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Barriga-Rodríguez P, Falcón-Cubillo M, Mejías-Trueba M, Ciudad-Gutiérrez P, Guisado-Gil AB, Gómez-Bravo MÁ, Porras-López M, Gil-Navarro MV, Herrera-Hidalgo L. Pharmacokinetics of Different Tacrolimus Formulations in the Early Post-Liver Transplant Period: A Scoping Review. Pharmaceutics 2025; 17:619. [PMID: 40430910 PMCID: PMC12114635 DOI: 10.3390/pharmaceutics17050619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2025] [Revised: 04/30/2025] [Accepted: 05/02/2025] [Indexed: 05/29/2025] Open
Abstract
Background: Tacrolimus (TAC) is the cornerstone of immunosuppression after liver transplantation (LT). TAC has a narrow therapeutic index and high inter- and intra-individual pharmacokinetic (PK) variability, requiring dose individualization. This variability is more noticeable in the early post-LT period. Objectives: This study aimed to compare the PK of different TAC formulations in the early post-LT period and describe the main PK characteristics and plasma levels obtained with each TAC formulation used. Methods: The search was conducted in MEDLINE (PubMed) and EMBASE in accordance with PRISMA-ScR guidelines. The main inclusion criteria were clinical trials and observational studies focusing on the PK parameters of TAC in LT recipients during the first month post-transplant. Results: A total of 2169 articles were identified, of which 23 met the inclusion criteria. Various PK parameters were analyzed after LT for the different TAC formulations: intravenous (iv) and oral forms, such as immediate-release (IRT), prolonged-release (PRT), and extended-release (LCPT) formulations. PK variability was higher in the initial days after LT, with different TAC exposure between formulations. IV TAC allows the rapid attainment of therapeutic levels, but it has fallen into disuse. Regarding oral formulations, IRT reaches target levels faster than PRT and LCPT. PRT and LCPT exposure seem more stable during the first month post-LT than when using IRT. Conclusions: TAC formulations exhibit relevant differences in their PK profile in the early post-LT period. PK differences might influence the dose regimen and the time to achieve PK targets. Given these variations, therapeutic drug monitoring (TDM) is essential for optimizing treatment.
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Affiliation(s)
- Paloma Barriga-Rodríguez
- Department of Pharmacy, Virgen del Rocío University Hospital, 41013 Seville, Spain; (P.B.-R.); (M.F.-C.); (P.C.-G.); (A.B.G.-G.); (M.V.G.-N.); (L.H.-H.)
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital, Consejo Superior de Investigaciones Científicas (CSIC), University of Seville, 41013 Seville, Spain
| | - Marta Falcón-Cubillo
- Department of Pharmacy, Virgen del Rocío University Hospital, 41013 Seville, Spain; (P.B.-R.); (M.F.-C.); (P.C.-G.); (A.B.G.-G.); (M.V.G.-N.); (L.H.-H.)
| | - Marta Mejías-Trueba
- Department of Pharmacy, Virgen del Rocío University Hospital, 41013 Seville, Spain; (P.B.-R.); (M.F.-C.); (P.C.-G.); (A.B.G.-G.); (M.V.G.-N.); (L.H.-H.)
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital, Consejo Superior de Investigaciones Científicas (CSIC), University of Seville, 41013 Seville, Spain
| | - Pablo Ciudad-Gutiérrez
- Department of Pharmacy, Virgen del Rocío University Hospital, 41013 Seville, Spain; (P.B.-R.); (M.F.-C.); (P.C.-G.); (A.B.G.-G.); (M.V.G.-N.); (L.H.-H.)
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital, Consejo Superior de Investigaciones Científicas (CSIC), University of Seville, 41013 Seville, Spain
| | - Ana Belén Guisado-Gil
- Department of Pharmacy, Virgen del Rocío University Hospital, 41013 Seville, Spain; (P.B.-R.); (M.F.-C.); (P.C.-G.); (A.B.G.-G.); (M.V.G.-N.); (L.H.-H.)
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital, Consejo Superior de Investigaciones Científicas (CSIC), University of Seville, 41013 Seville, Spain
| | - Miguel Ángel Gómez-Bravo
- Department of Hepatobiliary-Pancreatic Surgery, General and Digestive Surgery Service, Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital, Consejo Superior de Investigaciones Científicas (CSIC), University of Seville, 41013 Seville, Spain;
| | - Manuel Porras-López
- Department of Intensive Care, Virgen del Rocío University Hospital, 41013 Seville, Spain;
| | - María Victoria Gil-Navarro
- Department of Pharmacy, Virgen del Rocío University Hospital, 41013 Seville, Spain; (P.B.-R.); (M.F.-C.); (P.C.-G.); (A.B.G.-G.); (M.V.G.-N.); (L.H.-H.)
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital, Consejo Superior de Investigaciones Científicas (CSIC), University of Seville, 41013 Seville, Spain
| | - Laura Herrera-Hidalgo
- Department of Pharmacy, Virgen del Rocío University Hospital, 41013 Seville, Spain; (P.B.-R.); (M.F.-C.); (P.C.-G.); (A.B.G.-G.); (M.V.G.-N.); (L.H.-H.)
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital, Consejo Superior de Investigaciones Científicas (CSIC), University of Seville, 41013 Seville, Spain
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Arnol M, Naumovic R, Dimitrov EP, Racki S, Bucsa CA, Covic A, Mitic I, Vavic N, Radovanovic RMV, Zibar L, Bizilj S, Erculj V, Missoni TS, Stupica KT, Knotek M. Immunosuppressive regimens following kidney transplantation in five European countries: The observational RECORD study. TRANSPLANTATION REPORTS 2020. [DOI: 10.1016/j.tpr.2020.100061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Undre N, Baccarani U, Britz R, Popescu I. Pharmacokinetic Profile of Prolonged-Release Tacrolimus When Administered via Nasogastric Tube in De Novo Liver Transplantation: A Sub-Study of the DIAMOND Trial. Ann Transplant 2019; 24:268-272. [PMID: 31086126 PMCID: PMC6534968 DOI: 10.12659/aot.909693] [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: 11/24/2022] Open
Abstract
Background For patients unable to swallow during the immediate post-transplant period, immunosuppressant therapy may be initiated by administering prolonged-release tacrolimus as a suspension via a nasogastric tube. Material/Methods In this sub-study of the DIAMOND randomized controlled trial of prolonged-release tacrolimus in de novo liver transplant recipients, we investigated the pharmacokinetic (PK) profile of prolonged-release tacrolimus when administered via nasogastric tube immediately post-transplant. PK analyses were performed on whole-blood samples collected on Day 1 of tacrolimus administration and on Day 3 post-transplantation. Endpoints included AUC0–24, Cmax, Tmax, and Cmin. Results In total, 10 patients were included in the PK sub-study. The overall mean daily dose of prolonged-release tacrolimus administered via nasogastric tube was higher on Day 1 (0.179 mg/kg) vs. Day 3 (0.140 mg/kg). Mean AUC0–24 was higher and less variable on Day 3 vs. Day 1 (AUC0–24 (coefficient of variation; CV): 301 (50.8) vs. 193 (94.5) ng·h/mL). Mean Cmax was lower and median Tmax was shorter on Day 1 vs. Day 3 (Cmax (CV): 15.1 (73.9) vs. 19.1 (47.9) ng/mL; Tmax (range): 2.0 (2.0–24.0) vs. 4.5 (0.5–24.0) h). A similar pattern was also observed when data were normalized for dose and body weight. Conclusions In contrast to previously reported findings in healthy volunteers, nasogastric administration of prolonged-release tacrolimus suspension in liver transplant patients did not substantially affect the PK profile of tacrolimus vs. intact capsules. Nasogastric administration is thus a feasible option to ensure appropriate early tacrolimus exposure in de novo liver transplant recipients.
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Affiliation(s)
- Nasrullah Undre
- Medical Affairs, Astellas Pharma Global Development inc., Chertsey, United Kingdom
| | - Umberto Baccarani
- Liver Transplant Unit, Department of Medicine, University of Udine, Udine, Italy
| | - Russel Britz
- Department of Transplant Surgery, Wits University Donald Gordon Medical Centre, Johannesburg, South Africa
| | - Irinel Popescu
- Center of General Surgery and Liver Transplantation, Fundeni Clinical Institute, Bucharest, Romania
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Guo T, Lei J, Gao J, Li Z, Liu Z. The hepatic protective effects of tacrolimus as a rinse solution in liver transplantation: A meta-analysis. Medicine (Baltimore) 2019; 98:e15809. [PMID: 31124980 PMCID: PMC6571202 DOI: 10.1097/md.0000000000015809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Tacrolimus was used as a rinse solution against ischaemia-reperfusion injury (IRI) in liver transplantation for years but its protective effects remain controversies. METHODS We conducted literature retrieval in electronic databases including MEDLINE, EMBASE and Cochrane Central to identify relevant randomized controlled trials (RCTs) investigating the effects of tacrolimus as a rinse solution in liver transplantation. Postoperative liver function, including alanine aminotransferase (ALT), aspartate aminotransferase (AST) and total bilirubin (TBIL), at postoperative day (POD) 1, 2 and 7 was extracted for pooled estimation. Forest plots were generated to calculate the differences between the groups. The I2 index statistic was used to assess heterogeneity. Publication bias was evaluated using funnel plots and Egger's test. RESULTS Three RCTs including 70 liver transplants were evaluated in this study. Pooled estimation revealed that rinse with tacrolimus in liver transplantation did not provide hepatic protection with respect to postoperative ALT (Test Z = 1.36; P = .175), AST (Test Z = 1.70; P = .090) or TBIL (Test Z = 0.69; P = .490). Sensitivity analysis by excluding extended donor criteria (EDC) livers showed similar results. Funnel plots and Egger's test demonstrated that there was no substantial bias. CONCLUSION We may tentatively conclude that tacrolimus is ineffective for amelioration of postoperative liver function as a rinse solution in liver transplantation. Nevertheless, there is great space for future research in this area, and the potential clinical value of tacrolimus needs to be further addressed. We are expecting more evidence to support our speculations.
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Affiliation(s)
- Tao Guo
- Department of Hepatobiliary and Pancreatic Surgery, Department of General Surgery
| | - Junhao Lei
- Department of Urology Surgery, Zhongnan Hospital of Wuhan University, Wuhan
| | - Jiamin Gao
- Department of Emergency, Huashan Hospital, Fudan University, Shanghai, P.R. China
| | - Zhen Li
- Department of Hepatobiliary and Pancreatic Surgery, Department of General Surgery
| | - Zhisu Liu
- Department of Hepatobiliary and Pancreatic Surgery, Department of General Surgery
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Allard M, Puszkiel A, Conti F, Chevillard L, Kamar N, Noé G, White-Koning M, Thomas-Schoemann A, Simon T, Vidal M, Calmus Y, Blanchet B. Pharmacokinetics and Pharmacodynamics of Once-daily Prolonged-release Tacrolimus in Liver Transplant Recipients. Clin Ther 2019; 41:882-896.e3. [DOI: 10.1016/j.clinthera.2019.03.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 02/28/2019] [Accepted: 03/10/2019] [Indexed: 01/26/2023]
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Vondrak K, Dhawan A, Parisi F, Grenda R, Debray D, Marks SD, Webb NJA, Lachaux A, Kazeem G, Undre N. Comparative pharmacokinetics of tacrolimus in de novo pediatric transplant recipients randomized to receive immediate- or prolonged-release tacrolimus. Pediatr Transplant 2018; 22:e13289. [PMID: 30358019 DOI: 10.1111/petr.13289] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 07/27/2018] [Accepted: 08/13/2018] [Indexed: 11/29/2022]
Abstract
Phase 2, parallel-group, multicenter, open-label, 4-week study, comparing PK of PR-T vs IR-T in de novo pediatric patients undergoing primary kidney, liver, or heart transplantation. Patients randomized 1:1 to receive once daily, PR-T-, or twice-daily, IR-T-based regimens; dose adjustments permitted after Day 1. Twenty-four-hour PK profiles collected on Days 1, 7, and 28. Primary endpoint: tacrolimus AUC24 . Secondary end points included tacrolimus C24 and Cmax . Endpoints compared between PR-T and IR-T on Days 1, 7, and 28. Predefined similarity interval for CIs of LSM ratios: 80%-125%. PK analysis set comprised 33 patients (PR-T, n = 15; IR-T, n = 18). Overall, AUC24 and Cmax were lower on Day 1 vs 7 and 28. Geometric LSM ratios of PR-T:IR-T on Days 1, 7, and 28 were 66.3%, 92.5%, 99.9%, respectively, for AUC24 ; 66.3%, 82.2%, 90.9% for C24 ; and 77.3%, 120.3%, 92.2% for Cmax . AUC24 90% CI within predefined similarity interval on Day 28; other 90% CIs fell outside. Linear relationship was similar between AUC24 and C24 , and between tacrolimus formulations, suggesting that the same therapeutic drug monitoring method can be used with both formulations in de novo pediatric allograft recipients.
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Affiliation(s)
- Karel Vondrak
- Department of Pediatrics, University Hospital Motol, Second School of Medicine, Charles University, Prague, Czech Republic
| | - Anil Dhawan
- Paediatric Liver GI and Nutrition Center, King's College Hospital, London, UK
| | - Francesco Parisi
- Department of Pediatric Cardiology and Cardiac Surgery, Thoracic Transplant Unit, Osp Pediatrico Bambino Gesù, Rome, Italy
| | - Ryszard Grenda
- Department of Nephrology and Kidney Transplantation, The Children's Memorial Health Institute, Warsaw, Poland
| | - Dominique Debray
- Pediatric Hepatology Unit, APHP-Hôpital Universitaire Necker-Enfants Malades, Paris, France
| | - Stephen D Marks
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Nicholas J A Webb
- Department of Paediatric Nephrology, Royal Manchester Children's Hospital, Manchester University Foundation Trust, Manchester, UK
| | - Alain Lachaux
- Service d'Hépatologie Pédiatrique, Université Lyon 1 et Hospices Civils de Lyon, HFME, Bron Cedex, France
| | - Gbenga Kazeem
- Astellas Pharma Europe Ltd, Chertsey, UK.,BENKAZ Consulting Ltd, Cambridge, UK
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Shin MH, Song GW, Lee SG, Hwang S, Kim KH, Ahn CS, Moon DB, Ha TY, Jung DH, Park GC, Yun YI, Kim WJ, Kang WH, Kim SH, Jiang H, Lee S, Tak EY. Once-daily, prolonged-release tacrolimus vs twice-daily, immediate-release tacrolimus in de novo living-donor liver transplantation: A Phase 4, randomized, open-label, comparative, single-center study. Clin Transplant 2018; 32:e13376. [PMID: 30098071 DOI: 10.1111/ctr.13376] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 07/15/2018] [Accepted: 07/28/2018] [Indexed: 11/27/2022]
Abstract
Randomized, open-label, comparative, single-center, Phase 4, 24-week study comparing pharmacokinetics (PK), safety, and efficacy of once-daily, prolonged-release tacrolimus (PR-T) with twice-daily, immediate-release tacrolimus (IR-T) in adult de novo living-donor liver transplant (LDLT) recipients in Korea. All patients received intravenous tacrolimus from Day 0 (transplantation) for 4 days and were randomized (1:1) to receive oral PR-T or IR-T from Day 5. PK profiles were taken on Days 6 and 21. Primary endpoint: area under the concentration-time curve over 24 hour (AUC0-24 ). Predefined similarity interval for confidence intervals of ratios: 80%-125%. Secondary endpoints included: tacrolimus concentration at 24 hour (C24 ), patient/graft survival, biopsy-confirmed acute rejection (BCAR), treatment-emergent adverse events (TEAEs). One-hundred patients were included (PR-T, n = 50; IR-T, n = 50). Compared with IR-T, 40% and 66% higher mean PR-T daily doses resulted in similar AUC0-24 between formulations on Day 6 (PR-T:IR-T ratio of means 96.8%), and numerically higher AUC0-24 with PR-T on Day 21 (128.8%), respectively. Linear relationship was similar between AUC0-24 and C24 , and formulations. No graft loss/deaths, incidence of BCAR and TEAEs similar between formulations. Higher PR-T vs IR-T doses were required to achieve comparable systemic exposure in Korean de novo LDLT recipients. PR-T was efficacious; no new safety signals were detected.
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Affiliation(s)
- Min-Ho Shin
- Division of Hepatobiliary Pancreatic Surgery and Transplantation, Department of Surgery, Chosun University College of Medicine, Gwangju, Korea
| | - Gi-Won Song
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Gyu Lee
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Shin Hwang
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ki-Hun Kim
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chul-Soo Ahn
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Deok-Bog Moon
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae-Yong Ha
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong-Hwan Jung
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gil-Chun Park
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young-In Yun
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Wan-Jun Kim
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Woo-Hyoung Kang
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seok-Hwan Kim
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hongsi Jiang
- Medical Affairs Asia Oceania, Astellas Pharma, Inc., Singapore City, Singapore
| | - Sungmin Lee
- Medical Affairs, Astellas Pharma Korea, Inc., Seoul, Korea
| | - Eun-Young Tak
- Asan Institute for Life Sciences, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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