 m(2) at month 36; P = 0.623). Even when patients reinitiating dialysis were counted as eGFR = 0, the mean eGFR was very stable. In fact, a small but significant increase was observed at 36 months versus baseline (+0.1 mL/min per 1.73 m(2); P = 0.025). An increase in proteinuria was observed at 36 months versus baseline (+0.11 g/24 h; P < 0.001). Acute rejection rates were low during the study. CONCLUSIONS Conversion from BID-TAC to QD-TAC in a large cohort of stable KTR was safe and associated with a very stable renal function after 3 years. Comparative studies are warranted to assess the feasibility of such conversion.
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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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Limited sampling strategy for prolonged-release tacrolimus in renal transplant patients by use of the dried blood spot technique. Eur J Clin Pharmacol 2015; 71:811-6. [PMID: 25980838 PMCID: PMC4464598 DOI: 10.1007/s00228-015-1863-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Accepted: 05/05/2015] [Indexed: 11/15/2022]
Abstract
Purpose The aim of this study was to develop a clinically applicable limited sampling strategy for ambulatory Caucasian kidney transplant patients to estimate area under the curve in a 24-h period (AUC0–24) of prolonged-release tacrolimus. Methods Twenty six kidney recipients, at least 6 months after transplantation, receiving prolonged-release tacrolimus, were enrolled. In each patient, seven blood samples were collected during a period of 24 h by use of the validated dried blood spot method. Best subset selection multiple linear regression was performed to derive limited sampling strategy (LSS). The equations were constrained to include a maximum of three samples collected within 4 h after the intake to maintain clinical applicability. To assess the predictive performance of LSS, residuals for each patient were calculated based on models fitted to a dataset where that patient was omitted. Results The prediction formula for the AUC0–24 using the time points 0, 2, and 4 h after ingestion (C0h-C2h-C4h) provided the highest correlation with the AUC0–24 (r2 = 0.95): AUC0–24 = 44.9 + 8.9 × C0h + 2.1 × C2h + 7.6 × C4h. Measures for bias and precision, i.e., median percentage prediction error (MPPE) and median absolute prediction error (MAPE), were 0.4 and 4.8 %, respectively. For the same patients, the correlation between C24h and AUC0–24 was worse (r2 = 0.77) while MPPE and MAPE were 6.2 and 7.2 %, respectively. Conclusion In the outpatient department, a LSS using C0h-C2h-C4h can be used for reliable estimation of the AUC0–24 of prolonged-release tacrolimus. Electronic supplementary material The online version of this article (doi:10.1007/s00228-015-1863-6) contains supplementary material, which is available to authorized users.
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Impact of Conversion From Advagraf to Twice-Daily Generic Tacrolimus in Kidney Transplant Recipients: A Single-Center Study. Transplant Proc 2015; 47:911-3. [DOI: 10.1016/j.transproceed.2015.03.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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