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Kamińska D, Hożejowski R, Chamienia A, Dębska-Ślizień A, Idasiak-Piechocka I, Oko A, Baranowicz-Gąszczyk I, Załuska W, Mazanowska O, Krajewska M. Conversion From Immediate-Release to Prolonged-Release Tacrolimus in Kidney Transplant Patients With Tremor: A Case Series Study. Transplant Proc 2024; 56:776-780. [PMID: 38453593 DOI: 10.1016/j.transproceed.2024.01.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Accepted: 01/23/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND/AIM Tremor is common with tacrolimus treatment and is linked with peak blood drug concentrations. We investigated the effect of switching from immediate-release tacrolimus (IR-TAC) to MeltDose prolonged-release tacrolimus (LCPT) on tremor in kidney transplant recipients experiencing tremor at therapeutic levels of IR-TAC. METHODS The Activities of Daily Living Subscale (ADL, range 0-48, lower = better) of the Essential Tremor Rating Scale was used to assess the effect of therapy change on speech, occupational impairment and social activities over a 12-month follow-up period. RESULTS The study included 18 patients (mean age = 45.6 y, range 26-73; median (IQR) time from transplant = 1.1 y (0.6-1.5), with baseline IR-TAC trough concentrations (C0) ranging from 4.2 to 9.4 ng/mL (mean C0 = 6.7 ± 1.3 ng/mL). After the switch to LCPT, the mean ADL score improved from baseline 11.2 to 8.4 after 7 to 14 days (an 18% improvement, P < .001). This improvement was sustained after 3 months (ADL score = 5.0, 46% improvement vs baseline), 6 months (ADL score = 4.4, 48% improvement vs baseline), and 12 months (ADL score = 3.6, 63% improvement vs baseline); all P < .001. Despite a 40% reduction in LCPT daily doses (mean -1.9 mg/day compared to IR-TAC), the achieved C0 was constant during the course of the 12-month observation (P = .755). The renal function remained stable after conversion (eGFR 12 months vs baseline = +1.1 mL/min/1.73 m2, 95% CI: -5.6 to +7.9). CONCLUSION Conversion to LCPT may alleviate symptom burden and improve daily activities in kidney transplant recipients experiencing tremor within therapeutic IR-TAC concentrations.
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Affiliation(s)
- Dorota Kamińska
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wroclaw, Poland.
| | | | - Andrzej Chamienia
- Department of Nephrology, Transplantology and Internal Diseases, Faculty of Medicine, Medical University of Gdansk, Gdansk, Poland
| | - Alicja Dębska-Ślizień
- Department of Nephrology, Transplantology and Internal Diseases, Faculty of Medicine, Medical University of Gdansk, Gdansk, Poland
| | - Ilona Idasiak-Piechocka
- Department of Nephrology, Transplantology and Internal Diseases, Poznan University of Medical Sciences, Poznan, Poland
| | - Andrzej Oko
- Department of Nephrology, Transplantology and Internal Diseases, Poznan University of Medical Sciences, Poznan, Poland
| | | | - Wojciech Załuska
- Department of Nephrology, Medical University of Lublin, Lublin, 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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Karaterzi S, Tönshoff B, Ahlenstiel-Grunow T, Baghai M, Beck B, Büscher A, Eifler L, Giese T, Lezius S, Müller C, Oh J, Zapf A, Weber LT, Pape L. A multi-center interventional study to assess pharmacokinetics, effectiveness, and tolerability of prolonged-release tacrolimus after pediatric kidney transplantation: study protocol for a prospective, open-label, randomized, two-phase, two-sequence, single dose, crossover, phase III b trial. FRONTIERS IN NEPHROLOGY 2024; 4:1331510. [PMID: 38444519 PMCID: PMC10912931 DOI: 10.3389/fneph.2024.1331510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 01/25/2024] [Indexed: 03/07/2024]
Abstract
Background Tacrolimus, a calcineurin inhibitor (CNI), is currently the first-line immunosuppressive agent in kidney transplantation. The therapeutic index of tacrolimus is narrow due to due to the substantial impact of minor variations in drug concentration or exposure on clinical outcomes (i.e., nephrotoxicity), and it has a highly variable intra- and inter-individual bioavailability. Non-adherence to immunosuppressants is associated with rejection after kidney transplantation, which is the main cause of long-term graft loss. Once-daily formulations have been shown to significantly improve adherence compared to twice-daily dosing. Envarsus®, the once-daily prolonged-release formulation of tacrolimus, offers the same therapeutic efficacy as the conventional twice-daily immediate-release tacrolimus formulation (Prograf®) with improved bioavailability, a more consistent pharmacokinetic profile, and a reduced peak to trough, which may reduce CNI-related toxicity. Envarsus® has been approved as an immunosuppressive therapy in adults following kidney or liver transplantation but has not yet been approved in children. The objective of this study is to evaluate the pharmacokinetic profile, efficacy, and tolerability of Envarsus® in children and adolescents aged ≥ 8 and ≤ 18 years to assess its potential role as an additional option for immunosuppressive therapy in children after kidney transplantation. Methods/design The study is designed as a randomized, prospective crossover trial. Each patient undergoes two treatment sequences: sequence 1 includes 4 weeks of Envarsus® and sequence 2 includes 4 weeks of Prograf®. Patients are randomized to either group A (sequence 1, followed by sequence 2) or group B (sequence 2, followed by sequence 1). The primary objective is to assess equivalency between total exposure (of tacrolimus area under the curve concentration (AUC0-24)), immediate-release tacrolimus (Prograf®) therapy, and prolonged-release tacrolimus (Envarsus®) using a daily dose conversion factor of 0.7 for prolonged- versus immediate-release tacrolimus. Secondary objectives are the assessment of pharmacodynamics, pharmacogenetics, adherence, gut microbiome analyses, adverse events (including tacrolimus toxicity and biopsy-proven rejections), biopsy-proven rejections, difference in estimated glomerular filtration rate (eGFR), and occurrence of donor-specific antibodies (DSAs). Discussion This study will test the hypothesis that once-daily prolonged-release tacrolimus (Envarsus®) is bioequivalent to twice-daily intermediate-release tacrolimus after pediatric kidney transplantation and may reduce toxicity and facilitate medication adherence. This novel concept may optimize immunosuppressive therapy for more stable graft function and increased graft survival by avoiding T-cell mediated and/or antibody-mediated rejection due to improved adherence. In addition, the study will provide data on the pharmacodynamics and pharmacogenetics of prolonged-release tacrolimus in children and adolescents. Clinical Trial Registration EUDRA-CT 2019-003710-13 and ClinicalTrial.gov, identifier NCT06057545.
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Affiliation(s)
- Sinem Karaterzi
- Department of Pediatrics II, University Hospital of Essen, Essen, Germany
| | - Burkhard Tönshoff
- Department of Pediatrics I, University Children’s Hospital Heidelberg, Heidelberg, Germany
| | | | - Maral Baghai
- Department of Pediatrics I, University Children’s Hospital Heidelberg, Heidelberg, Germany
- Structural and Computational Biology Unit, European Molecular Biology Laboratory, Heidelberg, Germany
| | - Bodo Beck
- Institute of Human Genetics, University Hospital of Cologne, Cologne, Germany
| | - Anja Büscher
- Department of Pediatrics II, University Hospital of Essen, Essen, Germany
| | - Lisa Eifler
- Children’s and Adolescents’ Hospital, Pediatric Nephrology, University Hospital of Cologne, Cologne, Germany
| | - Thomas Giese
- Department of Immunology, University Hospital Heidelberg, Heidelberg, Germany
| | - Susanne Lezius
- Institute of Medical Biometry and Epidemiology, University Hospital Eppendorf, Hamburg, Germany
| | - Carsten Müller
- Pharmacology at the Laboratory Diagnostics Centre, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Jun Oh
- Department of Pediatric Nephrology and Gastroenterology, University Hospital Eppendorf, Hamburg, Germany
| | - Antonia Zapf
- Institute of Medical Biometry and Epidemiology, University Hospital Eppendorf, Hamburg, Germany
| | - Lutz T. Weber
- Children’s and Adolescents’ Hospital, Pediatric Nephrology, University Hospital of Cologne, Cologne, Germany
| | - Lars Pape
- Department of Pediatrics II, University Hospital of Essen, Essen, Germany
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King CP, Cossart AR, Isbel NM, Campbell SB, Staatz CE. The association between tacrolimus exposure and tremor, headache and insomnia in adult kidney transplant recipients: A systematic review. Transplant Rev (Orlando) 2024; 38:100815. [PMID: 38071930 DOI: 10.1016/j.trre.2023.100815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 11/28/2023] [Accepted: 11/30/2023] [Indexed: 01/08/2024]
Abstract
PURPOSE Tremor, headache and insomnia have been linked to the immunosuppressant, tacrolimus. The aim of this systematic review was to determine if there is a correlation between tacrolimus exposure and new-onset tremor, headache and insomnia experienced by adult kidney transplant recipients. METHODS PubMed, Embase, Cochrane Library and CINAHL databases were searched up to 11 April 2023 for published studies which reported on tacrolimus exposure in adult kidney transplant recipients, alongside information on treatment-emergent neurologic manifestations, including tremor, headache and insomnia. Review articles, case studies, conference abstracts and articles not published in English in peer-reviewed journals were excluded. The Physiotherapy Evidence Database and Newcastle-Ottawa Quality Assessment Scales were used to assess risk of bias. Extracted data was analysed via a narrative synthesis. RESULTS Eighteen studies involving 4030 patients in total were included in the final analysis. These comprised five randomised control trials and thirteen observational studies. Studies failed to find significant association between tacrolimus trough concentrations in whole blood and the incidence of neurologic side effects such as tremor, headache and insomnia; however, in one study the incidence of toxicity requiring a dose reduction increased with increasing, supratherapeutic targeted levels. Females, especially Black females, and older age were positively associated with the prevalence of neurologic adverse effects. Results were conflicting regarding whether extended-release formulations were associated with fewer neurologic complications than immediate-release formulations. CONCLUSION The varied study designs and criteria for reporting tremor, headache and insomnia impacted on the quality of the data for exploring the relationship between tacrolimus exposure and the onset of neurologic manifestations experienced after kidney transplantation. Studies that examine defined neurologic complications as the primary outcome, and that consider novel markers of tacrolimus exposure while assessing the potential contribution of multiple covariate factors, are required.
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Affiliation(s)
- Catherine P King
- School of Pharmacy, The University of Queensland, Brisbane, QLD, Australia.
| | - Amelia R Cossart
- School of Pharmacy, The University of Queensland, Brisbane, QLD, Australia
| | - Nicole M Isbel
- Department of Nephrology, The Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Scott B Campbell
- Department of Nephrology, The Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Christine E Staatz
- School of Pharmacy, The University of Queensland, Brisbane, QLD, Australia
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Wagle Shukla A, Lunny C, Mahboob O, Khalid U, Joyce M, Jha N, Nagaraja N, Shukla AM. Tremor Induced by Cyclosporine, Tacrolimus, Sirolimus, or Everolimus: A Review of the Literature. Drugs R D 2023; 23:301-329. [PMID: 37606750 PMCID: PMC10676343 DOI: 10.1007/s40268-023-00428-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2023] [Indexed: 08/23/2023] Open
Abstract
Calcineurin inhibitors such as cyclosporine and tacrolimus are immunosuppressant drugs that are known to induce tremors. Non-calcineurin inhibitors such as sirolimus and everolimus have also reportedly been accompanied by tremors, albeit less likely. However, the prevalence rates reported in the literature are notably wide, and the risk profiles for these drug-induced tremors are less understood. We searched PubMed to extract data on the risk of tremors with these drugs when prescribed for various transplant and non-transplant indications. We ascertained whether the risk of drug-induced tremor is influenced by the underlying diagnosis, dosing formulations, drug concentrations, and blood monitoring. We extracted data on treatment strategies and outcomes for tremors. Articles were primarily screened based on English language publications, abstracts, and studies with n ≥ 5, which included case series, retrospective studies, case-controlled studies, and prospective studies. We found 81 eligible studies comprising 33 cyclosporine, 43 tacrolimus, 6 sirolimus, and 1 everolimus that discussed tremor as an adverse event. In the pooled analysis of studies with n > 100, the incidence of tremor was 17% with cyclosporine, 21.5% with tacrolimus, and 7.8% with sirolimus and everolimus together. Regarding the underlying diagnosis, tremor was more frequently reported in kidney transplant (cyclosporine 28%, tacrolimus 30.1%) and bone marrow transplant (cyclosporine 40%, tacrolimus 41.9%) patients compared with liver transplant (cyclosporine 9%, tacrolimus 11.5%) and nontransplant indications (cyclosporine 21.5%, tacrolimus 11.3%). Most studies did not report whether the risk of tremors correlated with drug concentrations in the blood. The prevalence of tremors when using the twice-daily formulation of tacrolimus was nearly the same as the once-daily formulation (17% vs 18%). Data on individual-level risk factors for tremors were lacking. Except for three studies that found some benefit to maintaining magnesium levels, there were minimal data on treatments and outcomes. A large body of data supports a substantive and wide prevalence of tremor resulting from tacrolimus use followed by cyclosporine, especially in patients receiving a kidney transplant. However, there is little reporting on the patient-related risk factors for tremor, risk relationship with drug concentrations, treatment strategies, and outcomes.
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Affiliation(s)
- Aparna Wagle Shukla
- Department of Neurology, Fixel Institute for Neurological Diseases, University of Florida, Fixel Institute for Neurological Disorders, 3009 Williston Road, Gainesville, FL, 32608, USA.
| | - Caroline Lunny
- Department of Neurology, Fixel Institute for Neurological Diseases, University of Florida, Fixel Institute for Neurological Disorders, 3009 Williston Road, Gainesville, FL, 32608, USA
| | - Omar Mahboob
- Florida State University Medical School, Tallahassee, FL, USA
| | - Uzair Khalid
- University of Toronto Medical School, Toronto, ON, Canada
| | - Malea Joyce
- North Florida South Georgia Veteran Healthcare System, Gainesville, FL, USA
| | - Nivedita Jha
- Department of Neurology, Tower Health, Reading Hospital, Reading, PA, USA
| | - Nandakumar Nagaraja
- Department of Neurology, Penn State University College of Medicine, Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Ashutosh M Shukla
- North Florida South Georgia Veteran Healthcare System, Gainesville, FL, USA
- Division of Nephrology, Department of Medicine, University of Florida, Gainesville, FL, USA
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Henkel L, Jehn U, Thölking G, Reuter S. Tacrolimus-why pharmacokinetics matter in the clinic. FRONTIERS IN TRANSPLANTATION 2023; 2:1160752. [PMID: 38993881 PMCID: PMC11235362 DOI: 10.3389/frtra.2023.1160752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 08/07/2023] [Indexed: 07/13/2024]
Abstract
The calcineurin inhibitor (CNI) Tacrolimus (Tac) is the most prescribed immunosuppressant drug after solid organ transplantation. After renal transplantation (RTx) approximately 95% of recipients are discharged with a Tac-based immunosuppressive regime. Despite the high immunosuppressive efficacy, its adverse effects, narrow therapeutic window and high intra- and interpatient variability (IPV) in pharmacokinetics require therapeutic drug monitoring (TDM), which makes treatment with Tac a major challenge for physicians. The C/D ratio (full blood trough level normalized by daily dose) is able to classify patients receiving Tac into two major metabolism groups, which were significantly associated with the clinical outcomes of patients after renal or liver transplantation. Therefore, the C/D ratio is a simple but effective tool to identify patients at risk of an unfavorable outcome. This review highlights the challenges of Tac-based immunosuppressive therapy faced by transplant physicians in their daily routine, the underlying causes and pharmacokinetics (including genetics, interactions, and differences between available Tac formulations), and the latest data on potential solutions to optimize treatment of high-risk patients.
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Affiliation(s)
- Lino Henkel
- Department of Medicine D, University of Münster, Münster, Germany
| | - Ulrich Jehn
- Department of Medicine D, University of Münster, Münster, Germany
| | - Gerold Thölking
- Department of Medicine D, University of Münster, Münster, Germany
- Department of Internal Medicine and Nephrology, University Hospital of Münster Marienhospital Steinfurt, Steinfurt, Germany
| | - Stefan Reuter
- Department of Medicine D, University of Münster, Münster, Germany
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Wöhl DS, James B, Götz M, Brennfleck F, Holub-Hayles I, Mutzbauer I, Baccar S, Brunner SM, Geissler EK, Schlitt HJ. EnGraft: a multicentre, open-label, randomised, two-arm, superiority study protocol to assess bioavailability and practicability of Envarsus® versus Advagraf™ in liver transplant recipients. Trials 2023; 24:325. [PMID: 37170284 PMCID: PMC10176804 DOI: 10.1186/s13063-023-07344-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Accepted: 05/02/2023] [Indexed: 05/13/2023] Open
Abstract
BACKGROUND Graft rejection and chronic CNI toxicity remain obstacles to organ transplant success. Current formulations of tacrolimus, such as Prograf® and Advagraf™, exhibit limitations in terms of pharmacokinetics and tolerability, related in part to suboptimal bioavailability. As dosing non-compliance can result in graft rejection, the once daily formulation of tacrolimus, Advagraf™, was developed (vs 2x/day Prograf®). Benefits of Advagraf™ are counterbalanced by delayed achievement of therapeutic trough levels and need for up to 50% higher doses to maintain Prograf®-equivalent troughs. Envarsus® is also a prolonged-release once-daily tacrolimus formulation, developed using MeltDose™ drug-delivery technology to increase drug bioavailability; improved bioavailability results in low patient drug absorption variability and less pronounced peak-to-trough fluctuations. In phase III de novo kidney transplant studies, Envarsus® proved non-inferior to twice-daily tacrolimus; however, no phase IV studies show superiority of Envarsus® vs Advagraf™ in de novo liver transplant (LTx) recipients. METHODS The EnGraft compares bioavailability and tests superiority of Envarsus® (test arm) versus Advagraf™ (comparator arm) in de novo LTx recipients. A total of 268 patients from 15 German transplant centres will be randomised 1:1 within 14 days post-LTx. The primary endpoint is dose-normalised trough level (C/D ratio) measured 12 weeks after randomisation. Secondary endpoints include the number of dose adjustments, time to reach first defined trough level and incidence of graft rejections. Additionally, clinical and laboratory parameters will be assessed over a 3-year period. DISCUSSION C/D ratio is an estimate for tacrolimus bioavailability. Improving bioavailability and increasing C/D ratio using Envarsus could reduce renal dysfunction and other tacrolimus-related toxicities; previous trials have shown that a higher C/D ratio (i.e. slower tacrolimus metabolism) is not only associated with improved renal function but also linked to reduced neurotoxic side effects. A higher C/D ratio could improve clinical outcomes for LTx recipients; EnGraft has begun, with one third of patients recruited by January 2022. TRIAL REGISTRATION This trial has been registered (4 May 2020) in the EU Clinical Trials Register, EudraCT-Nummer: 2020-000796-20. Additionally, this trial has been registered (22 January 2021) at ClinicalTrials.gov: NCT04720326. The trial received a favourable opinion from the concerned lead ethics committee at the University of Regensburg, under the reference 20-1842-112.
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Affiliation(s)
- D S Wöhl
- Department of Surgery, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany.
| | - B James
- coTrial Associates, Department of Surgery, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - M Götz
- Department of Surgery, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - F Brennfleck
- Department of Surgery, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - I Holub-Hayles
- coTrial Associates, Department of Surgery, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - I Mutzbauer
- coTrial Associates, Department of Surgery, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - S Baccar
- coTrial Associates, Department of Surgery, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - S M Brunner
- Department of Surgery, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - E K Geissler
- Department of Surgery, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - H J Schlitt
- Department of Surgery, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
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Czarnecka P, Czarnecka K, Baczkowska T, Lagiewska B, Durlik M. Real-life comparison of efficacy and safety profiles of two prolonged-release tacrolimus formulations in de novo kidney transplant recipients: 24 months of follow-up. PLoS One 2023; 18:e0278894. [PMID: 36662740 PMCID: PMC9858018 DOI: 10.1371/journal.pone.0278894] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 11/23/2022] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION Calcineurin inhibitors constitute a cornerstone of immunosuppressive therapy in kidney transplant recipients. There are two main formulations of tacrolimus (Tac) which exhibit a prolonged-release mode of action: Advagraf® (MR-4) and Envarsus® (LCPT). However, they are not bioequivalent. Data comparing both once-daily prolonged-release formulations of Tac are insufficient. OBJECTIVE The aim of the study was to compare safety and efficacy profiles of once-daily LCPT and MR-4 formulations of tacrolimus in adult kidney transplant recipients. PATIENTS AND METHODS An observational, cohort single-center study was performed. One hundred fifteen kidney transplant recipients transplanted between 2016 and 2019 were enrolled to the study (59 vs 56, Envarsus® vs Advagraf®, respectively). Safety and efficacy profiles were assessed. RESULTS Patient and graft survival at 12 and 24 months did not differ between the groups. There were no significant differences in serum creatinine at any timepoint. C/D ratio in the LCPT group was significantly higher at 12 and 24 months. Sepsis occurrence was more frequent in MR-4 group at 12 months. CONCLUSION Both prolonged-release formulations of tacrolimus are safe and effective in immunosuppressive therapy in kidney transplant recipients.
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Affiliation(s)
- Paulina Czarnecka
- Department of Transplantation Medicine, Nephrology and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Kinga Czarnecka
- Department of Transplantation Medicine, Nephrology and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Teresa Baczkowska
- Department of Transplantation Medicine, Nephrology and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Beata Lagiewska
- Department of General Surgery and Transplantations, Medical University of Warsaw, Warsaw, Poland
| | - Magdalena Durlik
- Department of Transplantation Medicine, Nephrology and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
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Fernandez Rivera C, Calvo Rodríguez M, Poveda JL, Pascual J, Crespo M, Gomez G, Cabello Pelegrin S, Paul J, Lauzurica R, Perez Mir M, Moreso F, Perelló M, Andres A, González E, Fernandez A, Mendiluce A, Fernández Carbajo B, Sanchez Fructuoso A, Calvo N, Suarez A, Bernal Blanco G, Osuna A, Ruiz-Fuentes MC, Melilli E, Montero Perez N, Ramos A, Fernández B, López V, Hernandez D. Bioavailability of once-daily tacrolimus formulations used in clinical practice in the management of De Novo kidney transplant recipients: the better study. Clin Transplant 2021; 36:e14550. [PMID: 34851532 PMCID: PMC9285676 DOI: 10.1111/ctr.14550] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 10/26/2021] [Accepted: 11/13/2021] [Indexed: 12/21/2022]
Abstract
Multicenter, prospective, observational study to compare the relative bioavailability of once‐daily tacrolimus formulations in de novo kidney transplant recipients. De novo kidney transplant recipients who started a tacrolimus‐based regimen were included 14 days post‐transplant and followed up for 6 months. Data from 218 participants were evaluated: 129 in the LCPT group (Envarsus) and 89 in the PR‐Tac (Advagraf) group. Patients in the LCPT group exhibited higher relative bioavailability (Cmin /total daily dose [TDD]) vs. PR‐Tac (61% increase; P < .001) with similar Cmin and 30% lower TDD levels (P < .0001). The incidence of treatment failure was 3.9% in the LCPT group and 9.0% in the PR‐Tac group (P = .117). Study discontinuation rates were 6.2% in the LCPT group and 12.4% in the PR‐Tac group (P = .113). Adverse events, renal function and other complications were comparable between groups. The median accumulated dose of tacrolimus in the LCPT group from day 14 to month 6 was 889 mg. Compared to PR‐Tac, LCPT showed higher relative bioavailability, similar effectiveness at preventing allograft rejection, comparable effect on renal function, safety, adherence, treatment failure and premature discontinuation rates.
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Affiliation(s)
| | | | | | - Julio Pascual
- Nephrology Department, University Hospital del Mar, Barcelona, Spain
| | - Marta Crespo
- Nephrology Department, University Hospital del Mar, Barcelona, Spain
| | - Gonzalo Gomez
- Nephrology Department, University Hospital Son Espases, Palma de Mallorca, Spain
| | | | - Javier Paul
- Nephrology Department, Hospital Miguel Servet, Zaragoza, Spain
| | - Ricardo Lauzurica
- Nephrology Department, University Hospital Germans Trias y Pujol, Badalona, Spain
| | - Mònica Perez Mir
- Nephrology Department, University Hospital Germans Trias y Pujol, Badalona, Spain
| | - Francesc Moreso
- University Hospital Vall d'Hebron, Department of Medicine, Universitat Autònoma de Barcelona, Nephrology Department, Barcelona, Spain
| | - Manel Perelló
- University Hospital Vall d'Hebron, Department of Medicine, Universitat Autònoma de Barcelona, Nephrology Department, Barcelona, Spain
| | - Amado Andres
- Nephrology Department, University Hospital Doce de Octubre, Madrid, Spain
| | - Esther González
- Nephrology Department, University Hospital Doce de Octubre, Madrid, Spain
| | - Ana Fernandez
- Nephrology Department, University Hospital Ramón y Cajal, Madrid, Spain
| | - Alicia Mendiluce
- Nephrology Department, University Hospital Clínico de Valladolid, Valladolid, Spain
| | | | | | - Natividad Calvo
- Nephrology Department, University Hospital Clínico San Carlos, Madrid, Spain
| | - Alejandro Suarez
- Nephrology Department, University Hospital Virgen del Rocio, Sevilla, Spain
| | | | - Antonio Osuna
- Nephrology Department, University Hospital Virgen de las Nieves, Granada, Spain
| | | | - Edoardo Melilli
- Nephrology Department, University Hospital Bellvitge, Hospitalet de Llobregat, Spain
| | - Nuria Montero Perez
- Nephrology Department, University Hospital Bellvitge, Hospitalet de Llobregat, Spain
| | - Ana Ramos
- Nephrology Department, Fundación Jiménez Díaz, Madrid, Spain
| | | | - Verónica López
- University Hospital Regional, Málaga, IBIMA, University of Málaga, REDinREN (RED16/0009/0006), Nephrology Department, Spain
| | - Domingo Hernandez
- University Hospital Regional, Málaga, IBIMA, University of Málaga, REDinREN (RED16/0009/0006), Nephrology Department, Spain
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Del Bello A, Gaible C, Longlune N, Hebral AL, Esposito L, Gandia P, Kamar N. Tacrolimus Intrapatient Variability After Switching From Immediate or Prolonged-Release to Extended-Release Formulation, After an Organ Transplantation. Front Pharmacol 2021; 12:602764. [PMID: 34690747 PMCID: PMC8529208 DOI: 10.3389/fphar.2021.602764] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 07/26/2021] [Indexed: 01/06/2023] Open
Abstract
Background and Purpose: Several formulations of tacrolimus are available, but evidence of the benefit of changing to the most recent formulations is lacking. Tacrolimus intra-patient variability (tacrolimus IPV) is an emerging risk factor associated with poor graft outcomes after solid organ transplantations. Here, we examined the modifications of tacrolimus IPV after switching to a different formulation of tacrolimus. Experimental Approach: We identified 353 solid organ transplant recipients that were switched in our center from immediate-release (IR-tacrolimus) or prolonged-release tacrolimus (PR-tacrolimus) to extended-release, LCP-tacrolimus (LCP-tacrolimus). Among them, 54 patients underwent at least 3 available tacrolimus blood concentrations before and after the switch, allowing us to investigate tacrolimus IPV. Key Results: The switch was considered as a safe procedure since only four of the 353 patients presented a graft rejection after the switch, and no patient was hospitalized for tacrolimus overdose. The tacrolimus IPV estimated by the coefficient of variation (CV-IPV) was stable before and after the switch to LCP-tacrolimus (CV-IPV: 29.0% (IQR 25-75 (15.5; 38.5) before and 24.0% (15.8; 36.5) after the switch, p = 0.65). Conclusion and Implications: Switching from IR- or PR-tacrolimus to LCP-tacrolimus is a safe procedure. However, the CV-tacrolimus IPV was not impacted by the change of formulation.
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Affiliation(s)
- Arnaud Del Bello
- Department of Nephrology and Organ Transplantation, CHU Rangueil, Toulouse, France.,INSERM U1043, IFR-BMT, CHU Purpan, Toulouse, France.,Université Paul Sabatier, Toulouse, France
| | - Clotilde Gaible
- Department of Nephrology and Organ Transplantation, CHU Rangueil, Toulouse, France
| | - Nathalie Longlune
- Department of Nephrology and Organ Transplantation, CHU Rangueil, Toulouse, France
| | - Anne-Laure Hebral
- Department of Nephrology and Organ Transplantation, CHU Rangueil, Toulouse, France
| | - Laure Esposito
- Department of Nephrology and Organ Transplantation, CHU Rangueil, Toulouse, France
| | - Peggy Gandia
- Pharmacokinetics and Toxicology Laboratory, Toulouse University Hospital, Toulouse, France.,INTHERES, INRAE, ENVT, Université de Toulouse, Toulouse, France
| | - Nassim Kamar
- Department of Nephrology and Organ Transplantation, CHU Rangueil, Toulouse, France.,INSERM U1043, IFR-BMT, CHU Purpan, Toulouse, France.,Université Paul Sabatier, Toulouse, France
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10
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Tan T, Bunnapradist S. Comparing the pharmacokinetics of extended-release tacrolimus (LCP-TAC) to immediate-release formulations in kidney transplant patients. Expert Opin Drug Metab Toxicol 2021; 17:1175-1186. [PMID: 34459696 DOI: 10.1080/17425255.2021.1974399] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION One of the most commonly used immunosuppressants in organ transplant, tacrolimus exhibits wide interpatient and intrapatient variability and narrow therapeutic index that necessitates routine concentration monitoring and dosage adjustments. Availability of modified -release tacrolimus products offer once-daily dosing options. The objective of this review is to highlight and compare available pharmacokinetic (PK) data of extended-release tacrolimus tablets (LCP-TAC) to immediate-release tacrolimus (IR-TAC) in kidney transplant recipients. AREAS COVERED A review of the literature was performed using PubMed and Embase search to identify relevant articles evaluating PK data for LCP-TAC compared to IR-TAC in kidney transplant patients including special populations. EXPERT OPINION LCP-TAC's unique PK profile may be more favorable than IR-TAC. While the clinical impact of these PK differences have not been established, several outcomes are being evaluated in ongoing studies. Results of these studies will add information incrementally to care for kidney transplant patients. Larger prospective studies evaluating kidney and patient survival differences are needed but it is unlikely that they will be conducted. Given that the patent exclusivity of LCP-TAC for the next several years and imminent loss of exclusivity of PR-TAC, our opinion is the use of LCP-TAC will be increasing, especially in Europe.
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Affiliation(s)
- Teresa Tan
- Department of Pharmaceutical Services, Ronald Reagan UCLA Medical Center, Los Angeles, CA
| | - Suphamai Bunnapradist
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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11
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Faravardeh A, Akkina S, Villicana R, Guerra G, Moten MA, Meier-Kriesche U, Stevens DR, Patel SJ, Bunnapradist S. Efficacy and Safety of Once-Daily LCP-Tacrolimus Versus Twice-Daily Immediate-Release Tacrolimus in Adult Hispanic Stable Kidney Transplant Recipients: Sub-Group Analysis from a Phase 3 Trial. Ann Transplant 2021; 26:e929535. [PMID: 33859155 PMCID: PMC8056872 DOI: 10.12659/aot.929535] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND The pharmacokinetics and metabolism of tacrolimus, an immunosuppressant commonly used to prevent transplant rejection, can differ in specific subpopulations. This analysis examined treatment outcomes and safety of immediate-release tacrolimus (IR-Tac) and LCP-tacrolimus (LCPT) in stable Hispanic kidney transplant recipients. MATERIAL AND METHODS This was a post hoc analysis of clinical trial data from Hispanic adult stable kidney transplant recipients randomized to remain on IR-Tac or convert from IR-Tac to a reduced dose of LCPT (NCT00817206). Composite treatment failure was evaluated at 12 months. Estimated glomerular filtration rate and tacrolimus trough concentrations were evaluated over 12 months. RESULTS Fifty-five stable (LCPT n=26, IR-Tac n=29) kidney transplant recipients who self-identified as Hispanic or Latino were included in this analysis. Composite treatment failure occurred in 1 patient (4%) who converted to LCPT and 1 (3%) who remained on IR-Tac. The estimated glomerular filtration rate was stable over time and similar in the 2 treatment groups (P=0.08). Tacrolimus trough levels for both groups were similar over time in the 2 treatment groups (P=0.98). Treatment-emergent adverse events were similar in patients who converted to LCPT and in those who remained on IR-Tac. CONCLUSIONS Efficacy and safety were similar in Hispanic kidney transplant recipients who converted from IR-Tac to LCPT and in those remaining on IR-Tac.
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Affiliation(s)
| | - Sanjeev Akkina
- Loyola Outpatient Center, Loyola University Medical Center, Maywood, IL, USA
| | - Rafael Villicana
- Loma Linda University Transplant Institute, Loma Linda University Health, Loma Linda, CA, USA
| | - Giselle Guerra
- Miami Transplant Institute, University of Miami Health System, Miami, FL, USA
| | - Misbah A Moten
- Department of Medical Affairs, Veloxis Pharmaceuticals, Cary, NC, USA
| | | | - Daniel R Stevens
- Department of Medical Affairs, Veloxis Pharmaceuticals, Cary, NC, USA
| | - Samir J Patel
- Department of Medical Affairs, Veloxis Pharmaceuticals, Cary, NC, USA
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12
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Khuroo T, Mohamed EM, Dharani S, Afrooz H, Barakh Ali SF, Cook P, Khan MA, Rahman Z. Coating characterization by hyperspectroscopy and predictive dissolution models of tablets coated with blends of cellulose acetate and cellulose acetate phthalate. AAPS PharmSciTech 2021; 22:122. [PMID: 33811299 DOI: 10.1208/s12249-021-01986-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 03/09/2021] [Indexed: 02/04/2023] Open
Abstract
The objective of current research was to develop the models of dissolution prediction of tablets coated with cellulose acetate (CA 320S or CA 398-10) and cellulose acetate phthalate (C-A-P) blends. Independent variables selected were coating percent (X1) and percent of CA 320S or CA 398-10 (X2) in the blend. Dependent variables selected were dissolution in 1 (Y1), 8 (Y2), and 24 h (Y3). Diclofenac sodium core tablets were coated with blend of either CA 320S and C-A-P or CA 398-10 and C-A-P at approximately 5, 7.5, and 10% weight gain. CA 320S and CA 398-10 content in the corresponding blends varied from 33.3-66.7% and 25.0-50.0% relative to C-A-P, respectively. Dissolution was performed in phosphate buffer 6.8 using USP apparatus 2. Coated tablets were also characterized for surface morphology and coating uniformity by near infrared hyperspectroscopy. Y1, Y2, and Y3 were statistically (p < 0.05) affected by X2 in CA 320S/C-A-P and CA 398-10/C-A-P blends coated tablets. On the other hand, X1 had statistically significant (p < 0.05) effect only on the Y3 in CA 320S/C-A-P while Y1 was statistically (p < 0.05) affected by X2 in CA 398-10/C-A-P. Analysis of variance also indicated statistically significant (p < 0.05) effect of the studied variables on the dependent variables for both the blends. The models were verified by independent experiment. Model predicted and empirical values of Y1, Y2, and Y3 were close with maximum residual of 7.0%. In conclusion, dissolution can be modulated by varying composition of blend, polymer type, and coating weight.
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13
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Faravelli I, Velardo D, Podestà MA, Ponticelli C. Immunosuppression-related neurological disorders in kidney transplantation. J Nephrol 2021; 34:539-555. [PMID: 33481222 PMCID: PMC8036223 DOI: 10.1007/s40620-020-00956-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 12/27/2020] [Indexed: 01/06/2023]
Abstract
A large number of neurological disorders can affect renal transplant recipients, potentially leading to disabling or life-threatening complications. Prevention, early diagnosis and appropriate management of these conditions are critical to avoid irreversible lesions. A pivotal role in the pathogenesis of common post-transplant neurological disorders is played by immunosuppressive therapy. The most frequently administered regimen consists of triple immunosuppression, which comprises a calcineurin inhibitor (CNI), a purine synthesis inhibitor and glucocorticoids. Some of these immunosuppressive drugs may lead to neurological signs and symptoms through direct neurotoxic effects, and all of them may be responsible for the development of tumors or opportunistic infections. In this review, after a brief summary of neurotoxic pathogenetic mechanisms encompassing recent advances in the field, we focus on the clinical presentation of more common and severe immunosuppression-related neurological complications, classifying them by characteristics of urgency and anatomic site. Our goal is to provide a general framework that addresses such clinical issues with a multidisciplinary approach, as these conditions require.
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Affiliation(s)
- Irene Faravelli
- Neuroscience Section, Department of Pathophysiology and Transplantation (DEPT), Dino Ferrari Centre, Università degli Studi di Milano, Milan, Italy.
| | - Daniele Velardo
- Neurology Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Manuel Alfredo Podestà
- Renal Division, ASST Santi Paolo e Carlo, Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
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14
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Willuweit K, Frey A, Hörster A, Saner F, Herzer K. Real-World Administration of Once-Daily MeltDose ® Prolonged-Release Tacrolimus (LCPT) Allows for Dose Reduction of Tacrolimus and Stabilizes Graft Function Following Liver Transplantation. J Clin Med 2020; 10:jcm10010124. [PMID: 33396492 PMCID: PMC7795274 DOI: 10.3390/jcm10010124] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 12/28/2020] [Accepted: 12/28/2020] [Indexed: 01/16/2023] Open
Abstract
The calcineurin inhibitor tacrolimus is included in most immunosuppressive protocols after liver transplantation. This retrospective, observational 24-month study investigated the tolerability of once-daily MeltDose® prolonged-release tacrolimus (LCPT) after switching from twice-daily immediate-release tacrolimus (IR-Tac) in a real-world cohort of 150 patients with previous liver transplantation. No graft rejection or new safety signals were observed. Only 7.3% of patients discontinued LCPT due to side effects. In the overall patient population, median liver transaminases, total cholesterol, triglycerides, glucose, and HbA1c remained constant after switching to LCPT. Total cholesterol significantly decreased (p ≤ 0.002) in patients with initially elevated levels (>200 mg/dL). A total of 71.8% of 96 patients maintained a glomerular filtration rate > 60 mL/min/1.73 m2 throughout the study, while 44.7% of patients were classified as fast metabolizers and 55.3% as slow metabolizers. Median daily tacrolimus dose could be reduced by 50% in fast metabolizers and by 30% in slow metabolizers, while trough levels were maintained in the target range (4–6 ng/mL). In conclusion, our observational study confirmed previous evidence of good overall tolerability and a favorable outcome for the patients after switching from IR-Tac to LCPT after liver transplantation.
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Affiliation(s)
- Katharina Willuweit
- Department of Gastroenterology and Hepatology, University Hospital Essen, University of Duisburg-Essen, Hufelandstraße 55, 45147 Essen, Germany; (A.F.); (A.H.)
- Correspondence: (K.W.); (K.H.); Tel.: +49-2641-860 (K.H.)
| | - Alexandra Frey
- Department of Gastroenterology and Hepatology, University Hospital Essen, University of Duisburg-Essen, Hufelandstraße 55, 45147 Essen, Germany; (A.F.); (A.H.)
| | - Anne Hörster
- Department of Gastroenterology and Hepatology, University Hospital Essen, University of Duisburg-Essen, Hufelandstraße 55, 45147 Essen, Germany; (A.F.); (A.H.)
| | - Fuat Saner
- Department of General, Visceral and Transplant Surgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstraße 55, 45147 Essen, Germany;
| | - Kerstin Herzer
- Department of Gastroenterology and Hepatology, University Hospital Essen, University of Duisburg-Essen, Hufelandstraße 55, 45147 Essen, Germany; (A.F.); (A.H.)
- Knappschaftsklinik Bad Neuenahr, Georg-Kreuzberg-Straße 2-6, 53474 Bad Neuenahr, Germany
- Correspondence: (K.W.); (K.H.); Tel.: +49-2641-860 (K.H.)
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15
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Sánchez Fructuoso A, Ruiz JC, Franco A, Diekmann F, Redondo D, Calviño J, Serra N, Aladrén MJ, Cigarrán S, Manonelles A, Ramos A, Gómez G, González Posada JM, Andrés A, Beneyto I, Muñiz AL, Perelló M, Lauzurica R. Effectiveness and safety of the conversion to MeltDose ® extended-release tacrolimus from other formulations of tacrolimus in stable kidney transplant patients: A retrospective study. Clin Transplant 2019; 34:e13767. [PMID: 31815310 PMCID: PMC7050537 DOI: 10.1111/ctr.13767] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 11/14/2019] [Accepted: 11/25/2019] [Indexed: 12/24/2022]
Abstract
Tacrolimus is the cornerstone of immunosuppressive therapy after kidney transplantation. Its narrow therapeutic window mandates serum level strict monitoring and dose adjustments to ensure the optimal risk‐benefit balance. This observational retrospective study analyzed the effectiveness and safety of conversion from twice‐daily immediate‐release tacrolimus (IR‐Tac) or once‐daily prolonged‐release tacrolimus (PR‐Tac) to the recent formulation once‐daily MeltDose® extended‐release tacrolimus (LCP‐Tac) in 365 stable kidney transplant recipients. We compared kidney function three months before and three months after the conversion. Three months after conversion, the total daily dose was reduced ~35% (P < .0001), and improved bioavailability and stable serum LCP‐Tac concentrations were observed. There was no increase in the number of patients requiring tacrolimus dose adjustments after conversion. Renal function was unaltered, and no cases of BPAR were reported. Reports of tremors, as collected in the clinical histories for each patient, decreased from pre‐conversion (20.8%) to post‐conversion (11.8%, P < .0001). LCP‐Tac generated a cost reduction of 63% compared with PR‐Tac. In conclusion, the conversion strategy to LCP‐Tac from other tacrolimus formulations in stable kidney transplant patients showed safety and effectiveness in a real‐world setting, confirming the data from RCTs. The specific pharmacokinetic properties of LCP‐Tac could be potentially advantageous in patients with tacrolimus‐related adverse events.
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Affiliation(s)
| | - Juan Carlos Ruiz
- Nephrology, University Hospital Marqués de Valdecilla, Santander, Spain
| | - Antonio Franco
- Nephrology, University Hospital General, Alicante, Spain
| | - Fritz Diekmann
- Nephrology, University Hospital Clinic, Barcelona, Spain
| | | | | | - Nuria Serra
- Nephrology, Fundación Puigvert, Barcelona, Spain
| | | | | | - Ana Manonelles
- Nephrology, University Hospital Bellvitge, Hospitalet de Llobregat, Spain
| | - Ana Ramos
- Nephrology, Fundación Jiménez Díaz, Madrid, Spain
| | - Gonzalo Gómez
- Nephrology, University Hospital son Espases, Palma de Mallorca, Spain
| | | | - Amado Andrés
- Nephrology, University Hospital Doce de Octubre, Madrid, Spain
| | | | | | - Manel Perelló
- Nephrology, University Hospital Vall de Hebrón, Barcelona, Spain
| | - Ricardo Lauzurica
- Nephrology, University Hospital Germans Trias y Pujol, Badalona, Spain
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