ADVERSE REACTIONS SECTION.

ADVERSE REACTIONS. Liver Transplantation. The principal adverse reactions of Prograf are tremor, headache, diarrhea, hypertension, nausea, and abnormal renal function. These occur with oral and IV administration of Prograf and may respond to reduction in dosing. Diarrhea was sometimes associated with other gastrointestinal complaints such as nausea and vomiting.Hyperkalemia and hypomagnesemia have occurred in patients receiving Prograf therapy. Hyperglycemia has been noted in many patients; some may require insulin therapy (see WARNINGS).The incidence of adverse events was determined in two randomized comparative liver transplant trials among 514 patients receiving tacrolimus and steroids and 515 patients receiving cyclosporine-based regimen (CBIR). The proportion of patients reporting more than one adverse event was 99.8% in the tacrolimus group and 99.6% in the CBIR group. Precautions must be taken when comparing the incidence of adverse events in the U.S. study to that in the European study. The 12-month posttransplant information from the U.S. study and from the European study is presented below. The two studies also included different patient populations and patients were treated with immunosuppressive regimens of differing intensities. Adverse events reported in >= 15% in tacrolimus patients (combined study results) are presented below for the two controlled trials in liver transplantation:LIVER TRANSPLANTATION: ADVERSE EVENTS OCCURRING IN >= 15% OF PROGRAF-TREATED PATIENTS U.S. STUDYEUROPEAN STUDYPrograf(N=250)CBIR(N=250)Prograf(N=264)CBIR(N=265)Nervous SystemHeadache (see WARNINGS)Tremor (see WARNINGS)InsomniaParesthesia64%56%64%40%60%46%68%30%37%48%32%17%26%32%23%17%GastrointestinalDiarrheaNauseaConstipationLFT AbnormalAnorexiaVomiting72%46%24%36%34%27%47%37%27%30%24%15%37%32%23%6%7%14%27%27%21%5%5%11%CardiovascularHypertension (see PRECAUTIONS)47%56%38%43%UrogenitalKidney Function Abnormal (see WARNINGS)Creatinine Increased (see WARNINGS)BUN Increased (see WARNINGS)Urinary Tract InfectionOliguria40%39%30%16%18%27%25%22%18%15%36%24%12%21%19%23%19%9%19%12%Metabolic and NutritionalHyperkalemia (see WARNINGS)HypokalemiaHyperglycemia (see WARNINGS)Hypomagnesemia45%29%47%48%26%34%38%45%13%13%33%16%9%16%22%9%Hemic and LymphaticAnemiaLeukocytosis Thrombocytopenia47%32%24%38%26%20%5%8%14%1%8%19%MiscellaneousAbdominal PainPainFeverAstheniaBack PainAscitesPeripheral Edema59%63%48%52%30%27%26%54%57%56%48%29%22%26%29%24%19%11%17%7%12%22%22%22%7%17%8%14%Respiratory SystemPleural EffusionAtelectasisDyspnea30%28%29%32%30%23%36%5%5%35%4%4%Skin and AppendagesPruritusRash36%24%20%19%15%10%7%4%Less frequently observed adverse reactions in both liver transplantation and kidney transplantation patients are described under the subsection Less Frequently Reported Adverse Reactions below.. Kidney Transplantation. The most common adverse reactions reported were infection, tremor, hypertension, abnormal renal function, constipation, diarrhea, headache, abdominal pain and insomnia.Adverse events that occurred in >= 15% of kidney transplant patients treated with Prograf in conjunction with azathioprine are presented below:KIDNEY TRANSPLANTATION: ADVERSE EVENTS OCCURRING IN >= 15% OF PATIENTS TREATED WITH PROGRAF IN CONJUNCTION WITH AZATHIOPRINEPrograf(N=205)CBIR(N=207)Nervous SystemTremor (see WARNINGS)Headache (see WARNINGS)InsomniaParesthesiaDizziness54%44%32%23%19%34%38%30%16%16%GastrointestinalDiarrheaNauseaConstipationVomitingDyspepsia44%38%35%29%28%41%36%43%23%20%CardiovascularHypertension (see PRECAUTIONS)Chest pain50%19%52%13%UrogenitalCreatinine Increased (see WARNINGS)Urinary Tract Infection45%34%42%35%Metabolic and NutritionalHypophosphatemiaHypomagnesemiaHyperlipemiaHyperkalemia (see WARNINGS)Diabetes Mellitus (see WARNINGS)HypokalemiaHyperglycemia (see WARNINGS)Edema49%34%31%31%24%22%22%18%53%17%38%32%9%25%16%19%Hemic and LymphaticAnemiaLeukopenia30%15%24%17%MiscellaneousInfectionPeripheral EdemaAstheniaAbdominal PainPainFeverBack Pain45%36%34%33%32%29%24%49%48%30%31%30%29%20%Respiratory SystemDyspneaCough Increased22%18%18%15%MusculoskeletalArthralgia25%24%SkinRashPruritus17%15%12%7%Adverse events that occurred in >= 10% of kidney transplant patients treated with Prograf in conjunction with MMF in Study are presented below:Study was conducted entirely outside of the United States. Such studies often report lower incidence of adverse events in comparison to US studies.KIDNEY TRANSPLANTATION: ADVERSE EVENTS OCCURRING IN >= 10% OF PROGRAF-TREATED PATIENTS Prograf (Group C)Cyclosporine (Group A)Cyclosporine (Group B) (N=403)(N=384)(N=408)Anemia17%19%17%Leucopenia13%10%10%Diarrhea25%16%13%Edema peripheral11%12%13%Urinary tract infection24%28%24%Hyperlipidemia10%15%13%Hypertension (see PRECAUTIONS)13%14%12%Adverse events that occurred in >=15% of kidney transplant patients treated with Prograf in conjunction with MMF in Study are presented below:KIDNEY TRANSPLANTATION: ADVERSE EVENTS OCCURRING IN >= 15% OF PROGRAF-TREATED PATIENTS PrografCyclosporine (N=212)(N=212)Gastrointestinal Disorders Diarrhea44%26%Nausea39%47%Constipation36%41%Vomiting26%25%Dyspepsia18%15% Injury, Poisoning, and Procedural Complications Post Procedural Pain29%27%Incision Site Complication28%23%Graft Dysfunction24%18% Metabolism and Nutrition Disorders Hypomagnesemia28%22%Hypophosphatemia28%21%Hyperkalemia (see WARNINGS)26%19%Hyperglycemia (see WARNINGS)21%15%Hyperlipidemia18%25%Hypokalemia16%18% Nervous System Disorders Tremor 34%20%Headache24%25% Blood and Lymphatic System Disorders Anemia30%28%Leukopenia16%12% Miscellaneous Edema Peripheral35%46%Hypertension (see PRECAUTIONS)32%35%Insomnia30%21%Urinary Tract Infection26%22%Blood creatinine increased23%23%Less frequently observed adverse reactions in both liver transplantation and kidney transplantation patients are described under the subsection Less Frequently Reported Adverse Reactions shown below.. Heart Transplantation. The more common adverse reactions in Prograf-treated heart transplant recipients were abnormal renal function hypertension, diabetes mellitus, CMV infection, tremor, hyperglycemia, leukopenia, infection, and hyperlipemia.Adverse events in heart transplant patients in the European trial are presented below:HEART TRANSPLANTATION: ADVERSE EVENTS OCCURRING IN >= 15% OF PROGRAF-TREATED PATIENTSCOSTART Body SystemCOSTART TermPrograf+Azathioprine (n=157)CsA Azathioprine(n=157)Cardiovascular SystemHypertension (See PRECAUTIONS)62%69%Pericardial effusion15%14%Body as WholeCMV infection32%30%Infection24%21%Metabolic and Nutritional DisordersHyperlipemia18%27%Diabetes Mellitus (See WARNINGS)26%16%Hyperglycemia (See WARNINGS)23%17%Hemic and Lymphatic SystemLeukopenia48%39%Anemia 50%36%Urogenital SystemKidney function abnormal (See WARNINGS)56%57%Urinary tract infection16%12%Respiratory SystemBronchitis17%18%Nervous SystemTremor (See WARNINGS)15%6%In the European study, the cyclosporine trough concentrations were above the pre-defined target range (i.e., 100-200 ng/mL) at Day 122 and beyond in 32-68% of the patients in the cyclosporine treatment arm, whereas the tacrolimus trough concentrations were within the pre-defined target range (i.e., 5-15 ng/mL) in 74-86% of the patients in the tacrolimus treatment arm.Only selected targeted treatment-emergent adverse events were collected in the US heart transplantation study. Those events that were reported at rate of 15% or greater in patients treated with Prograf and mycophenolate mofetil include the following: any target adverse events (99.1%), hypertension (88.8%), hyperglycemia requiring antihyperglycemic therapy (70.1%) (see WARNINGS), hypertriglyceridemia (65.4%), anemia (hemoglobin <10.0 g/dL) (65.4%), fasting blood glucose >140 mg/dL (on two separate occasions) (60.7%) (see WARNINGS), hypercholesterolemia (57.0%), hyperlipidemia (33.6%), WBCs <3000 cells/mcL (33.6%), serious bacterial infections (29.9%), magnesium <1.2 mEq/L (24.3%), platelet count <75,000 cells/mcL (18.7%), and other opportunistic infections (15.0%).Other targeted treatment-emergent adverse events in Prograf-treated patients occurred at rate of less than 15%, and include the following: Cushingoid features, impaired wound healing, hyperkalemia, Candida infection, and CMV infection/syndrome.. Less Frequently Reported Adverse Reactions. The following adverse events were reported in either liver, kidney, and/or heart transplant recipients who were treated with tacrolimus in clinical trials.. Nervous System. (see WARNINGS)Abnormal dreams, agitation, amnesia, anxiety, confusion, convulsion, crying, depression, dizziness, elevated mood, emotional lability, encephalopathy, haemorrhagic stroke, hallucinations, headache, hypertonia, incoordination, insomnia, monoparesis, myoclonus, nerve compression, nervousness, neuralgia, neuropathy, paresthesia, paralysis flaccid, psychomotor skills impaired, psychosis, quadriparesis, somnolence, thinking abnormal, vertigo, writing impaired Special Senses. Abnormal vision, amblyopia, ear pain, otitis media, tinnitus. Gastrointestinal. Anorexia, cholangitis, cholestatic jaundice, diarrhea, duodenitis, dyspepsia, dysphagia, esophagitis, flatulence, gastritis, gastroesophagitis, gastrointestinal hemorrhage, GGT increase, GI disorder, GI perforation, hepatitis, hepatitis granulomatous, ileus, increased appetite, jaundice, liver damage, liver function test abnormal, nausea, nausea and vomiting, oesophagitis ulcerative, oral moniliasis, pancreatic pseudocyst, rectal disorder, stomatitis, vomiting. Cardiovascular. Abnormal ECG, angina pectoris, arrhythmia, atrial fibrillation, atrial flutter, bradycardia, cardiac fibrillation, cardiopulmonary failure, cardiovascular disorder, chest pain, congestive heart failure, deep thrombophlebitis, echocardiogram abnormal, electrocardiogram QRS complex abnormal, electrocardiogram ST segment abnormal, heart failure, heart rate decreased, hemorrhage, hypotension, peripheral vascular disorder, phlebitis, postural hypotension, syncope, tachycardia, thrombosis, vasodilatation Urogenital. (see WARNINGS)Acute kidney failure, albuminuria, BK nephropathy, bladder spasm, cystitis, dysuria, hematuria, hydronephrosis, kidney failure, kidney tubular necrosis, nocturia, oliguria, pyuria, toxic nephropathy, urge incontinence, urinary frequency, urinary incontinence, urinary retention, vaginitis Metabolic/Nutritional Acidosis, alkaline phosphatase increased, alkalosis, ALT (SGPT) increased, AST (SGOT) increased, bicarbonate decreased, bilirubinemia, BUN increased, dehydration, edema, GGT increased, gout, healing abnormal, hypercalcemia, hypercholesterolemia, hyperkalemia, hyperlipemia, hyperphosphatemia, hyperuricemia, hypervolemia, hypocalcemia, hypoglycemia, hypokalemia, hypomagnesemia, hyponatremia, hypophosphatemia, hypoproteinemia, lactic dehydrogenase increase, peripheral edema, weight gain Endocrine (see PRECAUTIONS)Cushings syndrome, diabetes mellitus Hemic/Lymphatic Coagulation disorder, ecchymosis, haematocrit increased, haemoglobin abnormal, hypochromic anemia, leukocytosis, leukopenia, polycythemia, prothrombin decreased, serum iron decreased, thrombocytopenia Miscellaneous Abdomen enlarged, abdominal pain, abscess, accidental injury, allergic reaction, asthenia, back pain, cellulitis, chills, fall, feeling abnormal, fever, flu syndrome, generalized edema, hernia, mobility decreased, pain, peritonitis, photosensitivity reaction, sepsis, temperature intolerance, ulcer Musculoskeletal Arthralgia, cramps, generalized spasm, joint disorder, leg cramps, myalgia, myasthenia, osteoporosis Respiratory Asthma, bronchitis, cough increased, dyspnea, emphysema, hiccups, lung disorder, lung function decreased, pharyngitis, pleural effusion, pneumonia, pneumothorax, pulmonary edema, respiratory disorder, rhinitis, sinusitis, voice alteration. Skin Acne, alopecia, exfoliative dermatitis, fungal dermatitis, herpes simplex, herpes zoster, hirsutism, neoplasm skin benign, skin discoloration, skin disorder, skin ulcer, sweating.. Post Marketing. Post Marketing Adverse Events The following adverse events have been reported from worldwide marketing experience with Prograf. Because these events are reported voluntarily from population of uncertain size, are associated with concomitant diseases and multiple drug therapies and surgical procedures, it is not always possible to reliably estimate their frequency or establish causal relationship to drug exposure. Decisions to include these events in labeling are typically based on one or more of the following factors: (1) seriousness of the event, (2) frequency of the reporting, or (3) strength of causal connection to the drug.There have been rare spontaneous reports of myocardial hypertrophy associated with clinically manifested ventricular dysfunction in patients receiving Prograf therapy (see PRECAUTIONS- Myocardial Hypertrophy).Other events include: Cardiovascular. Atrial fibrillation, atrial flutter, cardiac arrhythmia, cardiac arrest, electrocardiogram wave abnormal, flushing, myocardial infarction, myocardial ischaemia, pericardial effusion, QT prolongation, Torsade de Pointes, venous thrombosis deep limb, ventricular extrasystoles, ventricular fibrillation Gastrointestinal Bile duct stenosis, colitis, enterocolitis, gastroenteritis, gastrooesophageal reflux disease, hepatic cytolysis, hepatic necrosis, hepatotoxicity, impaired gastric emptying, liver fatty, mouth ulceration, pancreatitis haemorrhagic, pancreatitis necrotizing, stomach ulcer, venoocclusive liver disease Hemic/Lymphatic Disseminated intravascular coagulation, neutropenia, pancytopenia, thrombocytopenic purpura, thrombotic thrombocytopenic purpura Metabolic/Nutritional Glycosuria, increased amylase including pancreatitis, weight decreased. Miscellaneous. Feeling hot and cold, feeling jittery, hot flushes, multi-organ failure, primary graft dysfunction Nervous System Carpal tunnel syndrome, cerebral infarction, hemiparesis, leukoencephalopathy, mental disorder, mutism, posterior reversible encephalopathy syndrome (PRES), progressive multifocal leukoencephalopathy (PML), quadriplegia, speech disorder, syncope Respiratory Acute respiratory distress syndrome, interstitial lung disease, lung infiltration, respiratory distress, respiratory failure Skin Stevens-Johnson syndrome, toxic epidermal necrolysis Special Senses Blindness, blindness cortical, hearing loss including deafness, photophobia. Urogenital Acute renal failure, cystitis haemorrhagic, hemolytic-uremic syndrome, micturition disorder.

CLINICAL PHARMACOLOGY SECTION.

CLINICAL PHARMACOLOGY. Mechanism of Action. Tacrolimus prolongs the survival of the host and transplanted graft in animal transplant models of liver, kidney, heart, bone marrow, small bowel and pancreas, lung and trachea, skin, cornea, and limb.In animals, tacrolimus has been demonstrated to suppress some humoral immunity and, to greater extent, cell-mediated reactions such as allograft rejection, delayed type hypersensitivity, collagen-induced arthritis, experimental allergic encephalomyelitis, and graft versus host disease.Tacrolimus inhibits T-lymphocyte activation, although the exact mechanism of action is not known. Experimental evidence suggests that tacrolimus binds to an intracellular protein, FKBP-12. complex of tacrolimus-FKBP-12, calcium, calmodulin, and calcineurin is then formed and the phosphatase activity of calcineurin inhibited. This effect may prevent the dephosphorylation and translocation of nuclear factor of activated T-cells (NF-AT), nuclear component thought to initiate gene transcription for the formation of lymphokines (such as interleukin-2, gamma interferon). The net result is the inhibition of T-lymphocyte activation (i.e., immunosuppression).. Pharmacokinetics. Tacrolimus activity is primarily due to the parent drug. The pharmacokinetic parameters (mean+-S.D.) of tacrolimus have been determined following intravenous (IV) and/or oral (PO) administration in healthy volunteers, and in kidney transplant, liver transplant, and heart transplant patients. (See table below.)PopulationNRoute(Dose)ParametersCmax (ng/mL)Tmax (hr)AUC(ngohr/mL)t1/2 (hr)CI(L/hr/kg)V(L/kg)HealthyVolunteers8IV(0.025 mg/kg/4hr)not applicable598AUC0-120; +- 12534.2+- 7.70.040+- 0.0091.91+- 0.3116PO(5 mg)29.7+- 7.21.6+- 0.7243AUC0-72 +- 7334.8+- 11.40.041 Corrected for individual bioavailability +- 0.0081.94 +- 0.53KidneyTransplantPts26IV(0.02 mg/kg/12 hr)294AUC0-inf; +- 26218.8+- 16.70.083+- 0.0501.41+- 0.66PO(0.2 mg/kg/day)19.2+- 10.33.0203 +- 42not availablePO(0.3 mg/kg/day)24.2+- 15.81.5288 +- 93LiverTransplantPts17IV(0.05 mg/kg/12 hr)3300 +- 213011.7+- 3.90.053+- 0.0170.85+- 0.30PO(0.3 mg/kg/day)68.5+- 30.02.3+- 1.5519 +- 179HeartTransplant Patients11IV(0.01 mg/kg/day as continuous infusion)954AUC0-t; +-33423.6+-9.220.051+-0.01511PO (0.075mg/kg/day)Determined after the first dose14.7+7.792.1 [0.5-6.0]Median [range] 82.7AUC0-12 +-63.214PO (0.15mg/kg/day)24.5+- 13.71.5 [0.4-4.0] 142+-116Due to intersubject variability in tacrolimus pharmacokinetics, individualization of dosing regimen is necessary for optimal therapy. (See DOSAGE AND ADMINISTRATION). Pharmacokinetic data indicate that whole blood concentrations rather than plasma concentrations serve as the more appropriate sampling compartment to describe tacrolimus pharmacokinetics.. Absorption. Absorption of tacrolimus from the gastrointestinal tract after oral administration is incomplete and variable. The absolute bioavailability of tacrolimus was 17+-10% in adult kidney transplant patients (N=26), 22+-6% in adult liver transplant patients (N=17), 23+-9% in adult heart transplant patients (N=11) and 18+-5% in healthy volunteers (N=16).A single dose study conducted in 32 healthy volunteers established the bioequivalence of the mg and mg capsules. Another single dose study in 32 healthy volunteers established the bioequivalence of the 0.5 mg and mg capsules. Tacrolimus maximum blood concentrations (Cmax) and area under the curve (AUC) appeared to increase in dose-proportional fashion in 18 fasted healthy volunteers receiving single oral dose of 3, 7, and 10 mg.In 18 kidney transplant patients, tacrolimus trough concentrations from to 30 ng/mL measured at 10-12 hours post-dose (Cmin) correlated well with the AUC (correlation coefficient 0.93). In 24 liver transplant patients over concentration range of 10 to 60 ng/mL, the correlation coefficient was 0.94. In 25 heart transplant patients over concentration range of to 24 ng/mL, the correlation coefficient was 0.89 after an oral dose of 0.075 or 0.15 mg/kg/day at steady-state.. Food Effects The rate and extent of tacrolimus absorption were greatest under fasted conditions. The presence and composition of food decreased both the rate and extent of tacrolimus absorption when administered to 15 healthy volunteers.The effect was most pronounced with high-fat meal (848 kcal, 46% fat): mean AUC and Cmax were decreased 37% and 77%, respectively; Tmax was lengthened 5-fold. high-carbohydrate meal (668 kcal, 85% carbohydrate) decreased mean AUC and mean Cmax by 28% and 65%, respectively.In healthy volunteers (N=16), the time of the meal also affected tacrolimus bioavailability. When given immediately following the meal, mean Cmax was reduced 71%, and mean AUC was reduced 39%, relative to the fasted condition. When administered 1.5 hours following the meal, mean Cmax was reduced 63%, and mean AUC was reduced 39%, relative to the fasted condition.In 11 liver transplant patients, Prograf administered 15 minutes after high fat (400 kcal, 34% fat) breakfast, resulted in decreased AUC (27+-18%) and Cmax (50+-19%), as compared to fasted state.. Distribution. The plasma protein binding of tacrolimus is approximately 99% and is independent of concentration over range of 5-50 ng/mL. Tacrolimus is bound mainly to albumin and alpha-1-acid glycoprotein, and has high level of association with erythrocytes. The distribution of tacrolimus between whole blood and plasma depends on several factors, such as hematocrit, temperature at the time of plasma separation, drug concentration, and plasma protein concentration. In U.S. study, the ratio of whole blood concentration to plasma concentration averaged 35 (range 12 to 67).. Metabolism. Tacrolimus is extensively metabolized by the mixed-function oxidase system, primarily the cytochrome P-450 system (CYP3A). metabolic pathway leading to the formation of possible metabolites has been proposed. Demethylation and hydroxylation were identified as the primary mechanisms of biotransformation in vitro. The major metabolite identified in incubations with human liver microsomes is 13-demethyl tacrolimus. In in vitro studies, 31-demethyl metabolite has been reported to have the same activity as tacrolimus.. Excretion. The mean clearance following IV administration of tacrolimus is 0.040, 0.083, and 0.053, and 0.051 L/hr/kg in healthy volunteers, adult kidney transplant patients, adult liver transplant patients, and adult heart transplant patients, respectively. In man, less than 1% of the dose administered is excreted unchanged in urine.In mass balance study of IV administered radiolabeled tacrolimus to healthy volunteers, the mean recovery of radiolabel was 77.8+-12.7%. Fecal elimination accounted for 92.4+-1.0% and the elimination half-life based on radioactivity was 48.1+-15.9 hours whereas it was 43.5+-11.6 hours based on tacrolimus concentrations. The mean clearance of radiolabel was 0.029+-0.015 L/hr/kg and clearance of tacrolimus was 0.029+-0.009 L/hr/kg. When administered PO, the mean recovery of the radiolabel was 94.9+-30.7%. Fecal elimination accounted for 92.6+-30.7%, urinary elimination accounted for 2.3+-1.1% and the elimination half-life based on radioactivity was 31.9+-10.5 hours whereas it was 48.4+- 12.3 hours based on tacrolimus concentrations. The mean clearance of radiolabel was 0.226+-0.116 L/hr/kg and clearance of tacrolimus 0.172+- 0.088 L/hr/kg.. Special Populations. Pediatric. Pharmacokinetics of tacrolimus have been studied in liver transplantation patients, 0.7 to 13.2 years of age. Following IV administration of 0.037 mg/kg/day dose to 12 pediatric patients, mean terminal half-life, volume of distribution and clearance were 11.5+-3.8 hours, 2.6+-2.1 L/kg and 0.138+- 0.071 L/hr/kg, respectively. Following oral administration to patients, mean AUC and Cmax were 337+-167 ng.hr/mL and 48.4+-27.9 ng/mL, respectively. The absolute bioavailability was 31+-24%.Whole blood trough concentrations from 31 patients less than 12 years old showed that pediatric patients needed higher doses than adults to achieve similar tacrolimus trough concentrations. (See DOSAGE AND ADMINISTRATION).. Renal and Hepatic Insufficiency. The mean pharmacokinetic parameters for tacrolimus following single administrations to patients with renal and hepatic impairment are given in the following tablePopulation(No. of Patients)DoseAUC0-t (ng.hr/mL)t1/2 (hr)V(L/kg)CI(L/hr/kg)RenalImpairment(n=12)0.02mg/kg/4hrIV393+-123(t=60 hr)26.3 +-9.21.07+-0.200.038+-0.014Mild Hepatic Impairment(n=6)0.02mg/kg/4hrIV367+-107(t=72 hr)60.6+-43.8Range: 27.8 1413.1+-1.60.042+-0.027.7 mgPO488+-320(t=72 hr)66.1+-44.8Range: 29.5 1383.7+-4.7corrected for bioavailability 0.034+-0.019 SevereHepaticImpairment(n=6, IV)0.02 mg/kg/4hrIV (n=2)0.01 mg/kg/8hrIV (n=4)762+-204(t=120 hr)289+-117(t=144 hr)198+-158Range:81-4363.9+-1.00.017+-0.013(n=5, PO)1 patient did not receive the PO dose mg PO(n=1)5 mg PO(n=4)4 mg PO(n=1)658(t=120 hr)533+-156 (t=144 hr)119+-35Range: 85-1783.1+-3.4 0.016+-0.011 Renal Insufficiency: Tacrolimus pharmacokinetics following single IV administration were determined in 12 patients (7 not on dialysis and on dialysis, serum creatinine of 3.9+-1.6 and 12.0+-2.4 mg/dL, respectively) prior to their kidney transplant. The pharmacokinetic parameters obtained were similar for both groups.The mean clearance of tacrolimus in patients with renal dysfunction was similar to that in normal volunteers (see previous table).Hepatic Insufficiency: Tacrolimus pharmacokinetics have been determined in six patients with mild hepatic dysfunction (mean Pugh score: 6.2) following single IV and oral administrations. The mean clearance of tacrolimus in patients with mild hepatic dysfunction was not substantially different from that in normal volunteers (see previous table). Tacrolimus pharmacokinetics were studied in patients with severe hepatic dysfunction (mean Pugh score: >10). The mean clearance was substantially lower in patients with severe hepatic dysfunction, irrespective of the route of administration.RaceA formal study to evaluate the pharmacokinetic disposition of tacrolimus in Black transplant patients has not been conducted. However, retrospective comparison of Black and Caucasian kidney transplant patients indicated that Black patients required higher tacrolimus doses to attain similar trough concentrations. (See DOSAGE AND ADMINISTRATION.)GenderA formal study to evaluate the effect of gender on tacrolimus pharmacokinetics has not been conducted, however, there was no difference in dosing by gender in the kidney transplant trial. retrospective comparison of pharmacokinetics in healthy volunteers, and in kidney, liver and heart transplant patients indicated no gender-based differences.

CLINICAL STUDIES SECTION.

CLINICAL STUDIES. Liver Transplantation. The safety and efficacy of Prograf-based immunosuppression following orthotopic liver transplantation were assessed in two prospective, randomized, non-blinded multicenter studies. The active control groups were treated with cyclosporine-based immunosuppressive regimen. Both studies used concomitant adrenal corticosteroids as part of the immunosuppressive regimens. These studies were designed to evaluate whether the two regimens were therapeutically equivalent, with patient and graft survival at 12 months following transplantation as the primary endpoints. The Prograf-based immunosuppressive regimen was found to be equivalent to the cyclosporine-based immunosuppressive regimens.In one trial, 529 patients were enrolled at 12 clinical sites in the United States; prior to surgery, 263 were randomized to the Prograf-based immunosuppressive regimen and 266 to cyclosporine-based immunosuppressive regimen (CBIR). In 10 of the 12 sites, the same CBIR protocol was used, while sites used different control protocols. This trial excluded patients with renal dysfunction, fulminant hepatic failure with Stage IV encephalopathy, and cancers; pediatric patients (<= 12 years old) were allowed.In the second trial, 545 patients were enrolled at clinical sites in Europe; prior to surgery, 270 were randomized to the Prograf-based immunosuppressive regimen and 275 to CBIR. In this study, each center used its local standard CBIR protocol in the active-control arm. This trial excluded pediatric patients, but did allow enrollment of subjects with renal dysfunction, fulminant hepatic failure in Stage IV encephalopathy, and cancers other than primary hepatic with metastases.One-year patient survival and graft survival in the Prograf-based treatment groups were equivalent to those in the CBIR treatment groups in both studies. The overall 1-year patient survival (CBIR and Prograf-based treatment groups combined) was 88% in the U.S. study and 78% in the European study. The overall 1-year graft survival (CBIR and Prograf-based treatment groups combined) was 81% in the U.S. study and 73% in the European study. In both studies, the median time to convert from IV to oral Prograf dosing was days.Because of the nature of the study design, comparisons of differences in secondary endpoints, such as incidence of acute rejection, refractory rejection or use of OKT3 for steroid-resistant rejection, could not be reliably made.. Kidney Transplantation. Prograf/azathioprinePrograf-based immunosuppression in conjunction with azathioprine and corticosteroids following kidney transplantation was assessed in Phase randomized, multicenter, non-blinded, prospective study. There were 412 kidney transplant patients enrolled at 19 clinical sites in the United States. Study therapy was initiated when renal function was stable as indicated by serum creatinine <= mg/dL (median of days after transplantation, range to 14 days). Patients less than years of age were excluded.There were 205 patients randomized to Prograf-based immunosuppression and 207 patients were randomized to cyclosporine-based immunosuppression. All patients received prophylactic induction therapy consisting of an antilymphocyte antibody preparation, corticosteroids and azathioprine. Overall year patient and graft survival was 96.1% and 89.6%, respectively and was equivalent between treatment arms.Because of the nature of the study design, comparisons of differences in secondary endpoints, such as incidence of acute rejection, refractory rejection or use of OKT3 for steroid-resistant rejection, could not be reliably made.Prograf/mycophenolate mofetil (MMF)Prograf-based immunosuppression in conjunction with MMF, corticosteroids, and induction has been studied. In randomized, open-label, multi-center trial (Study 1), 1589 kidney transplant patients received Prograf (Group C, n=401), sirolimus (Group D, n=399), or one of two cyclosporine regimens (Group A, n=390 and Group B, n=399) in combination with MMF and corticosteroids; all patients, except those in one of the two cyclosporine groups, also received induction with daclizumab. The study was conducted outside the United States; the study population was 93% Caucasian. In this study, mortality at 12 months in patients receiving Prograf/MMF was similar (2.7%) compared to patients receiving cyclosporine/MMF (3.3% and 1.8%) or sirolimus/MMF (3.0%). Patients in the Prograf group exhibited higher estimated creatinine clearance rates (eCLcr) using the Cockcroft-Gault formula (Table 1) and experienced fewer efficacy failures, defined as biopsy proven acute rejection (BPAR), graft loss, death, and/or lost to follow-up (Table 2) in comparison to each of the other three groups. Patients randomized to Prograf/MMF were more likely to develop diarrhea and diabetes after the transplantation and experienced similar rates of infections compared to patients randomized to either cyclosporine/MMF regimen (see ADVERSE REACTIONS). Table 1: Estimated Creatinine Clearance at 12 Months in Study 1Key: CsA=Cyclosporine, CS=Corticosteroids, Tac=Tacrolimus, Siro=SirolimusGroupeCLcr [mL/min] at Month 12 All death/graft loss (n=41, 27, 23 and 42 in Groups A, B, and D) and patients whose last recorded creatinine values were prior to month visit (n=10, 9, and in Groups A, B, and D) were inputed with GFR of 10 mL/min; subjects last observed creatinine value from month on was used for the remainder of subjects with missing creatinine at month 12 (n=11, 12, 15 and 19 for Groups A, B, and D). Weight was also imputed in the calculation of estimated GFR, if missing. NMEANSDMEDIANTreatment Difference with Group (99.2% CI Adjusted for multiple (6) pairwise comparisons using Bonferroni corrections.)(A) CsA/MMF/CS 39056.525.856.9-8.6 (-13.7, -3.7)(B) CsA/MMF/CS/Daclizumab39958.925.660.9-6.2 (-11.2, -1.2)(C) Tac/MMF/CS/Daclizumab 40165.127.466.2-(D) Siro/MMF/CS/Daclizumab 39956.227.457.3-8.9 (-14.1, -3.9)Total158959.226.860.5 Table 2: Incidence of BPAR, Graft Loss, Death or Loss to Follow-up at 12 Months in Study 1Group =CsA/MMF/CS, =CsA/MMF/CS/Daclizumab, C=Tac/MMF/CS/Daclizumab, and D=Siro/MMF/CS/DaclizumabAN=390BN=399CN=401DN=399Overall FailureComponents of efficacy failure BPAR Graft loss excluding death Mortality Lost to follow-upTreatment Difference of efficacy failure compared to Group (99.2% CI Adjusted for multiple (6) pairwise comparisons using Bonferroni corrections. )141 (36.2%)113 (29.0%)28 (7.2%)13 (3.3%)5 (1.3%)15.8% (7.1%, 24.3%)126 (31.6%)106 (26.6%)20 (5.0%)7 (1.8%)7 (1.8%)11.2% (2.7%, 19.5%)82 (20.4%)60 (15.0%)12 (3.0%)11 (2.7%)5 (1.3%)-185 (46.4%)152 (38.1%)30 (7.5%)12 (3.0%)6 (1.5%)26.0% (17.2%, 34.7%)The protocol-specified target tacrolimus trough concentrations (Ctrough,Tac) were 3-7 ng/mL; however, the observed median Ctroughs,Tac approximated ng/mL throughout the 12 month study (Table 3). Table 3: Tacrolimus Whole Blood Trough Concentrations (Study 1)Time Median (P10-P90 Range of Ctrough, Tac that excludes lowest 10% and highest 10% of Ctrough, Tac) tacrolimus whole blood trough concentrations(ng/mL)Day 30 (N=366)6.9 (4.4 11.3)Day 90 (N=351)6.8 (4.1 10.7)Day 180(N=355)6.5 (4.0 9.6)Day 365 (N=346)6.5 (3.8 10.0) The protocol-specified target cyclosporine trough concentrations (Ctrough,CsA) for Group were 50-100 ng/mL; however, the observed median Ctroughs,CsA approximated 100 ng/mL throughout the 12 month study. The protocol-specified target Ctroughs,CsA for Group were 150-300 ng/mL for the first months and 100-200 ng/mL from month to month 12; the observed median Ctroughs, CsA approximated 225 ng/mL for the first months and 140 ng/mL from month to month 12. While patients in all groups started MMF at 1g BID, the MMF dose was reduced to <2 g/day in 63% of patients in the tacrolimus treatment arm by month 12 (Table 4); approximately 50% of these MMF dose reductions were due to adverse events. By comparison, the MMF dose was reduced to <2 g/day in 49% and 45% of patients in the two cyclosporine arms (Group and Group B, respectively), by month 12 and approximately 40% of MMF dose reductions were due to adverse events. Table 4: MMF Dose Over Time in Prograf/MMF (Group C) (Study 1)Time-averaged MMF dose (total MMF dose)/(duration of treatment)Time period (Days)Time-averaged MMF dose (g/day) Percentage of patients for each time-averaged MMF dose range during various treatment periods. Two g/day of time-averaged MMF dose means that MMF dose was not reduced in those patients during the treatment periods. <2.02.0>2.00-30 (N=364)37%60%2%0-90 (N=373)47%51%2%0-180 (N=377)56%42%2%0-365 (N=380)63%36%1% In second randomized, open-label, multi-center trial (Study 2), 424 kidney transplant patients received Prograf (n=212) or cyclosporine (n=212) in combination with MMF gram BID, basiliximab induction, and corticosteroids. In this study, the rate for the combined endpoint of biopsy proven acute rejection, graft failure, death, and/or lost to follow-up at 12 months in the Prograf/MMF group was similar to the rate in the cyclosporine/MMF group. There was, however, an imbalance in mortality at 12 months in those patients receiving Prograf/MMF (4.2%) compared to those receiving cyclosporine/MMF (2.4%), including cases attributed to overimmunosuppression (Table 5). Table 5: Incidence of BPAR, Graft Loss, Death or Loss to Follow-up at 12 Months in Study Prograf/MMFCyclosporine/MMF (n=212)(n=212)Overall Failure32 (15.1%)36 (17.0%)Components of efficacy failure BPAR16 (7.5%)29 (13.7%) Graft loss excluding death6 (2.8%)4 (1.9%) Mortality9 (4.2%)5 (2.4%) Lost to follow-up4 (1.9%)1 (0.5%)Treatment Difference of efficacy failure compared to Prograf/MMF group (95% CI95% confidence interval calculated using Fishers Exact Test) -1.9% (-5.2%, 9.0%)The protocol-specified target tacrolimus whole blood trough concentrations (Ctrough,Tac) in Study were 7-16 ng/mL for the first three months and 5-15 ng/mL thereafter. The observed median Ctroughs,Tac approximated 10 ng/mL during the first three months and ng/mL from month to month 12 (Table 6). Table 6: Tacrolimus Whole Blood Trough Concentrations (Study 2)Time Median (P10-P90Range of Ctrough,Tac that excludes lowest 10% and highest 10% of Ctrough, Tac) tacrolimus whole blood trough concentrations(ng/mL)Day 30 (N=174)10.5 (6.3 16.8)Day 60 (N=179)9.2 (5.9 15.3)Day 120 (N=176)8.3 (4.6 13.3)Day 180 (N=171)7.8 (5.5 13.2)Day 365 (N=178)7.1 (4.2 12.4) The protocol-specified target cyclosporine whole blood concentrations (Ctrough,CsA) were 125 to 400 ng/mL for the first three months, and 100 to 300 ng/mL thereafter. The observed median Ctroughs, CsA approximated 280 ng/mL during the first three months and 190 ng/mL from month to month 12.Patients in both groups started MMF at 1g BID. The MMF dose was reduced to <2 g/day by month 12 in 62% of patients in the Prograf/MMF group (Table 7) and in 47% of patients in the cyclosporine/MMF group. Approximately 63% and 55% of these MMF dose reductions were because of adverse events in the Prograf/MMF group and the cyclosporine/MMF group, respectively. Table 7: MMF Dose Over Time in the Prograf/MMF group (Study 2)Time-averaged MMF dose=(total MMF dose)/(duration of treatment)Time period (Days)Time-averaged MMF dose (g/day) Percentage of patients for each time-averaged MMF dose range during various treatment periods. Two g/day of time-averaged MMF dose means that MMF dose was not reduced in those patients during the treatment periods. <2.02.0>2.0 0-30 (N=212)25%69%6%0-90 (N=212)41%53%6%0-180 (N=212)52%41%7%0-365 (N=212)62%34%4%. Heart Transplantation. Two open-label, randomized, comparative studies evaluated the safety and efficacy of Prograf-based and cyclosporine-based immunosuppression in primary orthotopic heart transplantation. In Phase study conducted in Europe, 314 patients received regimen of antibody induction, corticosteroids and azathioprine in combination with Prograf or cyclosporine modified for 18 months. In 3-arm study conducted in the US, 331 patients received corticosteroids and Prograf plus sirolimus, Prograf plus mycophenolate mofetil (MMF) or cyclosporine modified plus MMF for year.In the European Phase study, patient/graft survival at 18 months posttransplant was similar between treatment arms, 91.7% in the tacrolimus group and 89.2% in the cyclosporine group. In the US study, patient and graft survival at 12 months was similar with 93.5% survival in the Prograf plus MMF group and 86.1% survival in the cyclosporine modified plus MMF group. In the European study, the cyclosporine trough concentrations were above the pre-defined target range (i.e., 100-200 ng/mL) at Day 122 and beyond in 32-68% of the patients in the cyclosporine treatment arm, whereas the tacrolimus trough concentrations were within the pre-defined target range (i.e., 5-15 ng/mL) in 74-86% of the patients in the tacrolimus treatment arm.The US study contained third arm of combination regimen of sirolimus, mg per day, and full-dose Prograf; however, this regimen was associated with increased risk of wound healing complications, renal function impairment, and insulin-dependent post-transplant diabetes mellitus, and is not recommended (see WARNINGS).

DOSAGE & ADMINISTRATION SECTION.

DOSAGE AND ADMINISTRATION. Prograf injection (tacrolimus injection). For IV Infusion OnlyNOTE: Anaphylactic reactions have occurred with injectables containing castor oil derivatives. SeeWARNINGS.In patients unable to take oral Prograf capsules, therapy may be initiated with Prograf injection. The initial dose of Prograf should be administered no sooner than hours after transplantation. The recommended starting dose of Prograf injection is 0.01 mg/kg/day (heart) or 0.03-0.05 mg/kg/day (liver, kidney) as continuous IV infusion. Adult patients should receive doses at the lower end of the dosing range. Concomitant adrenal corticosteroid therapy is recommended early post-transplantation. Continuous IV infusion of Prograf injection should be continued only until the patient can tolerate oral administration of Prograf capsules.Preparation for Administration/StabilityPrograf injection must be diluted with 0.9% Sodium Chloride Injection or 5% Dextrose Injection to concentration between 0.004 mg/mL and 0.02 mg/mL prior to use. Diluted infusion solution should be stored in glass or polyethylene containers and should be discarded after 24 hours. The diluted infusion solution should not be stored in PVC container due to decreased stability and the potential for extraction of phthalates. In situations where more dilute solutions are utilized (e.g., pediatric dosing, etc.), PVC-free tubing should likewise be used to minimize the potential for significant drug adsorption onto the tubing. Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit. Due to the chemical instability of tacrolimus in alkaline media, Prograf injection should not be mixed or co-infused with solutions of pH or greater (e.g., ganciclovir or acyclovir).. Prograf capsules (tacrolimus capsules) Summary of Initial Oral Dosage Recommendations and Observed Whole Blood Trough ConcentrationsPatient PopulationRecommended Initial Oral DosageNote two divided doses, q12hObserved Whole Blood Trough ConcentrationsAdult kidney transplant patients In combination with azathioprine In combination with MMF/IL-2 receptor antagonist In second smaller study, the initial dose of tacrolimus was 0.15-0.2 mg/kg/day and observed tacrolimus concentrations were 6-16 ng/mL during month 1-3 and 5-12 ng/mL during month 4-12 (see CLINICAL STUDIES). 0.2 mg/kg/day0.1 mg/kg/daymonth 1-3: 7-20 ng/mLmonth 4-12: 5-15 ng/mLmonth 1-12: 4-11 ng/mLAdult liver transplant patients0.10-0.15 mg/kg/daymonth 1-12: 5-20 ng/mLPediatric liver transplant patients0.15-0.20 mg/kg/daymonth 1-12: 5-20 ng/mLAdult heart transplant patients0.075 mg/kg/daymonth 1-3: 10-20 ng/mLmonth >=4: 5-15 ng/mL. Liver Transplantation. It is recommended that patients initiate oral therapy with Prograf capsules if possible. If IV therapy is necessary, conversion from IV to oral Prograf is recommended as soon as oral therapy can be tolerated. This usually occurs within 2-3 days. The initial dose of Prograf should be administered no sooner than hours after transplantation. In patient receiving an IV infusion, the first dose of oral therapy should be given 8-12 hours after discontinuing the IV infusion. The recommended starting oral dose of Prograf capsules is 0.10 to 0.15 mg/kg/day administered in two divided daily doses every 12 hours. Co-administered grapefruit juice has been reported to increase tacrolimus blood trough concentrations in liver transplant patients. (See Drugs that May Alter Tacrolimus Concentrations).Dosing should be titrated based on clinical assessments of rejection and tolerability. Lower Prograf dosages may be sufficient as maintenance therapy. Adjunct therapy with adrenal corticosteroids is recommended early post-transplant.Dosage and typical tacrolimus whole blood trough concentrations are shown in the table above; blood concentration details are described in Blood Concentration Monitoring: Liver Transplantation below.. Kidney Transplantation. The recommended starting oral dose of Prograf (administered every 12 hours in two divided doses) is 0.2 mg/kg/day when used in combination with azathioprine or 0.1 mg/kg/day when used in combination with MMF and IL-2 receptor antagonist (see CLINICAL STUDIES). The initial dose of Prograf may be administered within 24 hours of transplantation, but should be delayed until renal function has recovered (as indicated for example by serum creatinine <= mg/dL). Black patients may require higher doses to achieve comparable blood concentrations. Dosage and typical tacrolimus whole blood trough concentrations are shown in the table above; blood concentration details are described in Blood Concentration Monitoring: Kidney Transplantation below.The data in kidney transplant patients indicate that the Black patients required higher dose to attain comparable trough concentrations compared to Caucasian patients.Time After TransplantCaucasian n=114Blackn=56Dose(mg/kg)Trough Concentrations(ng/mL)Dose(mg/kg)Trough Concentrations (ng/mL)Day 70.1812.00.2310.9Month 10.1712.80.2612.9Month 60.1411.80.2411.5Month 120.1310.10.1911.0. Heart Transplantation. The recommended starting oral dose of Prograf is 0.075 mg/kg/day administered every 12 hours in two divided doses. If possible, initiating oral therapy with Prograf capsules is recommended. If IV therapy is necessary, conversion from IV to oral Prograf is recommended as soon as oral therapy can be tolerated. This usually occurs within 2-3 days. The initial dose of Prograf should be administered no sooner than hours after transplantation. In patient receiving an IV infusion, the first dose of oral therapy should be given 8-12 hours after discontinuing the IV infusion. Dosing should be titrated based on clinical assessments of rejection and tolerability. Lower Prograf dosages may be sufficient as maintenance therapy. Adjunct therapy with adrenal corticosteroids is recommended early post transplant.Dosage and typical tacrolimus whole blood trough concentrations are shown in the table above; blood concentration details are described in Blood Concentration Monitoring: Heart Transplantationbelow.. Pediatric Patients. Pediatric liver transplantation patients without pre-existing renal or hepatic dysfunction have required and tolerated higher doses than adults to achieve similar blood concentrations. Therefore, it is recommended that therapy be initiated in pediatric patients at starting IV dose of 0.03-0.05 mg/kg/day and starting oral dose of 0.15-0.20 mg/kg/day. Dose adjustments may be required. Experience in pediatric kidney and heart transplantation patients is limited.. Patients with Hepatic or Renal Dysfunction. Due to the reduced clearance and prolonged half-life, patients with severe hepatic impairment (Pugh >= 10) may require lower doses of Prograf. Close monitoring of blood concentrations is warranted. Due to the potential for nephrotoxicity, patients with renal or hepatic impairment should receive doses at the lowest value of the recommended IV and oral dosing ranges. Further reductions in dose below these ranges may be required. Prograf therapy usually should be delayed up to 48 hours or longer in patients with post-operative oliguria.. Conversion from One Immunosuppressive Regimen to Another. Prograf should not be used simultaneously with cyclosporine. Prograf or cyclosporine should be discontinued at least 24 hours before initiating the other. In the presence of elevated Prograf or cyclosporine concentrations, dosing with the other drug usually should be further delayed.. Blood Concentration Monitoring. Monitoring of tacrolimus blood concentrations in conjunction with other laboratory and clinical parameters is considered an essential aid to patient management for the evaluation of rejection, toxicity, dose adjustments and compliance. Factors influencing frequency of monitoring include but are not limited to hepatic or renal dysfunction, the addition or discontinuation of potentially interacting drugs and the posttransplant time. Blood concentration monitoring is not replacement for renal and liver function monitoring and tissue biopsies. Two methods have been used for the assay of tacrolimus, microparticle enzyme immunoassay (MEIA) and ELISA. Both methods have the same monoclonal antibody for tacrolimus. Comparison of the concentrations in published literature to patient concentrations using the current assays must be made with detailed knowledge of the assay methods and biological matrices employed. Whole blood is the matrix of choice and specimens should be collected into tubes containing ethylene diamine tetraacetic acid (EDTA) anti-coagulant. Heparin anti-coagulation is not recommended because of the tendency to form clots on storage. Samples which are not analyzed immediately should be stored at room temperature or in refrigerator and assayed within days; if samples are to be kept longer they should be deep frozen at -20 for up to 12 months.. Liver Transplantation. Although there is lack of direct correlation between tacrolimus concentrations and drug efficacy, data from Phase II and III studies of liver transplant patients have shown an increasing incidence of adverse events with increasing trough blood concentrations. Most patients are stable when trough whole blood concentrations are maintained between to 20 ng/mL. Long-term post-transplant patients often are maintained at the low end of this target range.Data from the U.S. clinical trial show that tacrolimus whole blood concentrations, as measured by ELISA, were most variable during the first week post-transplantation. After this early period, the median trough blood concentrations, measured at intervals from the second week to one year post-transplantation, ranged from 9.8 ng/mL to 19.4 ng/mL.Therapeutic Drug Monitoring, 1995, Volume 17, Number contains consensus document and several position papers regarding the therapeutic monitoring of tacrolimus from the 1995 International Consensus Conference on Immunosuppressive Drugs. Refer to these manuscripts for further discussions of tacrolimus monitoring.. Kidney Transplantation. Data from Phase study of Prograf in conjunction with azathioprine indicate that trough concentrations of tacrolimus in whole blood, as measured by IMx(R) were most variable during the first week of dosing. During the first three months of that trial, 80% of the patients maintained trough concentrations between 7-20 ng/mL, and then between 5-15 ng/mL, through year.In separate clinical trial of Prograf in conjunction with MMF and daclizumab, approximately 80% of patients maintained tacrolimus whole blood concentrations between 4-11 ng/mL through year post-transplant. In another clinical trial of Prograf in conjunction with MMF and basiliximab, approximately 80% of patients maintained tacrolimus whole trough blood concentrations between 6-16 ng/mL during month 1-3 and, then, between 5-12 ng/mL from month through year.The relative risks of toxicity and efficacy failure are related to tacrolimus whole blood trough concentrations. Therefore, monitoring of whole blood trough concentrations is recommended to assist in the clinical evaluation of toxicity and efficacy failure.. Heart Transplantation. Data from European Phase study indicate that trough concentrations of tacrolimus in whole blood, as measured by IMx(R) were most variable during the first week of dosing. From week to months post transplant, approximately 80% of patients maintained trough concentrations between 8-20 ng/mL and, from months through 18 months post transplant, approximately 80% of patients maintained trough concentrations between 6-18 ng/mL.The relative risk of toxicity; for example, nephrotoxicity and post-transplant diabetes mellitus, is increased with higher trough concentrations. Therefore, monitoring of whole blood trough concentrations is recommended to assist in the clinical evaluation of toxicity.

PRECAUTIONS SECTION.

PRECAUTIONS. General. Hypertension is common adverse effect of Prograf therapy (see ADVERSE REACTIONS). Mild or moderate hypertension is more frequently reported than severe hypertension. Antihypertensive therapy may be required; the control of blood pressure can be accomplished with any of the common antihypertensive agents. Since tacrolimus may cause hyperkalemia, potassium-sparing diuretics should be avoided. While calcium-channel blocking agents can be effective in treating Prograf-associated hypertension, care should be taken since interference with tacrolimus metabolism may require dosage reduction (see Drug Interactions).. Renally and Hepatically Impaired Patients For patients with renal insufficiency some evidence suggests that lower doses should be used (see CLINICAL PHARMACOLOGY and DOSAGE AND ADMINISTRATION).The use of Prograf in liver transplant recipients experiencing post-transplant hepatic impairment may be associated with increased risk of developing renal insufficiency related to high whole-blood levels of tacrolimus. These patients should be monitored closely and dosage adjustments should be considered. Some evidence suggests that lower doses should be used in these patients (see DOSAGE AND ADMINISTRATION).. Myocardial Hypertrophy. Myocardial hypertrophy has been reported in association with the administration of Prograf, and is generally manifested by echocardiographically demonstrated concentric increases in left ventricular posterior wall and interventricular septum thickness. Hypertrophy has been observed in infants, children and adults. This condition appears reversible in most cases following dose reduction or discontinuance of therapy. In group of 20 patients with pre- and post-treatment echocardiograms who showed evidence of myocardial hypertrophy, mean tacrolimus whole blood concentrations during the period prior to diagnosis of myocardial hypertrophy ranged from 11 to 53 ng/mL in infants (N=10, age 0.4 to years), to 46 ng/mL in children (N=7, age to 15 years) and 11 to 24 ng/mL in adults (N=3, age 37 to 53 years).In patients who develop renal failure or clinical manifestations of ventricular dysfunction while receiving Prograf therapy, echocardiographic evaluation should be considered. If myocardial hypertrophy is diagnosed, dosage reduction or discontinuation of Prograf should be considered.. Information for Patients. Patients should be informed of the need for repeated appropriate laboratory tests while they are receiving Prograf. They should be given complete dosage instructions, advised of the potential risks during pregnancy, and informed of the increased risk of neoplasia. Patients should be informed that changes in dosage should not be undertaken without first consulting their physician.Patients should be informed that Prograf can cause diabetes mellitus and should be advised of the need to see their physician if they develop frequent urination, increased thirst or hunger. As with other immunosuppressive agents, owing to the potential risk of malignant skin changes, exposure to sunlight and ultraviolet (UV) light should be limited by wearing protective clothing and using sunscreen with high protection factor.. Laboratory Tests. Serum creatinine, potassium, and fasting glucose should be assessed regularly. Routine monitoring of metabolic and hematologic systems should be performed as clinically warranted.. Drug Interactions. Due to the potential for additive or synergistic impairment of renal function, care should be taken when administering Prograf with drugs that may be associated with renal dysfunction. These include, but are not limited to, aminoglycosides, amphotericin B, and cisplatin. Initial clinical experience with the co-administration of Prograf and cyclosporine resulted in additive/synergistic nephrotoxicity. Patients switched from cyclosporine to Prograf should receive the first Prograf dose no sooner than 24 hours after the last cyclosporine dose. Dosing may be further delayed in the presence of elevated cyclosporine levels. Drugs that May Alter Tacrolimus Concentrations. Since tacrolimus is metabolized mainly by the CYP3A enzyme systems, substances known to inhibit these enzymes may decrease the metabolism or increase bioavailability of tacrolimus as indicated by increased whole blood or plasma concentrations. Drugs known to induce these enzyme systems may result in an increased metabolism of tacrolimus or decreased bioavailability as indicated by decreased whole blood or plasma concentrations. Monitoring of blood concentrations and appropriate dosage adjustments are essential when such drugs are used concomitantly.This table is not all inclusive.Drugs That May Increase Tacrolimus Blood ConcentrationsCalciumChannel BlockersAntifungal AgentsMacrolideAntibioticsdiltiazemclotrimazoleclarithromycinnicardipinefluconazoleerythromycinnifedipineitraconazoletroleandomycinverapamilketoconazoleIn study of normal volunteers, significant increase in tacrolimus oral bioavailability (14+-5% vs. 30+-8%) was observed with concomitant ketoconazole administration (200 mg). The apparent oral clearance of tacrolimus during ketoconazole administration was significantly decreased compared to tacrolimus alone (0.430+-0.129 L/hr/kg vs. 0.148+-0.043 L/hr/kg). Overall, IV clearance of tacrolimus was not significantly changed by ketoconazole co-administration, although it was highly variable between patients. voriconazoleGastrointestinal Prokinetic Agents Other Drugscisapridebromocriptinemetoclopramidechloramphenicolcimetidinecyclosporinedanazolethinyl estradiolmethylprednisolonelansoprazoleLansoprazole (CYP2C19, CYP3A4 substrate) may potentially inhibit CYP3A4-mediated metabolism of tacrolimus and thereby substantially increase tacrolimus whole blood concentrations, especially in transplant patients who are intermediate or poor CYP2C19 metabolizers, as compared to those patients who are efficient CYP2C19 metabolizers. omeprazoleprotease inhibitorsnefazodonemagnesium-aluminum-hydroxideThis table is not all inclusive.Drugs That May Decrease Tacrolimus Blood ConcentrationsAnticonvulsantsAntimicrobialscarbamazepinerifabutinphenobarbitalcaspofunginphenytoinrifampinHerbal PreparationsOther DrugsSt. Johns WortsirolimusSt. Johns Wort (Hypericum perforatum) induces CYP3A4 and P-glycoprotein. Since tacrolimus is substrate for CYP3A4, there is the potential that the use of St. Johns Wort in patients receiving Prograf could result in reduced tacrolimus levels.In single-dose crossover study in healthy volunteers, co-administration of tacrolimus and magnesium-aluminum-hydroxide resulted in 21% increase in the mean tacrolimus AUC and 10% decrease in the mean tacrolimus Cmax relative to tacrolimus administration alone.In study of normal volunteers, significant decrease in tacrolimus oral bioavailability (14+-6% vs. 7+-3%) was observed with concomitant rifampin administration (600 mg). In addition, there was significant increase in tacrolimus clearance (0.036+-0.008 L/hr/kg vs. 0.053+-0.010 L/hr/kg) with concomitant rifampin administration.Interaction studies with drugs used in HIV therapy have not been conducted. However, care should be exercised when drugs that are nephrotoxic (e.g., ganciclovir) or that are metabolized by CYP3A (e.g., nelfinavir, ritonavir) are administered concomitantly with tacrolimus. Based on clinical study of liver transplant recipients, co-administration of tacrolimus with nelfinavir increased blood concentrations of tacrolimus significantly and, as result, reduction in the tacrolimus dose by an average of 16-fold was needed to maintain mean trough tacrolimus blood concentrations of 9.7 ng/mL. Thus, frequent monitoring of tacrolimus blood concentrations and appropriate dosage adjustments are essential when nelfinavir is used concomitantly. Tacrolimus may affect the pharmacokinetics of other drugs (e.g., phenytoin) and increase their concentration. Grapefruit juice affects CYP3A-mediated metabolism and should be avoided (see DOSAGE AND ADMINISTRATION).Following co-administration of tacrolimus and sirolimus (2 or mg/day) in stable renal transplant patients, mean tacrolimus AUC0-12 and Cmin decreased approximately by 30% relative to tacrolimus alone. Mean tacrolimus AUC0-12 and Cmin following co-administration of mg/day of sirolimus decreased approximately 3% and 11%, respectively. The safety and efficacy of tacrolimus used in combination with sirolimus for the prevention of graft rejection has not been established and is not recommended.. Other Drug Interactions. Immunosuppressants may affect vaccination. Therefore, during treatment with Prograf, vaccination may be less effective. The use of live vaccines should be avoided; live vaccines may include, but are not limited to measles, mumps, rubella, oral polio, BCG, yellow fever, and TY 21a typhoid.1 At given MMF dose, mycophenolic acid (MPA) exposure is higher with Prograf co-administration than with cyclosporine co-administration due to the differences in the interruption of the enterohepatic recirculation of MPA. Clinicians should be aware that there is also potential for increased MPA exposure after crossover from cyclosporine to tacrolimus in patients concomitantly receiving MMF or MPA.. Carcinogenesis, Mutagenesis and Impairment of Fertility. An increased incidence of malignancy is recognized complication of immunosuppression in recipients of organ transplants. The most common forms of neoplasms are non-Hodgkins lymphomas and carcinomas of the skin. As with other immunosuppressive therapies, the risk of malignancies in Prograf recipients may be higher than in the normal, healthy population. Lymphoproliferative disorders associated with Epstein-Barr Virus infection have been seen. It has been reported that reduction or discontinuation of immunosuppression may cause the lesions to regress.No evidence of genotoxicity was seen in bacterial (Salmonella and E. coli) or mammalian (Chinese hamster lung-derived cells) in vitro assays of mutagenicity, the in vitro CHO/HGPRT assay of mutagenicity, or in vivo clastogenicity assays performed in mice; tacrolimus did not cause unscheduled DNA synthesis in rodent hepatocytes.Carcinogenicity studies were carried out in male and female rats and mice. In the 80-week mouse study and in the 104-week rat study no relationship of tumor incidence to tacrolimus dosage was found. The highest doses used in the mouse and rat studies were 0.8 2.5 times (mice) and 3.5 7.1 times (rats) the recommended clinical dose range of 0.1 0.2 mg/kg/day when corrected for body surface area.No impairment of fertility was demonstrated in studies of male and female rats. Tacrolimus, given orally at 1.0 mg/kg (0.7 1.4X the recommended clinical dose range of 0.1 0.2 mg/kg/day based on body surface area corrections) to male and female rats, prior to and during mating, as well as to dams during gestation and lactation, was associated with embryolethality and with adverse effects on female reproduction. Effects on female reproductive function (parturition) and embryolethal effects were indicated by higher rate of pre-implantation loss and increased numbers of undelivered and nonviable pups. When given at 3.2 mg/kg (2.3 4.6X the recommended clinical dose range based on body surface area correction), tacrolimus was associated with maternal and paternal toxicity as well as reproductive toxicity including marked adverse effects on estrus cycles, parturition, pup viability, and pup malformations.. Pregnancy: Category C. In reproduction studies in rats and rabbits, adverse effects on the fetus were observed mainly at dose levels that were toxic to dams. Tacrolimus at oral doses of 0.32 and 1.0 mg/kg during organogenesis in rabbits was associated with maternal toxicity as well as an increase in incidence of abortions; these doses are equivalent to 0.5 1X and 1.6 3.3X the recommended clinical dose range (0.1 0.2 mg/kg) based on body surface area corrections. At the higher dose only, an increased incidence of malformations and developmental variations was also seen. Tacrolimus, at oral doses of 3.2 mg/kg during organogenesis in rats, was associated with maternal toxicity and caused an increase in late resorptions, decreased numbers of live births, and decreased pup weight and viability. Tacrolimus, given orally at 1.0 and 3.2 mg/kg (equivalent to 0.7 1.4X and 2.3 4.6X the recommended clinical dose range based on body surface area corrections) to pregnant rats after organogenesis and during lactation, was associated with reduced pup weights.No reduction in male or female fertility was evident.There are no adequate and well-controlled studies in pregnant women. Tacrolimus is transferred across the placenta. The use of tacrolimus during pregnancy has been associated with neonatal hyperkalemia and renal dysfunction. Prograf should be used during pregnancy only if the potential benefit to the mother justifies potential risk to the fetus.. Nursing Mothers. Since tacrolimus is excreted in human milk, nursing should be avoided.. Pediatric Patients. Experience with Prograf in pediatric kidney and heart transplant patients is limited. Successful liver transplants have been performed in pediatric patients (ages up to 16 years) using Prograf. Two randomized active-controlled trials of Prograf in primary liver transplantation included 56 pediatric patients. Thirty-one patients were randomized to Prograf-based and 25 to cyclosporine-based therapies. Additionally, minimum of 122 pediatric patients were studied in an uncontrolled trial of tacrolimus in living related donor liver transplantation. Pediatric patients generally required higher doses of Prograf to maintain blood trough concentrations of tacrolimus similar to adult patients (see DOSAGE AND ADMINISTRATION).

WARNINGS SECTION.

WARNINGS. (See boxed WARNING). Post-Transplant Diabetes Mellitus. Insulin-dependent post-transplant diabetes mellitus (PTDM) was reported in 20% of Prograf-treated kidney transplant patients without pretransplant history of diabetes mellitus in the Phase III study (See Tables Below). The median time to onset of PTDM was 68 days. Insulin dependence was reversible in 15% of these PTDM patients at one year and in 50% at years post transplant. Black and Hispanic kidney transplant patients were at an increased risk of development of PTDM.Incidence of Post Transplant Diabetes Mellitus and Insulin Use at Years in Kidney Transplant Recipients in the Phase III studyStatus of PTDMuse of insulin for 30 or more consecutive days, with 5 day gap, without prior history of insulin dependent diabetes mellitus or non insulin dependent diabetes mellitus.PrografCBIRPatients without pretransplant history of diabetes mellitus.151151New onset PTDM, 1st Year30/151 (20%)6/151 (4%)Still insulin dependent at one year in those without prior history of diabetes.25/151 (17%)5/151 (3%)New onset PTDM post year10Patients with PTDM at years16/151 (11%)5/151 (3%)Development of Post Transplant Diabetes Mellitus by Race and by Treatment Group during First Year Post Kidney Transplantation in the Phase III studyPatientRacePrografCBIRNo. of Patients at RiskPatients Who Developed PTDMuse of insulin for 30 or more consecutive days, with 5 day gap, without prior history of insulin dependent diabetes mellitus or non insulin dependent diabetes mellitus.No. of Patients At RiskPatients Who Developed PTDMBlack4115 (37%)363 (8%)Hispanic175 (29%)181 (6%)Caucasian8210 (12%)871 (1%)Other110 (0%)101 (10%)Total15130 (20%)1516 (4%)Insulin-dependent post-transplant diabetes mellitus was reported in 18% and 11% of Prograf-treated liver transplant patients and was reversible in 45% and 31% of these patients at year post transplant, in the U.S. and European randomized studies, respectively (See Table below). Hyperglycemia was associated with the use of Prograf in 47% and 33% of liver transplant recipients in the U.S. and European randomized studies, respectively, and may require treatment (see ADVERSE REACTIONS).Incidence of Post Transplant Diabetes Mellitus and Insulin Use at Year in Liver Transplant RecipientsStatus of PTDMuse of insulin for 30 or more consecutive days, with 5 day gap, without prior history of insulin dependent diabetes mellitus or non insulin dependent diabetes mellitus.US StudyEuropean StudyPrografCBIRPrografCBIRPatients at riskPatients without pretransplant history of diabetes mellitus. 239236239249New Onset PTDM 42 (18%)30 (13%)26 (11%)12 (5%)Patients still on insulin at year23 (10%)19 (8%)18 (8%)6 (2%)Insulin-dependent post-transplant diabetes mellitus was reported in 13% and 22% of Prograf-treated heart transplant patients receiving mycophenolate mofetil or azathioprine and was reversible in 30% and 17% of these patients at one year post transplant, in the US and European randomized studies, respectively (See Table below). Hyperglycemia defined as two fasting plasma glucose levels >=126 mg/dL was reported with the use of Prograf plus mycophenolate mofetil or azathioprine in 32% and 35% of heart transplant recipients in the US and European randomized studies, respectively, and may require treatment (see ADVERSE REACTIONS).Incidence of Post Transplant Diabetes Mellitus and Insulin Use at Year in Heart Transplant RecipientsStatus of PTDMuse of insulin for 30 or more consecutive days without prior history of insulin dependent diabetes mellitus or non insulin dependent diabetes mellitus. US StudyEuropean StudyPrograf/SirolimusPrograf/MMFCyclosporine/MMFPrograf/AZACyclosporine/AZAPatients at riskPatients without pretransplant history of diabetes mellitus. 857583132138New Onset PTDM 21 (25%)10 (13%)6 (7%)29 (22%)5 (4%)Patients still on insulin at year7-12 months for the US Study. 10 (12%)7 (9%)1 (1%)24 (18%)4 (3%). Nephrotoxicity. Prograf can cause nephrotoxicity, particularly when used in high doses. Nephrotoxicity was reported in approximately 52% of kidney transplantation patients and in 40% and 36% of liver transplantation patients receiving Prograf in the U.S. and European randomized trials, respectively, and in 59% of heart transplantation patients in European randomized trial (see ADVERSE REACTIONS). Use of Prograf with sirolimus in heart transplantation patients in US study was associated with increased risk of renal function impairment, and is not recommended (See CLINICAL STUDIES). More overt nephrotoxicity is seen early after transplantation, characterized by increasing serum creatinine and decrease in urine output. Patients with impaired renal function should be monitored closely as the dosage of Prograf may need to be reduced. In patients with persistent elevations of serum creatinine who are unresponsive to dosage adjustments, consideration should be given to changing to another immunosuppressive therapy. Care should be taken in using tacrolimus with other nephrotoxic drugs. In particular, to avoid excess nephrotoxicity, Prograf should not be used simultaneously with cyclosporine. Prograf or cyclosporine should be discontinued at least 24 hours prior to initiating the other. In the presence of elevated Prograf or cyclosporine concentrations, dosing with the other drug usually should be further delayed. Hyperkalemia. Mild to severe hyperkalemia was reported in 31% of kidney transplant recipients and in 45% and 13% of liver transplant recipients treated with Prograf in the U.S. and European randomized trials, respectively, and in 8% of heart transplant recipients in European randomized trial and may require treatment (see ADVERSE REACTIONS). Serum potassium levels should be monitored and potassium-sparing diuretics should not be used during Prograf therapy (see PRECAUTIONS).. Neurotoxicity. Prograf can cause neurotoxicity, particularly when used in high doses. Neurotoxicity, including tremor, headache, and other changes in motor function, mental status, and sensory function were reported in approximately 55% of liver transplant recipients in the two randomized studies. Tremor occurred more often in Prograf-treated kidney transplant patients (54%) and heart transplant patients (15%) compared to cyclosporine-treated patients. The incidence of other neurological events in kidney transplant and heart transplant patients was similar in the two treatment groups (see ADVERSE REACTIONS). Tremor and headache have been associated with high whole-blood concentrations of tacrolimus and may respond to dosage adjustment. Seizures have occurred in adult and pediatric patients receiving Prograf (see ADVERSE REACTIONS). Coma and delirium also have been associated with high plasma concentrations of tacrolimus. Patients treated with tacrolimus have been reported to develop posterior reversible encephalopathy syndrome (PRES). Symptoms indicating PRES include headache, altered mental status, seizures, visual disturbances and hypertension. Diagnosis may be confirmed by radiological procedure. If PRES is suspected or diagnosed, blood pressure control should be maintained and immediate reduction of immunosuppression is advised. This syndrome is characterized by reversal of symptoms upon reduction or discontinuation of immunosuppression.. Malignancy and Lymphoproliferative Disorders. As in patients receiving other immunosuppressants, patients receiving Prograf are at increased risk of developing lymphomas and other malignancies, particularly of the skin. The risk appears to be related to the intensity and duration of immunosuppression rather than to the use of any specific agent. lymphoproliferative disorder (LPD) related to Epstein-Barr Virus (EBV) infection has been reported in immunosuppressed organ transplant recipients. The risk of LPD appears greatest in young children who are at risk for primary EBV infection while immunosuppressed or who are switched to Prograf following long-term immunosuppression therapy. Because of the danger of oversuppression of the immune system which can increase susceptibility to infection, combination immunosuppressant therapy should be used with caution.. Latent Viral Infections. Immunosuppressed patients are at increased risk for opportunistic infections, including activation of latent viral infections. These include BK virus associated nephropathy and JC virus associated progressive multifocal leukoencephalopathy (PML) which have been observed in patients receiving tacrolimus. These infections may lead to serious, including fatal, outcomes.. Prograf in Combination with Sirolimus The use of full-dose Prograf with sirolimus (2 mg per day) in heart transplant recipients was associated with increased risk of wound healing complications, renal function impairment, and insulin-dependent post-transplant diabetes mellitus, and is not recommended (see CLINICAL STUDIES).. Anaphylactic Reactions. few patients receiving Prograf injection have experienced anaphylactic reactions. Although the exact cause of these reactions is not known, other drugs with castor oil derivatives in the formulation have been associated with anaphylaxis in small percentage of patients. Because of this potential risk of anaphylaxis, Prograf injection should be reserved for patients who are unable to take Prograf capsules.Patients receiving Prograf injection should be under continuous observation for at least the first 30 minutes following the start of the infusion and at frequent intervals thereafter. If signs or symptoms of anaphylaxis occur, the infusion should be stopped. An aqueous solution of epinephrine should be available at the bedside as well as source of oxygen.