These highlights do not include all the information needed to use TACROLIMUS CAPSULES safely and effectively. See full prescribing information for TACROLIMUS CAPSULES.TACROLIMUS capsules, for oral use Initial U.S. Approval: 1994

Tacrolimus by

Drug Labeling and Warnings

Tacrolimus by is a Prescription medication manufactured, distributed, or labeled by REMEDYREPACK INC.. Drug facts, warnings, and ingredients follow.

Drug Details [pdf]

TACROLIMUS- tacrolimus capsule 
REMEDYREPACK INC.

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FULL PRESCRIBING INFORMATION

WARNINGS: MALIGNANCIES AND SERIOUS INFECTIONS

• Increased risk of development of lymphoma and other malignancies, particularly of the skin, due to immunosuppression [see Warnings and Precautions( 5.2)].
• Increased susceptibility to bacterial, viral, fungal, and protozoal infections, including opportunistic infections [ see Warnings andPrecautions( 5.3, 5.4, 5.5)].
• Only physicians experienced in immunosuppressive therapy and management of organ transplant patients should prescribe tacrolimus. Patients receiving the drug should be managed in facilities equipped and staffed with adequate laboratory and supportive medical resources. The physician responsible for maintenance therapy should have complete information requisite for the follow-up of the patient [ see Warnings and Precautions( 5.1)].

1 INDICATIONS AND USAGE

1.1 Prophylaxis of Organ Rejection in Kidney Transplant

Tacrolimus Capsules is indicated for the prophylaxis of organ rejection in patients receiving allogeneic kidney transplants. It is recommended that tacrolimus be used concomitantly with azathioprine or mycophenolate mofetil (MMF) and adrenal corticosteroids [ see Clinical Studies( 14.1)] . Therapeutic drug monitoring is recommended for all patients receiving tacrolimus [ see Dosage and Administration( 2.6)].

1.2 Prophylaxis of Organ Rejection in Liver Transplant

Tacrolimus Capsules is indicated for the prophylaxis of organ rejection in patients receiving allogeneic liver transplants. It is recommended that tacrolimus be used concomitantly with adrenal corticosteroids [ see Clinical Studies( 14.2)]. Therapeutic drug monitoring is recommended for all patients receiving tacrolimus[ see Dosage and Administration( 2.6)].

1.3 Prophylaxis of Organ Rejection in Heart Transplant

Tacrolimus Capsules is indicated for the prophylaxis of organ rejection in patients receiving allogeneic heart transplants. It is recommended that tacrolimus capsules be used concomitantly with azathioprine or mycophenolate mofetil (MMF) and adrenal corticosteroids [ see Clinical Studies( 14.3)]. Therapeutic drug monitoring is recommended for all patients receiving tacrolimus capsules [ see Dosage and Administration( 2.6)].

1.4 Limitations of Use

Tacrolimus Capsules should not be used simultaneously with cyclosporine [ see Dosage and Administration( 2.5)].

Use with sirolimus is not recommended in liver and heart transplant. The safety and efficacy of tacrolimus with sirolimus has not been established in kidney transplant [ see Warnings and Precautions( 5.12)].

Intravenous use reserved for patients who cannot tolerate capsules orally.

2 DOSAGE AND ADMINISTRATION

2.1 Dosage in Adult Kidney, Liver or Heart Transplant Patients

The initial oral dosage recommendations for adult patients with kidney, liver or heart transplants along with recommendations for whole blood trough concentrations are shown in Table 1. The initial dose of tacrolimus should be administered no sooner than 6 hours after transplantation in the liver and heart transplant patients. In kidney transplant patients, the initial dose of tacrolimus may be administered within 24 hours of transplantation, but should be delayed until renal function has recovered. For blood concentration monitoring details [ see Dosage and Administration( 2.6)]

Table 1. Summary of Initial Oral Dosage Recommendations and Observed Whole Blood Trough Concentrations in Adults

Patient Population	Recommended Tacrolimus Initial Oral Dosage Note: daily doses should be administered as two divided doses, every 12 hours	Observed Tacrolimus Whole Blood Trough Concentrations
Adult kidney transplant patients		month 1-3: 7-20 ng/mL
In combination with azathioprine	0.2 mg/kg/day	month 4-12: 5-15 ng/mL
In combination with MMF/IL-2 receptor antagonist a	0.1 mg/kg/day	month 1-12: 4-11 ng/mL
Adult liver transplant patients	0.10-0.15 mg/kg/day	month 1-12: 5-20 ng/mL
Adult heart transplant patients	0.075 mg/kg/day	month 1-3: 10-20 ng/mL month ≥4: 5-15 ng/mL

a)In a second smaller trial, 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( 14.1)].

Dosing should be titrated based on clinical assessments of rejection and tolerability. Lower tacrolimus dosages than the recommended initial dosage may be sufficient as maintenance therapy. Adjunct therapy with adrenal corticosteroids is recommended early post-transplant.

The data in kidney transplant patients indicate that the Black patients required a higher dose to attain comparable trough concentrations compared to Caucasian patients Table 2.

Table 2. Comparative Dose and Trough Concentrations Based on Race 

Time After Transplant	Caucasian n=114		Black n=56
	Dose (mg/kg)	Trough Concentrations (ng/mL)	Dose (mg/kg)	Trough Concentrations (ng/mL)
Day 7	0.18	12.0	0.23	10.9
Month 1	0.17	12.8	0.26	12.9
Month 6	0.14	11.8	0.24	11.5
Month 12	0.13	10.1	0.19	11.0

Initial Dose – Injection

Tacrolimus injection should be used only as a continuous IV infusion and when the patient cannot tolerate oral administration of tacrolimus capsules. Tacrolimus injection should be discontinued as soon as the patient can tolerate oral administration of tacrolimus, usually within 2-3 days. In a patient receiving an IV infusion, the first dose of oral therapy should be given 8-12 hours after discontinuing the IV infusion.

The observed trough concentrations described above pertain to oral administration of tacrolimus only; while monitoring tacrolimus concentrations in patients receiving tacrolimus injection as a continuous IV infusion may have some utility, the observed concentrations will not represent comparable exposures to those estimated by the trough concentrations observed in patients on oral therapy.

The recommended starting dose of tacrolimus injection is 0.03-0.05 mg/kg/day in kidney and liver transplant and 0.01 mg/kg/day in heart transplant given as a 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.

Anaphylactic reactions have occurred with injectables containing castor oil derivatives, such as Tacrolimus injection [ see warnings and Precautions( 5.11)]

2.2 Dosage in Pediatric Liver Transplant Patients

The initial oral dosage recommendations for pediatric patients with liver transplants along with recommendations for whole blood trough concentrations are shown in Table 3. For blood concentration monitoring details [see Dosage and Administration (2.6)]. If necessary, pediatric patients may start on an IV dose of 0.03-0.05 mg/kg/day.

Table 3. Summary of Initial Oral Dosage Recommendations and Observed Whole Blood Trough Concentrations in Children 

Patient Population	Recommended Tacrolimus Initial Oral DosageNote: daily doses should be administered as two divided doses, every 12 hours	Observed Tacrolimus Whole Blood Trough Concentrations
Pediatric liver transplant patients	0.15-0.20 mg/kg/day	Month 1-12: 5-20 ng/mL

Pediatric liver transplantation patients without pre-existing renal or hepatic dysfunction have required and tolerated higher doses than adults to achieve similar blood concentrations. Experience in pediatric kidney and heart transplantation patients is limited.

2.3 Dosage Adjustment in Patients with Renal Impairment

Due to its potential for nephrotoxicity, consideration should be given to dosing tacrolimus at the lower end of the therapeutic dosing range in patients who have received a liver or heart transplant and have pre-existing renal impairment. Further reductions in dose below the targeted range may be required.

In kidney transplant patients with post-operative oliguria, the initial dose of tacrolimus should be administered no sooner than 6 hours and within 24 hours of transplantation, but may be delayed until renal function shows evidence of recovery.

2.4 Dosage Adjustment in Patients with Hepatic Impairment

Due to the reduced clearance and prolonged half-life, patients with severe hepatic impairment (Child Pugh ≥ 10) may require lower doses of tacrolimus. Close monitoring of blood concentrations is warranted.

The use of tacrolimus in liver transplant recipients experiencing post-transplant hepatic impairment may be associated with increased risk of developing renal insufficiency related to high whole-blood concentrations 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( 2.1), Use in Specific Populations( 8.7) and Clinical Pharmacology( 12.3) ].

2.5 Administration Instructions

It is recommended that patients initiate oral therapy with tacrolimus capsules if possible.

Initial dosage and observed tacrolimus whole blood trough concentrations for adults are shown in Table 1 and for pediatrics in Table 3 [ see Dosageand Administration( 2.1, 2.2)]; for blood concentration monitoring details in kidney transplant patients [ see Dosage and Administration( 2.1)].

It is important to take tacrolimus capsules consistently every day either with or without food because the presence and composition of food decreases the bioavailability of tacrolimus capsules [ see Clinical Pharmacology( 12.3)].

Patients should not eat grapefruit or drink grapefruit juice in combination with tacrolimus capsules [ see Drug Interactions( 7.2)]

Tacrolimus capsules should not be used simultaneously with cyclosporine. Tacrolimus or cyclosporine should be discontinued at least 24 hours before initiating the other. In the presence of elevated tacrolimus or cyclosporine concentrations, dosing with the other drug usually should be further delayed.

In patients unable to take oral tacrolimus capsules, therapy may be initiated with tacrolimus injection as a continuous IV infusion. If IV therapy is necessary, conversion from IV to oral tacrolimus is recommended as soon as oral therapy can be tolerated. This usually occurs within 2-3 days. In patients receiving an IV infusion, the first dose of oral therapy should be given 8-12 hours after discontinuing the IV infusion.

2.6 Therapeutic Drug 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. Observed whole blood trough concentrations can be found in Table 1. 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 post-transplant time. Blood concentration monitoring is not a replacement for renal and liver function monitoring and tissue biopsies. Data from clinical trials show that tacrolimus whole blood concentrations were most variable during the first week post-transplantation.

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.

Methods commonly used for the assay of tacrolimus include high performance liquid chromatography with tandem mass spectrometric detection (HPLC/MS/MS) and immunoassays. Immunoassays may react with metabolites as well as parent compound. Therefore assay results obtained with immunoassays may have a positive bias relative to results of HPLC/MS. The bias may depend upon the specific assay and laboratory. 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 a refrigerator and assayed within 7 days; see assay instructions for specifics. If samples are to be kept longer they should be deep frozen at -20° C. One study showed drug recovery >90% for samples stored at -20° C for 6 months, with reduced recovery observed after 6 months.

3 DOSAGE FORMS AND STRENGTHS

Oblong, hard capsule for oral administration contains anhydrous tacrolimus USP as follows:

o Tacrolimus Capsules USP, 1 mg are white to off white powder filled in hard gelatin capsule of size ‘4’, white opaque cap and white opaque body imprinted “ BP666” twice on the body and imprinted “1 mg” twice on the cap with red ink.

4 CONTRAINDICATIONS

Tacrolimus capsules are contraindicated in patients with a hypersensitivity to tacrolimus. Tacrolimus injection is contraindicated in patients with a hypersensitivity to HCO-60 (polyoxyl 60 hydrogenated castor oil). Hypersensitivity symptoms reported include dyspnea, rash, pruritus, and acute respiratory distress syndrome [see Adverse Reactions (6)].

5 WARNINGS AND PRECAUTIONS

5.1 Management of Immunosuppression

Only physicians experienced in immunosuppressive therapy and management of organ transplant patients should use tacrolimus. Patients receiving the drug should be managed in facilities equipped and staffed with adequate laboratory and supportive medical resources. The physicians responsible for maintenance therapy should have complete information requisite for the follow up of the patient [ see Boxed Warning].

5.2 Lymphoma and Other Malignancies

Patients receiving immunosuppressants, including tacrolimus, are at increased risk of developing lymphomas and other malignancies, particularly of the skin [ see Boxed Warning]. The risk appears to be related to the intensity and duration of immunosuppression rather than to the use of any specific agent.

As usual for patients with increased risk for skin cancer, exposure to sunlight and UV light should be limited by wearing protective clothing and using a sunscreen with a high protection factor.

Post transplant lymphoproliferative disorder (PTLD) has been reported in immunosuppressed organ transplant recipients. The majority of PTLD events appear related to Epstein Barr Virus (EBV) infection. The risk of PTLD appears greatest in those individuals who are EBV seronegative, a population which includes many young children.

5.3 Serious Infections

Patients receiving immunosuppressants, including tacrolimus, are at increased risk of developing bacterial, viral, fungal, and protozoal infections, including opportunistic infections [ see Boxed Warning and Warnings and Precautions( 5.4, 5.5)].

These infections may lead to serious, including fatal, outcomes. Because of the danger of oversuppression of the immune system which can increase susceptibility to infection, combination immunosuppressant therapy should be used with caution.

5.4 Polyoma Virus Infections

Patients receiving immunosuppressants, including Tacrolimus, are at increased risk for opportunistic infections, including polyoma virus infections. Polyoma virus infections in transplant patients may have serious, and sometimes fatal, outcomes. These include polyoma virus-associated nephropathy (PVAN), mostly due to BK virus infection, and JC virus-associated progressive multifocal leukoencephalopathy (PML) which have been observed in patients receiving Tacrolimus [ see Adverse Reactions( 6.2)].

PVAN is associated with serious outcomes, including deteriorating renal function and kidney graft loss [ see Adverse Reactions( 6.2)]. Patient monitoring may help detect patients at risk for PVAN.

Cases of PML have been reported in patients treated with Tacrolimus. PML, which is sometimes fatal, commonly presents with hemiparesis, apathy, confusion, cognitive deficiencies and ataxia. Risk factors for PML include treatment with immunosuppressant therapies and impairment of immune function. In immunosuppressed patients, physicians should consider PML in the differential diagnosis in patients reporting neurological symptoms and consultation with a neurologist should be considered as clinically indicated.

Reductions in immunosuppression should be considered for patients who develop evidence of PVAN or PML. Physicians should also consider the risk that reduced immunosuppression represents to the functioning allograft.

5.5 Cytomegalovirus (CMV) Infections

Patients receiving immunosuppressants, including tacrolimus, are at increased risk of developing CMV viremia and CMV disease. The risk of CMV disease is highest among transplant recipients seronegative for CMV at time of transplant who receive a graft from a CMV seropositive donor. Therapeutic approaches to limiting CMV disease exist and should be routinely provided. Patient monitoring may help detect patients at risk for CMV disease. Consideration should be given to reducing the amount of immunosuppression in patients who develop CMV viremia and/or CMV disease.

5.6 New Onset Diabetes After Transplant

Tacrolimus capsules shown to cause new onset diabetes mellitus in clinical trials of kidney, liver and heart transplantation. New onset diabetes after transplantation may be reversible in some patients. Black and Hispanic kidney transplant patients are at an increased risk. Blood glucose concentrations should be monitored closely in patients using Tacrolimus [ see Adverse Reactions( 6.1)].

5.7 Nephrotoxicity

Tacrolimus, like other calcineurin-inhibitors, can cause acute or chronic nephrotoxicity, particularly when used in high doses. Acute nephrotoxicity is most often related to vasoconstriction of the afferent renal arteriole, is characterized by increasing serum creatinine, hyperkalemia, and/or a decrease in urine output, and is typically reversible. Chronic calcineurin-inhibitor nephrotoxicity is associated with increased serum creatinine, decreased kidney graft life, and characteristic histologic changes observed on renal biopsy; the changes associated with chronic calcineurin-inhibitor nephrotoxicity are typically progressive. Patients with impaired renal function should be monitored closely as the dosage of tacrolimus 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.

Based on reported adverse reactions terms related to decreased renal function, nephrotoxicity was reported in approximately 52% of kidney transplantation patients and in 40% and 36% of liver transplantation patients receiving tacrolimus in the U.S. and European randomized trials, respectively, and in 59% of heart transplantation patients in a European randomized trial [ see Adverse Reactions( 6.1)].

Due to the potential for additive or synergistic impairment of renal function, care should be taken when administering tacrolimus with drugs that may be associated with renal dysfunction. These include, but are not limited to, aminoglycosides, ganciclovir, amphotericin B, cisplatin, nucleotide reverse transcriptase inhibitors (e.g., tenofovir) and protease inhibitors (e.g., ritonavir, indinavir). Similarly, care should be exercised when administering with CYP3A4 inhibitors such as antifungal drugs (e.g., ketoconazole), calcium channel blockers (e.g., diltiazem, verapamil), and macrolide antibiotics (e.g., clarithromycin, erythromycin, troleandomycin) which will result in increased tacrolimus whole blood concentrations due to inhibition of tacrolimus metabolism [ see Drug Interactions( 7.3, 7.4, 7.5, 7.6)].

5.8 Neurotoxicity

Tacrolimus may cause a spectrum of neurotoxicities, particularly when used in high doses. The most severe neurotoxicities include posterior reversible encephalopathy syndrome (PRES), delirium, and coma. Patients treated with tacrolimus have been reported to develop 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.

Coma and delirium, in the absence of PRES, have also been associated with high plasma concentrations of tacrolimus. Seizures have occurred in adult and pediatric patients receiving tacrolimus [ see Adverse Reactions( 6.1)].

Less severe neurotoxicities, include tremors, paresthesias, headache, and other changes in motor function, mental status, and sensory function [ see Adverse Reactions( 6.1)]. Tremor and headache have been associated with high whole-blood concentrations of tacrolimus and may respond to dosage adjustment.

5.9 Hyperkalemia

Hyperkalemia has been reported with Tacrolimus use. Serum potassium levels should be monitored. Careful consideration should be given prior to use of other agents also associated with hyperkalemia (e.g., potassium-sparing diuretics, ACE inhibitors, angiotensin receptor blockers) during Tacrolimus therapy [ see Adverse Reactions( 6.1)].

5.10 Hypertension

Hypertension is a common adverse effect of tacrolimus therapy and may require antihypertensive therapy [ see Adverse Reactions( 6.1)]. The control of blood pressure can be accomplished with any of the common antihypertensive agents, though careful consideration should be given prior to use of antihypertensive agents associated with hyperkalemia (e.g., potassium-sparing diuretics, ACE inhibitors, angiotensin receptor blockers) [ see Warnings and Precautions(5.9)]. Calcium-channel blocking agents may increase tacrolimus blood concentrations and therefore require dosage reduction of tacrolimus [ see Drug Interactions( 7.5)].

5.11 Anaphylactic Reactions with Tacrolimus Injections

Anaphylactic reactions have occurred with injectables containing castor oil derivatives, including tacrolimus, in a small percentage of patients (0.6%). The exact cause of these reactions is not known. Tacrolimus injection should be reserved for patients who are unable to take Tacrolimus capsules [ see Indications and Usage( 1.4)].
Patients receiving Tacrolimus 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 a source of oxygen.

5.12 Use with Sirolimus

The safety and efficacy of tacrolimus with sirolimus has not been established in kidney transplant patients.

Use of sirolimus with tacrolimus in studies of de novo liver transplant patients was associated with an excess mortality, graft loss, and hepatic artery thrombosis (HAT) and is not recommended [ see Indications and Usage( 1.4)].

Use of sirolimus (2 mg per day) with tacrolimus in heart transplant patients in a U.S. trial was associated with increased risk of renal function impairment, wound healing complications, and insulin-dependent post–transplant diabetes mellitus, and is not recommended [ see Clinical Studies( 14.3)].

5.13 Use with CYP3A4 Inhibitors and Inducers

When coadministering tacrolimus with strong CYP3A4 – inhibitors (e.g., telaprevir, boceprevir, ritonavir, ketoconazole, itraconazole, voriconazole, clarithromycin) and strong inducers (e.g., rifampin, rifabutin) adjustments in the dosing regimen of tacrolimus and subsequent frequent monitoring of tacrolimus whole blood trough concentrations and tacrolimus associated adverse reactions are recommended [ see DrugInteractions( 7)].

5.14 QT Prolongation

Tacrolimus Capsules may prolong the QT/QTc interval and may cause Torsade de Pointes. Avoid tacrolimus in patients with congenital long QT syndrome. In patients with congestive heart failure, bradyarrhythmias, those taking certain antiarrhythmic medications or other medicinal products that lead to QT prolongation, and those with electrolyte disturbances such as hypokalemia, hypocalcemia, or hypomagnesemia, consider obtaining electrocardiograms and monitoring electrolytes (magnesium, potassium, calcium) periodically during treatment.

When coadministering tacrolimus Capsules with other substrates and/or inhibitors of CYP3A4 that also have the potential to prolong the QT interval, a reduction in tacrolimus dose, frequent monitoring of tacrolimus whole blood concentrations, and monitoring for QT prolongation is recommended. Use of tacrolimus Capsules with amiodarone has been reported to result in increased tacrolimus whole blood concentrations with or without concurrent QT prolongation [ see Drug Interactions( 7)].

5.15 Myocardial Hypertrophy

Myocardial hypertrophy has been reported in infants, children, and adults, particularly those with high tacrolimus trough concentrations, and is generally manifested by echocardiographically demonstrated concentric increases in left ventricular posterior wall and interventricular septum thickness. This condition appears reversible in most cases following dose reduction or discontinuance of therapy. In patients who develop renal failure or clinical manifestations of ventricular dysfunction while receiving tacrolimus therapy, echocardiographic evaluation should be considered. If myocardial hypertrophy is diagnosed, dosage reduction or discontinuation of tacrolimus should be considered [ see Adverse Reactions( 6.2)].

5.16 Immunizations

The use of live vaccines should be avoided during treatment with tacrolimus; examples include (not limited to) the following: intranasal influenza, measles, mumps, rubella, oral polio, BCG, yellow fever, varicella, and TY21a typhoid vaccines.

5.17 Pure Red Cell Aplasia

Cases of pure red cell aplasia (PRCA) have been reported in patients treated with tacrolimus. A mechanism for tacrolimus-induced PRCA has not been elucidated. All patients reported risk factors for PRCA such as parvovirus B19 infection, underlying disease, or concomitant medications associated with PRCA. If PRCA is diagnosed, discontinuation of tacrolimus should be considered [ see Adverse Reactions( 6.2)].

5.18 Gastrointestinal Perforation

Gastrointestinal perforation has been reported in patients treated with Tacrolimus Capsules, USP; all reported cases were considered to be a complication of transplant surgery or accompanied by infection, diverticulum, or malignant neoplasm. As gastrointestinal perforation may be serious or life-threatening, appropriate medical/surgical management should be instituted promptly [ see Adverse Reactions( 6.1)].

6 ADVERSE REACTIONS

The following serious and otherwise important adverse drug reactions are discussed in greater detail in other sections of labeling:

• Lymphoma and Other Malignancies [ see Boxed Warning, Warnings and Precautions( 5.2)]
• Serious Infections [ see Boxed Warning, Warnings and Precautions( 5.3)]
• Polyoma Virus Infections [ see Boxed Warning, Warnings and Precautions( 5.4)]
• CMV Infections [ see Boxed Warning, Warnings and Precautions( 5.5)]
• New Onset Diabetes After Transplant [ see Warnings and Precautions( 5.6)]
• Nephrotoxicity [ see Warnings and Precautions( 5.7)]
• Neurotoxicity [ see Warnings and Precautions( 5.8)]
• Hyperkalemia [ see Warnings and Precautions( 5.9)]
• Hypertension [ see Warnings and Precautions( 5.10)]
• Anaphylaxis with Tacrolimus Injection [ see Warnings and Precautions( 5.11)]
• Myocardial Hypertrophy [ see Warnings and Precautions( 5.15)]
• Pure Red Cell Aplasia [ see Warnings and Precautions( 5.17)]
• Gastrointestinal Perforation [ see Warnings and Precautions( 5.18)]

6.1 Clinical Studies Experience

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. In addition, the clinical trials were not designed to establish comparative differences across study arms with regards to the adverse reactions discussed below.

Kidney Transplant

The incidence of adverse reactions was determined in three randomized kidney transplant trials. One of the trials used azathioprine (AZA) and corticosteroids and two of the trials used mycophenolate mofetil (MMF) and corticosteroids concomitantly for maintenance immunosuppression.

Tacrolimus-based immunosuppression in conjunction with azathioprine and corticosteroids following kidney transplantation was assessed in trial where 205 patients received Tacrolimus based immunosuppression and 207 patients received cyclosporine based immunosuppression. The trial population had a mean age of 43 years (mean±sd was 43±13 years on Tacrolimus and 44±12 years on cyclosporine arm), the distribution was 61% male, and the composition was White (58%), Black (25%), Hispanic (12%) and Other (5%). The 12 month post-transplant information from this trial is presented below.

The most common adverse reactions ( ≥30%) observed in Tacrolimus-treated kidney transplant patients are: infection, tremor, hypertension, abnormal renal function, constipation, diarrhea, headache, abdominal pain, insomnia, nausea, hypomagnesemia, urinary tract infection, hypophosphatemia, peripheral edema, asthenia, pain, hyperlipidemia, hyperkalemia and anemia.

Adverse reactions that occurred in ≥15% of kidney transplant patients treated with Tacrolimus in conjunction with azathioprine are presented below:

Table 4. Kidney Transplantation: Adverse Reactions Occurring in ≥15% of Patients Treated with Tacrolimus in Conjunction with Azathioprine (AZA) 

	Tacrolimus /AZA (N=205)	Cyclosporine/AZA; (N=207)
Nervous System
Tremor	54%	34%
Headache	44%	38%
Insomnia	32%	30%
Paresthesia	23%	16%
Dizziness	19%	16%
Gastrointestinal
Diarrhea	44%	41%
Nausea	38%	36%
Constipation	35%	43%
Vomiting	29%	23%
Dyspepsia	28%	20%
Cardiovascular
Hypertension	50%	52%
Chest Pain	19%	13%
Urogenital
Creatinine Increased	45%	42%
Urinary Tract Infection	34%	35%
Metabolic and Nutritional
Hypophosphatemia	49%	53%
Hypomagnesemia	34%	17%
Hyperlipemia	31%	38%
Hyperkalemia	31%	32%
Diabetes Mellitus	24%	9%
Hypokalemia	22%	25%
Hyperglycemia	22%	16%
Edema	18%	19%
Hemic and Lymphatic
Anemia	30%	24%
Leukopenia	15%	17%
Miscellaneous
Infection	45%	49%
Peripheral Edema	36%	48%
Asthenia	34%	30%
Abdominal Pain	33%	31%
Pain	32%	30%
Fever	29%	29%
Back Pain	24%	20%
Respiratory System
Dyspnea	22%	18%
Cough Increased	18%	15%
Musculoskeletal
Arthralgia	25%	24%
Skin
Rash	17%	12%
Pruritus	15%	7%

Two trials were conducted for Tacrolimus -based immunosuppression in conjunction with MMF and corticosteroids. In the non-US trial (Study 1), the incidence of adverse reactions was based on 1195 kidney transplant patients that received Tacrolimus (Group C, n=403), or one of two cyclosporine (CsA) regimens (Group A, n=384 and Group B, n=408) in combination with MMF and corticosteroids; all patients, except those in one of the two cyclosporine groups, also received induction with daclizumab. The trial population had a mean age of 46 years (range 17 to 76), the distribution was 65% male, and the composition was 93% Caucasian. The 12 month post-transplant information from this trial is presented below.

Adverse reactions that occurred in ≥10% of kidney transplant patients treated with Tacrolimus in conjunction with MMF in Study 1 [Note: This trial was conducted entirely outside of the United States. Such trials often report a lower incidence of adverse reactions in comparison to U.S. trials] are presented below:

Table 5. Kidney Transplantation: Adverse Reactions Occurring in ≥10% of Patients Treated with Tacrolimus in Conjunction with MMF (Study 1) 

	Tacrolimus (Group C) (N=403)	Cyclosporine (Group A) (N=384)	Cyclosporine (Group B) (N=408)
Diarrhea	25%	16%	13%
Urinary Tract Infection	24%	28%	24%
Anemia	17%	19%	17%
Hypertension	13%	14%	12%
Leukopenia	13%	10%	10%
Edema Peripheral	11%	12%	13%
Hyperlipidemia	10%	15%	13%
Key: Group A = CsA/MMF/CS, B = CsA/MMF/CS/Daclizumab, C= Tac/MMF/CS/Daclizumab; CsA= Cyclosporine, CS = Corticosteroids, Tac = Tacrolimus, MMF = mycophenolate mofetil

In the U.S. trial (Study 2) with Tacrolimus-based immunosuppression in conjunction with MMF and corticosteroids, 424 kidney transplant patients received Tacrolimus (n=212) or cyclosporine (n=212) in combination with MMF 1 gram twice daily, basiliximab induction, and corticosteroids. The trial population had a mean age of 48 years (range 17 to 77), the distribution was 63% male, and the composition was White (74%), Black (20%), Asian (3%) and other (3%). The 12 month post-transplant information from this trial is presented below.

Adverse reactions that occurred in ≥15% of kidney transplant patients treated with Tacrolimus in conjunction with MMF in Study 2 are presented below:

Table 6. Kidney Transplantation: Adverse Reactions Occurring in ≥ 15% of Patients Treated with Tacrolimus in Conjunction with MMF (Study 2) 

	Tacrolimus /MMF (N=212)	Cyclosporine/MMF (N=212)
Gastrointestinal Disorders
Diarrhea	44%	26%
Nausea	39%	47%
Constipation	36%	41%
Vomiting	26%	25%
Dyspepsia	18%	15%
Injury, Poisoning, and Procedural Complications
Post-Procedural Pain	29%	27%
Incision Site Complication	28%	23%
Graft Dysfunction	24%	18%
Metabolism and Nutrition Disorders
Hypomagnesemia	28%	22%
Hypophosphatemia	28%	21%
Hyperkalemia	26%	19%
Hyperglycemia	21%	15%
Hyperlipidemia	18%	25%
Hypokalemia	16%	18%
Nervous System Disorders
Tremor	34%	20%
Headache	24%	25%
Blood and Lymphatic System Disorders
Anemia	30%	28%
Leukopenia	16%	12%
Miscellaneous
Edema Peripheral	35%	46%
Hypertension	32%	35%
Insomnia	30%	21%
Urinary Tract Infection	26%	22%
Blood Creatinine Increased	23%	23%

 Less frequently observed adverse reactions in both liver transplantation and kidney transplantation patients are described under the subsection Less Frequently Reported Adverse Reactions.

Liver Transplantation

There were two randomized comparative liver transplant trials. In the U.S. trial, 263 adult and pediatric patients received Tacrolimus and steroids and 266 patients received cyclosporine-based immunosuppressive regimen (CsA/AZA). The trial population had a mean age of 44 years (range 0.4 to 70), the distribution was 52% male, and the composition was White (78%), Black (5%), Asian (2%), Hispanic (13%) and Other (2%). In the European trial, 270 patients received Tacrolimus and steroids and 275 patients received CsA/AZA. The trial population had a mean age of 46 years (range 15 to 68), the distribution was 59% male, and the composition was White (95.4%), Black (1%), Asian (2%) and Other (2%).

The proportion of patients reporting more than one adverse event was > 99% in both the Tacrolimus group and the CsA/AZA group. Precautions must be taken when comparing the incidence of adverse reactions in the U.S. trial to that in the European trial. The 12-month post-transplant information from the U.S. trial and from the European trial is presented below. The two trials also included different patient populations and patients were treated with immunosuppressive regimens of differing intensities. Adverse reactions reported in ≥ 15% in Tacrolimus patients (combined trial results) are presented below for the two controlled trials in liver transplantation.

The most common adverse reactions ( ≥40%) observed in Tacrolimus-treated liver transplant patients are: tremor, headache, diarrhea, hypertension, nausea, abnormal renal function, abdominal pain, insomnia, paresthesia, anemia, pain, fever, asthenia, hyperkalemia, hypomagnesemia, and hyperglycemia. These all occur with oral and IV administration of Tacrolimus and some may respond to a reduction in dosing (e.g., tremor, headache, paresthesia, hypertension). Diarrhea was sometimes associated with other gastrointestinal complaints such as nausea and vomiting. 

Table 7. Liver Transplantation: Adverse Reactions Occurring in ≥ 15% of Patients Treated with Tacrolimus 

	U.S. TRIAL		EUROPEAN TRIAL
	Tacrolimus (N=250)	Cyclosporine/AZA (N=250)	Tacrolimus (N=264)	Cyclosporine/AZA (N=265)
Nervous System
Headache	64%	60%	37%	26%
Insomnia	64%	68%	32%	23%
Tremor	56%	46%	48%	32%
Paresthesia	40%	30%	17%	17%
Gastrointestinal
Diarrhea	72%	47%	37%	27%
Nausea	46%	37%	32%	27%
LFT Abnormal	36%	30%	6%	5%
Anorexia	34%	24%	7%	5%
Vomiting	27%	15%	14%	11%
Constipation	24%	27%	23%	21%
Cardiovascular
Hypertension	47%	56%	38%	43%
Urogenital
Kidney Function Abnormal	40%	27%	36%	23%
Creatinine Increased	39%	25%	24%	19%
BUN Increased	30%	22%	12%	9%
Oliguria	18%	15%	19%	12%
Urinary Tract Infection	16%	18%	21%	19%
Metabolic and Nutritional
Hypomagnesemia	48%	45%	16%	9%
Hyperglycemia	47%	38%	33%	22%
Hyperkalemia	45%	26%	13%	9%
Hypokalemia	29%	34%	13%	16%
Hemic and Lymphatic
Anemia	47%	38%	5%	1%
Leukocytosis	32%	26%	8%	8%
Thrombocytopenia	24%	20%	14%	19%
Miscellaneous
Pain	63%	57%	24%	22%
Abdominal Pain	59%	54%	29%	22%
Asthenia	52%	48%	11%	7%
Fever	48%	56%	19%	22%
Back Pain	30%	29%	17%	17%
Ascites	27%	22%	7%	8%
Peripheral Edema	26%	26%	12%	14%
Respiratory System
Pleural Effusion	30%	32%	36%	35%
Dyspnea	29%	23%	5%	4%
Atelectasis	28%	30%	5%	4%
Skin and Appendages
Pruritus	36%	20%	15%	7%
Rash	24%	19%	10%	4%

 Less frequently observed adverse reactions in both liver transplantation and kidney transplantation patients are described under the subsection Less Frequently Reported Adverse Reactions.

Heart Transplantation

The incidence of adverse reactions was determined based on two trials in primary orthotopic heart transplantation. In a trial conducted in Europe, 314 patients received a regimen of antibody induction, corticosteroids and azathioprine (AZA) in combination with Tacrolimus (n=157) or cyclosporine (n=157) for 18 months. The trial population had a mean age of 51 years (range 18 to 65), the distribution was 82% male, and the composition was White (96%), Black (3%) and other (1%).

The most common adverse reactions ( ≥15%) observed in Tacrolimus-treated heart transplant patients are: abnormal renal function, hypertension, diabetes mellitus, CMV infection, tremor, hyperglycemia, leukopenia, infection, anemia, bronchitis, pericardial effusion, urinary tract infection and hyperlipemia.

Adverse reactions in heart transplant patients in the European trial are presented below: 

Table 8. Heart Transplantation: Adverse Reactions Occurring in ≥15% of Patients Treated with Tacrolimus in Conjunction with Azathioprine (AZA)

	Tacrolimus/AZA	Cyclosporine/AZA
	(n=157)	(n=157)
Cardiovascular System
Hypertension	62%	69%
Pericardial Effusion	15%	14%
Body as a Whole
CMV Infection	32%	30%
Infection	24%	21%
Metabolic and Nutritional Disorders
Diabetes Mellitus	26%	16%
Hyperglycemia	23%	17%
Hyperlipemia	18%	27%
Hemic and Lymphatic System
Anemia	50%	36%
Leukopenia	48%	39%
Urogenital System
Kidney Function Abnormal	56%	57%
Urinary Tract Infection	16%	12%
Respiratory System
Bronchitis	17%	18%
Nervous System
Tremor	15%	6%

In the European trial, the cyclosporine trough concentrations were above the pre-defined target range (i.e. 100 to 200 ng/mL) at Day 122 and beyond in 32 to 68% of the patients in the cyclosporine treatment arm, whereas the Tacrolimus trough concentrations were within the pre-defined target range (i.e., 5 to 15 ng/mL) in74 to 86% of the patients in the Tacrolimus treatment arm.

In the U.S. trial, the incidence of adverse reactions was based on 331 heart transplant patients that received corticosteroids and Tacrolimus in combination with sirolimus (n=109), Tacrolimus in combination with MMF (n=107) or cyclosporine modified in combination with MMF (n=115) for 1 year. The trial population had a mean age of 53 years (range 18 to 75), the distribution was 78% male, and the composition was White (83%), Black (13%) and other (4%).

Only selected targeted treatment-emergent adverse reactions were collected in the U.S. heart transplantation trial. Those reactions that were reported at a rate of 15% or greater in patients treated with Tacrolimus and MMF include the following: any target adverse reactions (99%), hypertension (89%), hyperglycemia requiring antihyperglycemic therapy (70%), hypertriglyceridemia (65%), anemia (hemoglobin < 10 g/dL) (65%), fasting blood glucose > 140 mg/dL (on two separate occasions) (61%), hypercholesterolemia (57%), hyperlipidemia (34%), WBCs <3000 cells/mcL (34%), serious bacterial infections (30%), magnesium <1.2 mEq/L (24%), platelet count <75,000 cells/mcL (19%), and other opportunistic infections (15%).

Other targeted treatment-emergent adverse reactions in Tacrolimus-treated patients occurred at a rate of less than 15%, and include the following: Cushingoid features, impaired wound healing, hyperkalemia, Candida infection, and CMV infection/syndrome.

New Onset Diabetes After Transplant

Kidney Transplant

New Onset Diabetes After Transplant (NODAT) is defined as a composite of fasting plasma glucose ≥126 mg/dL, HbA1C ≥ 6%, insulin use ≥30 days or oral hypoglycemic use. In a trial in kidney transplant patients (Study 2), NODAT was observed in 75% in the Tacrolimus-treated and 61% in the Neoral-treated patients without pre-transplant history of diabetes mellitus Table 9 [ see Clinical Studies( 14.1)]. 

Table 9. Incidence of New Onset Diabetes After Transplant at 1 Year in Kidney Transplant Recipients in a Phase 3 Trial (Study 2) 

Parameter	Treatment Group
	Tacrolimus/MMF (n = 212)	Neoral/MMF (n = 212)
NODAT	112/150 (75%)	93/152 (61%)
Fasting Plasma Glucose ≥126 mg/dL	96/150 (64%)	80/152 (53%)
HbA 1C≥6%	59/150 (39%)	28/152 (18%)
Insulin Use ≥30 days	9/150 (6%)	4/152 (3%)
Oral Hypoglycemic Use	15/150 (10%)	5/152 (3%)

In early trials of Tacrolimus, Post-Transplant Diabetes Mellitus (PTDM) was evaluated with a more limited criteria of "use of insulin for 30 or more consecutive days with < 5 day gap" in patients without a prior history of insulin-dependent diabetes mellitus or non-insulin dependent diabetes mellitus. Data are presented in Tables 10 to 13. PTDM was reported in 20% of Tacrolimus/Azathioprine (AZA)-treated kidney transplant patients without pre-transplant history of diabetes mellitus in a Phase 3 trial (Table 10) 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 2 years post-transplant. Black and Hispanic kidney transplant patients were at an increased risk of development of PTDM (Table 11) 

Table 10. Incidence of Post-Transplant Diabetes Mellitus and Insulin Use at 2 Years in Kidney Transplant Recipients in a Phase 3 Trial using Azathioprine (AZA) 

Status of PTDM a	Tacrolimus/AZA	CsA/AZA
Patients without pre-transplant history of diabetes mellitus	151	151
New onset PTDMa, 1st Year	30/151 (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 PTDMa post 1 year	1	0
Patients with PTDMa at 2 years	16/151 (11%)	5/151 (3%)

a)Use of insulin for 30 or more consecutive days, with < 5 day gap, without a prior history of insulin-dependent diabetes mellitus or non-insulin dependent diabetes mellitus. 

Table 11. Development of Post-Transplant Diabetes Mellitus by Race or Ethnicity and by Treatment Group During First Year Post Kidney Transplantation in a Phase 3 Trial 

	Patients Who Developed PTDM a
Patient Race	Tacrolimus	Cyclosporine
Black	15/41 (37%)	3 (8%)
Hispanic	5/17 (29%)	1 (6%)
Caucasian	10/82 (12%)	1 (1%)
Other	0/11 (0%)	1 (10%)
Total	30/151 (20%)	6 (4%)

a)Use of insulin for 30 or more consecutive days, with < 5 day gap, without a prior history of insulin-dependent diabetes mellitus or non-insulin dependent diabetes mellitus.

Liver Transplant

Insulin-dependent PTDM was reported in 18% and 11% of Tacrolimus-treated liver transplant patients and was reversible in 45% and 31% of these patients at 1 year post-transplant, in the U.S. and European randomized trials, respectively, (Table 12). Hyperglycemia was associated with the use of Tacrolimus in 47% and 33% of liver transplant recipients in the U.S. and European randomized trials, respectively, and may require treatment [ see Adverse Reactions( 6.1)]. 

Table 12. Incidence of Post-Transplant Diabetes Mellitus and Insulin Use at 1 Year in Liver Transplant Recipients 

	US Trial		EuropeanTrial
Status of PTDM a	Tacrolimus	Cyclosporine	Tacrolimus	Cyclosporine
Patients at riskb	239	236	239	249
New Onset PTDMa	42 (18%)	30 (13%)	26 (11%)	12 (5%)
Patients still on insulin at 1 year	23 (10%)	19 (8%)	18 (8%)	6 (2%)

 a) Use of insulin for 30 or more consecutive days, with < 5 day gap, without a prior history of insulin-dependent diabetes mellitus or non-insulin dependent diabetes mellitus.

bPatients without pre-transplant history of diabetes mellitus.

Heart Transplant

Insulin-dependent PTDM was reported in 13% and 22% of Tacrolimus-treated heart transplant patients receiving mycophenolate mofetil (MMF) or azathioprine (AZA) and was reversible in 30% and 17% of these patients at one year post-transplant, in the U.S. and European randomized trials, respectively (Table 13). Hyperglycemia defined as two fasting plasma glucose levels ≥126 mg/dL was reported with the use of Tacrolimus plus MMF or AZA in 32% and 35% of heart transplant recipients in the U.S. and European randomized trials, respectively, and may require treatment [see Clinical Studies( 6.1)].

Table 13. Incidence of Post-Transplant Diabetes Mellitus and Insulin Use at 1 Year in Heart Transplant Recipients 

Status of PTDM a	US Trial		European Trial
	Tacrolimus/MMF	Cyclosporine/MMF	Tacrolimus/AZA	Cyclosporine/AZA
Patients at riskb	75	83	132	138
New Onset PTDMa	10 (13%)	6 (7%)	29 (22%)	5 (4%)
Patients still on insulin at 1 yearc	7 (9%)	1 (1%)	24 (18%)	4 (3%)

 a) Use of insulin for 30 or more consecutive days without a prior history of insulin-dependent diabetes mellitus or non-insulin dependent diabetes mellitus.

bPatients without pre-transplant history of diabetes mellitus.

c7-12 months for the U.S. trial.

Less Frequently Reported Adverse Reactions(>3% and <15%)

The following adverse reactions were reported in either liver, kidney, and/or heart transplant recipients who were treated with Tacrolimus in clinical trials.

Nervous System[ see Warnings and Precautions( 5.8)]

Abnormal dreams, agitation, amnesia, anxiety, confusion, convulsion, crying, depression, elevated mood, emotional lability, encephalopathy, haemorrhagic stroke, hallucinations, hypertonia, incoordination, monoparesis, myoclonus, nerve compression, nervousness, neuralgia, neuropathy, paralysis flaccid, psychomotor skills impaired, psychosis, quadriparesis, somnolence, thinking abnormal, vertigo, writing impaired

Special Senses

Abnormal vision, amblyopia, ear pain, otitis media, tinnitus

Gastrointestinal

Cholangitis, cholestatic jaundice, duodenitis, dysphagia, esophagitis, flatulence, gastritis, gastroesophagitis, gastrointestinal hemorrhage, GGT increase, GI disorder, GI perforation, hepatitis, hepatitis granulomatous, ileus, increased appetite, jaundice, liver damage, oesophagitis ulcerative, oral moniliasis, pancreatic pseudocyst, rectal disorder, stomatitis

Cardiovascular

Abnormal ECG, angina pectoris, arrhythmia, atrial fibrillation, atrial flutter, bradycardia, cardiac fibrillation, cardiopulmonary failure, cardiovascular disorder, 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

Acute kidney failure [ see Warnings and Precautions( 5.7)], albuminuria, BK nephropathy, bladder spasm, cystitis, dysuria, hematuria, hydronephrosis, kidney failure, kidney tubular necrosis, nocturia, 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, dehydration, GGT increased, gout, healing abnormal, hypercalcemia, hypercholesterolemia, hyperphosphatemia, hyperuricemia, hypervolemia, hypocalcemia, hypoglycemia, hyponatremia, hypoproteinemia, lactic dehydrogenase increase, weight gain

Endocrine

Cushing’s syndrome

Hemic/Lymphatic

Coagulation disorder, ecchymosis, haematocrit increased, haemoglobin abnormal, hypochromic anemia, leukocytosis, polycythemia, prothrombin decreased, serum iron decreased

Miscellaneous

Abdomen enlarged, abscess, accidental injury, allergic reaction, cellulitis, chills, fall, feeling abnormal, flu syndrome, generalized edema, hernia, mobility decreased, peritonitis, photosensitivity reaction, sepsis, temperature intolerance, ulcer

Musculoskeletal

Arthralgia, cramps, generalized spasm, joint disorder, leg cramps, myalgia, myasthenia, osteoporosis

Respiratory

Asthma, emphysema, hiccups, lung disorder, lung function decreased, pharyngitis, 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.

6.2 Postmarketing Adverse Reactions

The following adverse reactions have been reported from worldwide marketing experience with tacrolimus. Because these reactions are reported voluntarily from a population of uncertain size it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. Decisions to include these reactions in labeling are typically based on one or more of the following factors: (1) seriousness of the reaction, (2) frequency of the reporting, or (3) strength of causal connection to the drug.

Other reactions include:

Cardiovascular

Atrial fibrillation, atrial flutter, cardiac arrhythmia, cardiac arrest, electrocardiogram T wave abnormal, flushing, myocardial infarction, myocardial ischaemia, pericardial effusion, QT prolongation, Torsade de Pointes, venous thrombosis deep limb, ventricular extrasystoles, ventricular fibrillation, myocardial hypertrophy [ see Warnings and Precautions( 5.15)].

Gastrointestinal

Bile duct stenosis, colitis, enterocolitis, gastroenteritis, gastroesophageal 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

Agranulocytosis, disseminated intravascular coagulation, hemolytic anemia, neutropenia, pancytopenia, thrombocytopenic purpura, thrombotic thrombocytopenic purpura, pure red cell aplasia [ see Warnings and Precautions( 5.17)]

Infections

Cases of progressive multifocal leukoencephalopathy (PML), sometimes fatal; -polyoma virus-associated nephropathy, (PVAN) including graft loss [ see Warnings and Precautions( 5.4)]

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) [ see Warnings and Precautions( 5.8)] , progressive multifocal leukoencephalopathy (PML) [ see Warnings and Precautions( 5.4)] , 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

7 DRUG INTERACTIONS

Since tacrolimus is metabolized mainly by CYP3A enzymes, drugs or substances known to inhibit these enzymes may increase tacrolimus whole blood concentrations. Drugs known to induce CYP3A enzymes may decrease tacrolimus whole blood concentrations [ see Warnings andPrecautions( 5.13)] and Clinical Pharmacology( 12.3)].Dose adjustments may be needed along with frequent monitoring of tacrolimus whole blood trough concentrations when tacrolimus is administered with CYP3A inhibitors or inducers. In addition, patients should be monitored for adverse reactions including changes in renal function and QT prolongation [ see Warnings and Precautions( 5.7) and ( 5.14)]

7.1 Mycophenolic Acid Products

With a given dose of mycophenolic acid (MPA) products, exposure to MPA is higher with tacrolimus co-administration than with cyclosporine co-administration because cyclosporine interrupts the enterohepatic recirculation of MPA while tacrolimus does not. Clinicians should be aware that there is also a potential for increased MPA exposure after crossover from cyclosporine to tacrolimus in patients concomitantly receiving MPA-containing products.

7.2 Grapefruit Juice

Grapefruit juice inhibits CYP3A-enzymes resulting in increased tacrolimus whole blood trough concentrations, and patients should avoid eating grapefruit or drinking grapefruit juice with tacrolimus [ see Dosage and Administration( 2.5)].

7.3 Protease Inhibitors

Most protease inhibitors inhibit CYP3A enzymes and may increase tacrolimus whole blood concentrations. It is recommended to avoid concomitant use of tacrolimus with nelfinavir unless the benefits outweigh the risks [ see Clinical Pharmacology( 12.3)]. Whole blood concentrations of tacrolimus are markedly increased when co-administered with telaprevir or with boceprevir [ see Clinical Pharmacology( 12.3)]. Monitoring of tacrolimus whole blood concentrations and tacrolimus associated adverse reactions, and appropriate adjustments in the dosing regimen of tacrolimus are recommended when tacrolimus and protease inhibitors (e.g., ritonavir, telaprevir, boceprevir) are used concomitantly.

7.4 Antifungal Agents

Frequent monitoring of whole blood concentrations and appropriate dosage adjustments of tacrolimus are recommended when concomitant use of the following antifungal drugs with tacrolimus is initiated or discontinued [ see Clinical Pharmacology( 12.3)].

Azoles: Voriconazole, posaconazole, itraconazole, ketoconazole, fluconazole and clotrimazole inhibit CYP3A metabolism of tacrolimus and increase tacrolimus whole blood concentrations. When initiating therapy with voriconazole or posaconazole in patients already receiving tacrolimus, it is recommended that the tacrolimus dose be initially reduced to one-third of the original dose and the subsequent tacrolimus doses be adjusted based on the tacrolimus whole blood concentrations.

Caspofungin is an inducer of CYP3A and decreases whole blood concentrations of tacrolimus.

7.5 Calcium Channel Blockers

Verapamil, diltiazem, nifedipine, and nicardipine inhibit CYP3A metabolism of tacrolimus and may increase tacrolimus whole blood concentrations. Monitoring of whole blood concentrations and appropriate dosage adjustments of tacrolimus are recommended when these calcium channel blocking drugs and tacrolimus are used concomitantly.

7.6 Antibacterials

Erythromycin, clarithromycin, troleandomycin and chloramphenicol inhibit CYP3A metabolism of tacrolimus and may increase tacrolimus whole blood concentrations. Monitoring of blood concentrations and appropriate dosage adjustments of tacrolimus are recommended when these drugs and tacrolimus are used concomitantly.

7.7 Antimycobacterials

Rifampin [ see Clinical Pharmacology( 12.3)] and rifabutin are inducers of CYP3A enzymes and may decrease tacrolimus whole blood concentrations. Monitoring of whole blood concentrations and appropriate dosage adjustments of tacrolimus are recommended when these antimycobacterial drugs and tacrolimus are used concomitantly.

7.8 Anticonvulsants

Phenytoin, carbamazepine and phenobarbital induce CYP3A enzymes and may decrease tacrolimus whole blood concentrations. Monitoring of whole blood concentrations and appropriate dosage adjustments of tacrolimus are recommended when these drugs and tacrolimus are used concomitantly.

Concomitant administration of phenytoin with tacrolimus may also increase phenytoin plasma concentrations. Thus, frequent monitoring phenytoin plasma concentrations and adjusting the phenytoin dose as needed are recommended when tacrolimus and phenytoin are administered concomitantly.

7.9 St. John’s Wort (Hypericum perforatum)

St. John’s Wort induces CYP3A enzymes and may decrease tacrolimus whole blood concentrations. Monitoring of whole blood concentrations and appropriate dosage adjustments of tacrolimus are recommended when St. John’s Wort and tacrolimus are co-administered.

7.10 Gastric Acid Suppressors/Neutralizers

Lansoprazole and omeprazole, as CYP2C19 and CYP3A4 substrates, may potentially inhibit the CYP3A4 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.

Cimetidine may also inhibit the CYP3A4 metabolism of tacrolimus and thereby substantially increase tacrolimus whole blood concentrations.

Coadministration with magnesium and aluminum hydroxide antacids increases tacrolimus whole blood concentrations [ see Clinical Pharmacology( 12.3)]. Monitoring of whole blood concentrations and appropriate dosage adjustments of tacrolimus are recommended when these drugs and tacrolimus are used concomitantly.

7.11 Others

Bromocriptine, nefazodone, metoclopramide, danazol, ethinyl estradiol, amiodarone, methylprednisolone and herbal products containing schisandra sphenanthera extracts may inhibit CYP3A metabolism of tacrolimus and increase tacrolimus whole blood concentrations. Monitoring of blood concentrations and appropriate dosage adjustments of tacrolimus are recommended when these drugs and tacrolimus are co-administered.

8 USE IN SPECIFIC POPULATIONS

8.1 Pregnancy

Pregnancy Category C - There are no adequate and well-controlled studies in pregnant women. Tacrolimus is transferred across the placenta. The use of tacrolimus during pregnancy in humans has been associated with neonatal hyperkalemia and renal dysfunction. Tacrolimus given orally to pregnant rabbits at 0.5 to 4.3 times the clinical dose and pregnant rats at 0.8 to 6.9 times the clinical dose was associated with an increased incidence of fetal death in utero, fetal malformations (cardiovascular, skeletal, omphalocele, and gallbladder agenesis) and maternal toxicity. Tacrolimus should be used during pregnancy only if the potential benefit to the mother justifies the potential risk to the fetus.

In pregnant rabbits, tacrolimus at oral doses of 0.32 and 1.0 mg/kg, 0.5 to 4.3 times the clinical dose range (0.075 – 0.2 mg/kg) based on body surface area, was associated with maternal toxicity as well as an increased incidence of abortions. At the 1 mg/kg dose, fetal rabbits showed an increased incidence of malformations (ventricular hypoplasia, interventricular septal defect, bulbous aortic arch, stenosis of ductus arteriosus, interrupted ossification of vertebral arch, vertebral and rib malformations, omphalocele, and gallbladder agenesis) and developmental variations. In pregnant rats, tacrolimus at oral doses of 3.2 mg/kg, 2.6 to 6.9 times the clinical dose range was associated with maternal toxicity, an increase in late resorptions, decreased numbers of live births, and decreased pup weight and viability. Tacrolimus, given orally to pregnant rats after organogenesis and during lactation at 1.0 and 3.2 mg/kg, 0.8 to 6.9 times the recommended clinical dose range was associated with reduced pup weights and pup viability (3.2 mg/kg only); among the high dose pups that died early, an increased incidence of kidney hydronephrosis was observed.

8.3 Nursing Mothers

Tacrolimus is excreted in human milk. As the effect of chronic exposure to tacrolimus in healthy infants is not established, patients maintained on tacrolimus should discontinue nursing taking into consideration importance of drug to the mother.

8.4 Pediatric Use

The safety and efficacy of tacrolimus in pediatric kidney and heart transplant patients have not been established. Successful liver transplants have been performed in pediatric patients (ages up to 16 years) using tacrolimus. Two randomized active-controlled trials of tacrolimus in primary liver transplantation included 56 pediatric patients. Thirty-one patients were randomized to tacrolimus-based and 25 to cyclosporine-based therapies. Additionally, a 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 tacrolimus to maintain blood trough concentrations of tacrolimus similar to adult patients [ see Dosage and Administration( 2.2)].

8.5 Geriatric Use

Clinical trials of tacrolimus did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. Other reported clinical experience has not identified differences in responses between the elderly and younger patients. In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy.

8.6 Use in Renal Impairment

The pharmacokinetics of tacrolimus in patients with renal impairment was similar to that in healthy volunteers with normal renal function. However, consideration should be given to dosing tacrolimus at the lower end of the therapeutic dosing range in patients who have received a liver or heart transplant and have pre-existing renal impairment. Further reductions in dose below the targeted range may be required [see Dosage and Administration( 2.3) and Clinical Pharmacology( 12.3)].

8.7 Use in Hepatic Impairment

The mean clearance of tacrolimus was substantially lower in patients with severe hepatic impairment (mean Child-Pugh score: >10) compared to healthy volunteers with normal hepatic function. Close monitoring of tacrolimus trough concentrations is warranted in patients with hepatic impairment [ see Clinical Pharmacology( 12.3)].

The use of tacrolimus in liver transplant recipients experiencing post-transplant hepatic impairment may be associated with increased risk of developing renal insufficiency related to high whole-blood trough concentrations 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 andAdministration( 2.3) and Clinical Pharmacology( 12.3)].

10 OVERDOSAGE

Limited overdosage experience is available. Acute overdosages of up to 30 times the intended dose have been reported. Almost all cases have been asymptomatic and all patients recovered with no sequelae. Acute overdosage was sometimes followed by adverse reactions consistent with those listed in Adverse Reactions( 6) (including tremors, abnormal renal function, hypertension, and peripheral edema); in one case of acute overdosage, transient urticaria and lethargy were observed. Based on the poor aqueous solubility and extensive erythrocyte and plasma protein binding, it is anticipated that tacrolimus is not dialyzable to any significant extent; there is no experience with charcoal hemoperfusion. The oral use of activated charcoal has been reported in treating acute overdoses, but experience has not been sufficient to warrant recommending its use. General supportive measures and treatment of specific symptoms should be followed in all cases of overdosage.

In acute oral and IV toxicity studies, mortalities were seen at or above the following doses: in adult rats, 52 times the recommended human oral dose; in immature rats, 16 times the recommended oral dose; and in adult rats, 16 times the recommended human IV dose (all based on body surface area corrections).

12 DESCRIPTION

Tacrolimus Capsules, USP are available for oral administration as capsules containing the equivalent of 0.5 mg, 1 mg or 5 mg of anhydrous tacrolimus USP. Inactive ingredients include anhydrous lactose NF DT, hypromellose USP, croscarmellose sodium NF, and magnesium stearate NF. The 0.5 mg capsule shell contains gelatin, titanium dioxide and yellow iron oxide, the 1 mg capsule shell contains gelatin and titanium dioxide, and the 5 mg capsule shell contains gelatin, titanium dioxide and red iron oxide.
Non-volatile components of the ink are Shellac Glaze, Iron Oxide Red, and Simethicone USP.
Tacrolimus USP, previously known as FK506, is the active ingredient in tacrolimus capsules, USP. Tacrolimus is a macrolide immunosuppressant produced by Streptomyces tsukubaensis. Chemically, tacrolimus is designated as
[3S [3R* [E (1S*, 3S* 4S*)], 4S*, 5R*, 8S*, 9E, 12R* 14R* 15S* 16R* 18S* 19S* 26aR*]] -5,6,8,11,12,13,14,15,16,17,18,19,24,25,26,26a-hexadecahydro-5,19-dihydroxy-3-[2-(4-hydroxy-3-methoxycyclohexyl)-1-methylethenyl]-14,16-dimethoxy-4,10,12,18-tetramethyl-8-(2-propenyl)-15,19-epoxy-3H-pyrido[2,1-c][1,4] oxaazacyclotricosine-1,7,20,21(4H,23H)-tetrone, monohydrate.
The chemical structure of tacrolimus is:

Tacrolimus has an empirical formula of C 44H 69NO 12H2O and a formula weight of 822.03. Tacrolimus appears as white crystals or crystalline powder. It is practically insoluble in water, freely soluble in ethanol, and very soluble in methanol and chloroform.
USP Dissolution Test 6 is used. USP Organic Impurities Procedure 2 is used.

12 CLINICAL PHARMACOLOGY

12.1 Mechanism of Action

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. A 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), a 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).

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 a greater extent, cell-mediated reactions such as allograft rejection, delayed type hypersensitivity, collagen-induced arthritis, experimental allergic encephalomyelitis, and graft versus host disease.

12.3 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 (Table 14). 

 Table 14. Pharmacokinetics Parameters (mean±S.D.) of Tacrolimus in Healthy Volunteers and Patients

Population	N	Route (Dose)	Parameters
			C max (ng/mL)	T max (hr)	AUC (ng hr/mL)	t  1/2 (hr)	CI (L/hr/kg)	V (L/kg)
Healthy Volunteers	8	IV (0.025 mg/kg/4hr)	a	a	598 b± 125	34.2 ± 7.7	0.040 ± 0.009	1.91 ± 0.31
	16	PO (5 mg)	29.7 ± 7.2	1.6 ± 0.7	243 c± 73	34.8 ± 11.4	0.041 d± 0.008	1.94d ± 0.53
Kidney Transplant Patients	26	IV (0.02 mg/kg/12 hr)	a	a	294 e± 262	18.8 ± 16.7	0.083 ± 0.050	1.41 ± 0.66
		PO (0.2 mg/kg/day)	19.2 ± 10.3	3.0	203 e± 42	f	f	f
		PO (0.3 mg/kg/day)	24.2 ± 15.8	1.5	288 e± 93	f	f	f
Liver Transplant Patients	17	IV (0.05 mg/kg/12 hr)	a	a	3300 e± 2130	11.7 ± 3.9	0.053 ± 0.017	0.85 ± 0.30
		PO (0.3 mg/kg/day)	68.5 ± 30	2.3 ± 1.5	519 e± 179	f	f	f
Heart Transplant Patients	11	IV (0.01 mg/kg/day as a continuous infusion)	a	a	954 g± 334	23.6 ± 9.22	0.051 ± 0.015	f
	11	PO (0.075 mg/kg/day)h	14.7 ± 7.79	2.1 [0.5-6] i	82.7 j± 63.2	a	f	f
	14	PO (0.15 mg/kg/day) h	24.5 ± 13.7	1.5 [0.4-4] i	142j ± 116	a	f	f

a)not applicable
b)AUC 0-120
c)AUC 0-72
d)Corrected for individual bioavailability
e)AUC 0-inf
f)not applicable
g)AUC 0-t
h)Determined after the first dose
i)Median [range]
j)AUC 0-12

Due to intersubject variability in Tacrolimus pharmacokinetics, individualization of dosing regimen is necessary for optimal therapy [ see Dosageand Administration( 2.6)].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 trial conducted in 32 healthy volunteers established the bioequivalence of the 1 mg and 5 mg capsules. Another single dose trial in 32 healthy volunteers established the bioequivalence of the 0.5 mg and 1 mg capsules. Tacrolimus maximum blood concentrations(C max) and area under the curve (AUC) appeared to increase in a dose-proportional fashion in 18 fasted healthy volunteers receiving a single oral dose of 3, 7, and 10 mg.

In 18 kidney transplant patients, Tacrolimus trough concentrations from 3 to 30 ng/mL measured at 10-12 hours post-dose(C min) correlated well with the AUC (correlation coefficient 0.93). In 24 liver transplant patients over a concentration range of 10 to 60 ng/mL, the correlation coefficient was 0.94. In 25 heart transplant patients over a concentration range of 2 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 a high-fat meal (848 kcal, 46% fat): mean AUC and Cmax were decreased 37% and 77%, respectively; T maxwas lengthened 5-fold. A high-carbohydrate meal (668 kcal, 85% carbohydrate) decreased mean AUC and mean C maxby 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 C maxwas reduced 71%, and mean AUC was reduced 39%, relative to the fasted condition. When administered 1.5 hours following the meal, mean C maxwas reduced 63%, and mean AUC was reduced 39%, relative to the fasted condition.

In 11 liver transplant patients, Tacrolimus administered 15 minutes after a high fat (400 kcal, 34% fat) breakfast, resulted in decreased AUC (27±18%) and C max(50±19%), as compared to a fasted state.

Tacrolimus capsules should be taken consistently every day either with or without food because the presence and composition of food decreases the bioavailability of Tacrolimus [ see Dosage and Administration( 2.5)].

Distribution

The plasma protein binding of Tacrolimus is approximately 99% and is independent of concentration over a range of 5-50 ng/mL. Tacrolimus is bound mainly to albumin and alpha-1-acid glycoprotein, and has a 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 a U.S. trial, 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). A metabolic pathway leading to the formation of 8 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, a 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 a mass balance study of IV administered radiolabeled Tacrolimus to 6 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.

Specific Populations

Pediatric

Pharmacokinetics of Tacrolimus have been studied in liver transplantation patients, 0.7 to 13.2 years of age. Following IV administration of a 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 9 patients, mean AUC and C maxwere 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( 2.2)].

Pharmacokinetics of Tacrolimus have also been studied in kidney transplantation patients, 8.2±2.4 years of age. Following IV infusion of a 0.06 (range 0.06 0.09) mg/kg/day to 12 pediatric patients (8 male and 4 female), mean terminal half-life and clearance were 10.2±5.0 (range 3.4-25) hours and 0.12±0.04 (range 0.06-0.17) L/hr/kg, respectively. Following oral administration to the same patients, mean AUC and C maxwere 181±65 (range 81-300) ng·hr/mL and 30±11 (range 14-49) ng/mL, respectively. The absolute bioavailability was 19±14 (range 5.2-56) %.

Renal and Hepatic Impairment
The mean pharmacokinetic parameters for Tacrolimus following single administrations to patients with renal and hepatic impairment are given in Table 15.

Table 15. Pharmacokinetic In Renal and Hepatic Impaired Patients 

Population (No. of Patients)	Dose	AUC 0-t (ng·hr/mL)	t 1/2 (hr)	V (L/kg)	CI L/hr/kg)
Renal Impairment (n=12)	0.02 mg/kg/4hr IV	393±123 (t=60 hr)	26.3±9.2	1.07 ±0.20	0.038 ±0.014
Mild Hepatic Impairment (n=6)	0.02 mg/kg/4hr IV	367±107 (t=72 hr)	60.6±43.8 Range: 27.8 to 141	3.1±1.6	0.042 ±0.02
	7.7 mg PO	488±320 (t=72 hr)	66.1±44.8 Range: 29.5 to 138	3.7±4.7 a	0.034 ±0.019 a
Severe Hepatic Impairment (n=6, IV)	0.02 mg/kg/4hr IV (n=2) 0.01 mg/kg/8hr IV (n=4)	762±204 (t=120 hr) 289±117 (t=144 hr)	198±158 Range: 81 to 436	3.9±1.0	0.017 ±0.013
(n=5, PO) b	8 mg PO (n=1) 5 mg PO (n=4) 4 mg PO (n=1)	658 (t=120 hr) 533±156 (t=144 hr)	119±35 Range: 85-178	3.1±3.4 a	0.016 ±0.011 a

 a)corrected for bioavailability
b)1 patient did not receive the PO dose

Renal Impairment: Tacrolimus pharmacokinetics following a single IV administration were determined in 12 patients (7 not on dialysis and 5 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 (Table 15) [ see Dosage and Administration( 2.3) and Use in Specefic Populations( 8.6)].

Hepatic Impairment: 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 6 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 [ see Dosage and Administration( 2.4) and Use in Specefic Populations( 8.7)]

R ace
The pharmacokinetics of Tacrolimus have been studied following single IV and oral administration of Tacrolimus to 10 African-American, 12 Latino-American, and 12 Caucasian healthy volunteers. There were no significant pharmacokinetic differences among the three ethnic groups following a 4-hour IV infusion of 0.015 mg/kg. However, after single oral administration of 5 mg, mean (±SD) Tacrolimus Cmax in African-Americans (23.6±12.1 ng/mL) was significantly lower than in Caucasians (40.2±12.6 ng/mL) and the Latino-Americans (36.2±15.8 ng/mL) (p<0.01). Mean AUC 0-inftended to be lower in African-Americans (203±115 ng·hr/mL) than Caucasians (344±186 ng·hr/mL) and Latino-Americans (274±150 ng·hr/mL). The mean (±SD) absolute oral bioavailability (F) in African-Americans (12±4.5%) and Latino-Americans (14±7.4%) was significantly lower than in Caucasians (19±5.8%, p=0.011). There was no significant difference in mean terminal T1/2 among the three ethnic groups (range from approximately 25 to 30 hours). A retrospective comparison of African-American and Caucasian kidney transplant patients indicated that African-American patients required higher Tacrolimus doses to attain similar trough concentrations [ see Dosage and Administration( 2.1)].

Gender

A formal trial 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. A retrospective comparison of pharmacokinetics in healthy volunteers, and in kidney, liver and heart transplant patients indicated no gender-based differences.

Drug Interactions

Frequent monitoring of whole blood concentrations and appropriate dosage adjustments of Tacrolimus are recommended when concomitant use of the following drugs with Tacrolimus is initiated or discontinued [see Drug Interactions (7)].

Telaprevir:In a single dose study in 9 healthy volunteers, coadministration of Tacrolimus (0.5 mg single dose) with telaprevir (750 mg three times daily for 13 days) increased the Tacrolimus dose normalized C maxby 9.3-fold and AUC by 70-fold compared to Tacrolimus alone [ see DrugInteractions( 7.3)]

Boceprevir:In a single dose study in 12 subjects, coadministration of Tacrolimus (0.5 mg single dose) with boceprevir (800 mg three times daily for 11 days) increased Tacrolimus Cmax by 9.9-fold and AUC by 17-fold compared to Tacrolimus alone [ see Drug Interactions( 7.3)]

Nelfinavir:Based on a clinical study of 5 liver transplant recipients, co-administration of Tacrolimus with nelfinavir increased blood concentrations of Tacrolimus significantly and, as a result, a 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. It is recommended to avoid concomitant use of Tacrolimus and nelfinavir unless the benefits outweigh the risks [ see Drug Interactions( 7.3)]

Rifampin:In a study of 6 normal volunteers, a significant decrease in Tacrolimus oral bioavailability (14±6% vs. 7±3%) was observed with concomitant rifampin administration (600 mg). In addition, there was a significant increase in Tacrolimus clearance (0.036±0.008 L/hr/kg vs. 0.053±0.010 L/hr/kg) with concomitant rifampin administration [ see Drug Interactions( 7.7)]

Magnesium-aluminum-hydroxide:In a single-dose crossover study in healthy volunteers, co-administration of Tacrolimus and magnesium-aluminum-hydroxide resulted in a 21% increase in the mean Tacrolimus AUC and a 10% decrease in the mean Tacrolimus Cmax relative to Tacrolimus administration alone [ see Drug Interactions( 7.10)]

Ketoconazole:In a study of 6 normal volunteers, a 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 [ see Drug Interactions( 7.4)]

Voriconazole (see complete prescribing information for VFEND ®) : Repeat oral dose administration of voriconazole (400 mg every 12 hours for one day, then 200 mg every 12 hours for 6 days) increased Tacrolimus (0.1 mg/kg single dose) Cmax and AUCτ in healthy subjects by an average of 2-fold (90% CI: 1.9, 2.5) and 3-fold (90% CI: 2.7, 3.8), respectively [ see Drug Interactions( 7.4)]

Posaconazole (see complete prescribing information for Noxafil ®): Repeat oral administration of posaconazole (400 mg twice daily for 7 days) increased Tacrolimus (0.05 mg/kg single dose) Cmax and AUC in healthy subjects by an average of 2-fold (90% CI: 2.01, 2.42) and 4.5-fold (90% CI 4.03, 5.19), respectively [ see Drug Interactions( 7.4)]

Caspofungin (see complete prescribing information for CANCIDAS ®): Caspofungin reduced the blood AUC0-12 of Tacrolimus by approximately 20%, peak blood concentration (Cmax) by 16%, and 12-hour blood concentration (C12hr) by 26% in healthy adult subjects when Tacrolimus (2 doses of 0.1 mg/kg 12 hours apart) was administered on the 10th day of CANCIDAS ®70 mg daily, as compared to results from a control period in which Tacrolimus was administered alone [ see Drug Interactions( 7.4)]

13 NONCLINICAL TOXICOLOGY

13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility

Carcinogenicity studies were conducted in male and female rats and mice. In the 80-week mouse oral study and in the 104-week rat oral study, no relationship of tumor incidence to tacrolimus dosage was found. The highest doses used in the mouse was 3.0 mg/kg/day (0.9 to 2.2 times the AUC at clinical doses of 0.075 to 0.2 mg/kg/day) and in the rat was 5.0 mg/kg/day (0.265 to 0.65 times the AUC at clinical doses of 0.075 to 0.2 mg/kg/day) [ see Boxed Warning and Warnings and Precautions( 5.2)].

A 104-week dermal carcinogenicity study was performed in mice with tacrolimus ointment (0.03% - 3%), equivalent to tacrolimus doses of 1.1-118 mg/kg/day or 3.3-354 mg/m2/day. In the study, the incidence of skin tumors was minimal and the topical application of tacrolimus was not associated with skin tumor formation under ambient room lighting. However, a statistically significant elevation in the incidence of pleomorphic lymphoma in high dose male (25/50) and female animals (27/50) and in the incidence of undifferentiated lymphoma in high dose female animals (13/50) was noted in the mouse dermal carcinogenicity study. Lymphomas were noted in the mouse dermal carcinogenicity study at a daily dose of 3.5 mg/kg (0.1% tacrolimus ointment). No drug-related tumors were noted in the mouse dermal carcinogenicity study at a daily dose of 1.1 mg/kg (0.03% tacrolimus ointment). The relevance of topical administration of tacrolimus in the setting of systemic tacrolimus use is unknown.

The implications of these carcinogenicity studies to the human condition are limited; doses of tacrolimus were administered that likely induced immunosuppression in these animals impairing their immune system’s ability to inhibit unrelated carcinogenesis.

No evidence of genotoxicity was seen in bacterial ( Salmonellaand 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.

Tacrolimus given orally at 1.0 mg/kg (0.8 to 2.2 times the clinical dose range of 0.075 to 0.2 mg/kg/day based on body surface area) to male and female rats, prior to and during mating, as well as to dams during gestation and lactation, was associated with embryolethality and adverse effects on female reproduction. Effects on female reproductive function (parturition) and embryolethal effects were indicated by a higher rate of pre-implantation loss and increased numbers of undelivered and nonviable pups. When given at 3.2 mg/kg (2.6 to 6.9 times the clinical dose range based on body surface area), 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.

14 CLINICAL STUDIES

14.1 Kidney Transplantation

Tacrolimus/azathioprine (AZA)Tacrolimus-based immunosuppression in conjunction with azathioprine and corticosteroids following kidney transplantation was assessed in a randomized, multicenter, non-blinded, prospective trial. 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 a serum creatinine 4 mg/dL (median of ≤4 days after transplantation, range 1 to 14 days). Patients less than 6 years of age were excluded.There were 205 patients randomized to Tacrolimus-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 1 year patient and graft survival was 96.1% and 89.6%, respectively.Data from this trial of Tacrolimus in conjunction with azathioprine indicate that 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 1 year.Tacrolimus/mycophenolate mofetil (MMF)Tacrolimus-based immunosuppression in conjunction with MMF, corticosteroids, and induction has been studied. In a randomized, open-label, multi-center trial (Study 1), 1589 kidney transplant patients received Tacrolimus (Group C, n=401), sirolimus (Group D, n=399), or one of two cyclosporine (CsA) 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 trial was conducted outside the United States; the trial population was 93% Caucasian. In this trial, mortality at 12 months in patients receiving Tacrolimus/MMF was similar (3%) compared to patients receiving cyclosporine/MMF (3% and 2%) or sirolimus/MMF (3%). Patients in the Tacrolimus group exhibited higher estimated creatinine clearance rates(eCLcr) using the Cockcroft-Gault formula (Table 16) and experienced fewer efficacy failures, defined as biopsy proven acute rejection (BPAR), graft loss, death, and/or lost to follow-up (Table 17) in comparison to each of the other three groups. Patients randomized to tacrolim us/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 (6.1)].

Table 16. Estimated Creatinine Clearance at 12 Months (Study 1) 

	eCLcr [mL/min] at Month 12 a
Group	N	MEAN	SD	MEDIAN	Treatment Difference with Group C (99.2% CIb)
(A) CsA/MMF/CS	390	56.5	25.8	56.9	-8.6 (-13.7, -3.7)
(B) CsA/MMF/CS/Daclizumab	399	58.9	25.6	60.9	-6.2 (-11.2, -1.2)
(C) Tac/MMF/CS/Daclizumab	401	65.1	27.4	66.2	-
(D) Siro/MMF/CS/Daclizumab	399	56.2	27.4	57.3	-8.9 (-14.1, -3.9)
Total	1589	59.2	26.8	60.5
Key: CsA=Cyclosporine, CS=Corticosteroids, Tac=Tacrolimus, Siro=Sirolimus

 a)All death/graft loss (n=41, 27, 23 and 42 in Groups A, B, C and D) and patients whose last recorded creatinine values were prior to month 3 visit (n=10, 9, 7 and 9 in Groups A, B, C and D, respectively) were inputed with Glomerular Filtration Rate (GFR) of 10 mL/min; a subject's last observed creatinine value from month 3 on was used for the remainder of subjects with missing creatinine at month 12 (n=11, 12, 15 and 19 for Groups A, B, C and D, respectively). Weight was also imputed in the calculation of estimated GFR, if missing.
b)Adjusted for multiple (6) pairwise comparisons using Bonferroni corrections.

Table 17. Incidence of BPAR, Graft Loss, Death or Loss to Follow-up at 12 Months (Study 1) 

	Group AN=390	Group BN=399	Group CN=401	Group DN=399
Overall Failure	141 (36.2%)	126 (31.6%)	82 (20.4%)	185 (46.4%)
Components of efficacy failure
BPAR	113 (29.0%)	106 (26.6%)	60 (15.0%)	152 (38.1%)
Graft loss excluding death	28 (7.2%)	20 (5.0%)	12 (3.0%)	30 (7.5%)
Mortality	13 (3.3%)	7 (1.8%)	11 (2.7%)	12 (3.0%)
Lost to follow-up	5 (1.3%)	7 (1.8%)	5 (1.3%)	6 (1.5%)
Treatment Difference of efficacy failure compared to Group C (99.2% CIa )	15.8% (7.1%, 24.3%)	11.2% (2.7%, 19.5%)	-	26.0% (17.2%, 34.7%)
Key: Group A=CsA/MMF/CS, B=CsA/MMF/CS/Daclizumab, C=Tac/MMF/CS/Daclizumab, and D=Siro/MMF/CS/Daclizumab

a)Adjusted for multiple (6) pairwise comparisons using Bonferroni corrections.The protocol-specified target Tacrolimus trough concentrations (C trough,Tac) were 3 -7 ng/mL; however, the observed median Ctroughs,Tac approximated 7 ng/mL throughout the 12 month trial (Table 18). Approximately 80% of patients maintained Tacrolimus whole blood concentrations between 4-11 ng/mL through 1 year post-transplant.

• Time: Median (P10-P90a) Tacrolimus whole blood trough concentrations(ng/mL)
• Day 30 (N=366): 6.9 (4.4 to 11.3)
• Day 90 (N=351): 6.8 (4.1 to 10.7)
• Day 180 (N=355): 6.5 (4.0 to 9.6)
• Day 365 (N=346): 6.5 (3.8 to 10.0)

a) 10 to the 90th Percentile: range of Ctrough,Tacthat excludes lowest 10% and highest 10% of Ctrough, Tac.The protocol-specified target cyclosporine trough concentrations (C trough,CsA) for Group B were 50-100 ng/mL; however, the observed median C troughs,CsAapproximated 100 ng/mL throughout the 12 month trial. The protocol-specified target C troughs,CsAfor Group A were 150-300 ng/mL for the first 3 months and 100-200 ng/mL from month 4 to month 12; the observed median C troughs, CsAapproximated 225 ng/mL for the first 3 months and 140 ng/mL from month 4 to month 12.While patients in all groups started MMF at 1gram twice daily, the MMF dose was reduced to less than 2 g per day in 63% of patients in the Tacrolimus treatment arm by month 12 (Table 19); approximately 50% of these MMF dose reductions were due to adverse reactions. By comparison, the MMF dose was reduced to less than 2 g per day in 49% and 45% of patients in the two cyclosporine arms (Group A and Group B, respectively), by month 12 and approximately 40% of MMF dose reductions were due to adverse reactions.

Table 19. MMF Dose Over Time in Tacrolimus/MMF (Group C) (Study 1) 

Time period (Days)	Time-averaged MMF dose (grams per day) a
	Less than 2.0	2.0	Greater than 2.0
0-30 (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%
Key: Time-averaged MMF dose = (total MMF dose)/(duration of treatment)

 a)Percentage of patients for each time-averaged MMF dose range during various treatment periods. Administration of 2 g per day of time-averaged MMF dose means that MMF dose was not reduced in those patients during the treatment periods.In a second randomized, open-label, multi-center trial (Study 2), 424 kidney transplant patients received Tacrolimus (N=212) or cyclosporine (N=212) in combination with MMF 1 gram twice daily, basiliximab induction, and corticosteroids. In this trial, the rate for the combined endpoint of BPAR, graft failure, death, and/or lost to follow-up at 12 months in the Tacrolimus/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 Tacrolimus/MMF (4%) compared to those receiving cyclosporine/MMF (2%), including cases attributed to overimmunosuppression (Table 20). 

Table 20. Incidence of BPAR, Graft Loss, Death or Loss to Follow-up at 12 Months (Study 2) 

	Tacrolimus/MMF (N=212)	Cyclosporine/MMF (N=212)
Overall Failure	32 (15.1%)	36 (17.0%)
Components of efficacy failure
BPAR	16 (7.5%)	29 (13.7%)
Graft loss excluding death	6 (2.8%)	4 (1.9%)
Mortality	9 (4.2%)	5 (2.4%)
Lost to follow-up	4 (1.9%)	5 (2.4%)
Treatment Difference of efficacy failure compared to Tacrolimus/MMF group (95% CIa)		1.9% (-5.2%, 9%)

 a) 95% confidence interval calculated using Fisher's Exact Test.

The protocol-specified target Tacrolimus whole blood trough concentrations (C trough,Tac) in Study 2 were 7-16 ng/mL for the first three months and 5-15 ng/mL thereafter. The observed median C troughs,Tacapproximated 10 ng/mL during the first three months and 8 ng/mL from month 4 to month 12 (Table 21). Approximately 80% of patients maintained Tacrolimus whole trough blood concentrations between 6 to 16 ng/mL during months 1 through 3 and, then, between 5 to 12 ng/mL from month 4 through 1 year. 

• Time: Median (P10-P90a) 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)

a) 10 to 90th Percentile: range of Ctrough, CsA that excludes lowest 10% and highest 10% of Ctrough, Tac.The protocol-specified target cyclosporine whole blood concentrations (C trough,CsA) were 125- 400 ng/mL for the first three months, and 100-300 ng/mL thereafter. The observed median C troughs, CsAapproximated 280 ng/mL during the first three months and 190 ng/mL from month 4 to month 12.Patients in both groups started MMF at 1gram twice daily. The MMF dose was reduced to less than 2 grams per day by month 12 in 62% of patients in the Tacrolimus/MMF group Table 22 and in 47% of patients in the cyclosporine/MMF group. Approximately 63% and 55% of these MMF dose reductions were because of adverse reactions in the Tacrolimus/MMF group and the cyclosporine/MMF group, respectively [ see Adverse Reactions( 6.1)].

Table 22. MMF Dose Over Time in the Tacrolimus /MMF Group (Study 2) 

Time period (Days)	Time-averaged MMF dose (grams per day) a
	Less than 2.0	2.0	Greater than 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%	41%	7%
Key: Time-averaged MMF dose=(total MMF dose)/(duration of treatment)

 a) Percentage of patients for each time-averaged MMF dose range during various treatment periods. Two grams per day of time-averaged MMF dose means that MMF dose was not reduced in those patients during the treatment periods.

14.2 Liver Transplantation

The safety and efficacy of tacrolimus-based immunosuppression following orthotopic liver transplantation were assessed in two prospective, randomized, non-blinded multicenter trials. The active control groups were treated with a cyclosporine-based immunosuppressive regimen (CsA/AZA). Both trials used concomitant adrenal corticosteroids as part of the immunosuppressive regimens. These trials compared patient and graft survival rates at 12 months following transplantation.

In one trial, 529 patients were enrolled at 12 clinical sites in the United States; prior to surgery, 263 were randomized to the tacrolimus-based immunosuppressive regimen and 266 to the CsA/AZA. In 10 of the 12 sites, the same CsA/AZA protocol was used, while 2 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 8 clinical sites in Europe; prior to surgery, 270 were randomized to the tacrolimus-based immunosuppressive regimen and 275 to CsA/AZA. In this trial, each center used its local standard CsA/AZA 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 tacrolimus-based treatment groups were similar to those in the CsA/AZA treatment groups in both trials. The overall 1-year patient survival (CsA/AZA and tacrolimus-based treatment groups combined) was 88% in the U.S. trial and 78% in the European trial. The overall 1-year graft survival (CsA/AZA and tacrolimus-based treatment groups combined) was 81% in the U.S. trial and 73% in the European trial. In both trials, the median time to convert from IV to oral tacrolimus dosing was 2 days.

Although there is a lack of direct correlation between tacrolimus concentrations and drug efficacy, data from clinical trials of liver transplant patients have shown an increasing incidence of adverse reactions with increasing trough blood concentrations. Most patients are stable when trough whole blood concentrations are maintained between 5 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 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.

14.3 Heart Transplantation

Two open-label, randomized, comparative trials evaluated the safety and efficacy of tacrolimus-based and cyclosporine-based immunosuppression in primary orthotopic heart transplantation. In a trial conducted in Europe, 314 patients received a regimen of antibody induction, corticosteroids and azathioprine in combination with tacrolimus or cyclosporine modified for 18 months. In a 3-arm trial conducted in the US, 331 patients received corticosteroids and tacrolimus plus sirolimus, tacrolimus plus mycophenolate mofetil (MMF) or cyclosporine modified plus MMF for 1 year.

In the European trial, patient/graft survival at 18 months post-transplant was similar between treatment arms, 92% in the tacrolimus group and 90% in the cyclosporine group. In the U.S. trial, patient and graft survival at 12 months was similar with 93% survival in the tacrolimus plus MMF group and 86% survival in the cyclosporine modified plus MMF group. In the European trial, the cyclosporine trough concentrations were above the pre-defined target range (i.e., 100 to 200 ng/mL) at Day 122 and beyond in 32 to 68% of the patients in the cyclosporine treatment arm, whereas the tacrolimus trough concentrations were within the pre-defined target range (i.e., 5 to 15 ng/mL) in 74 to 86% of the patients in the tacrolimus treatment arm. Data from this European trial indicate that from 1 week to 3 months post-transplant, approximately 80% of patients maintained trough concentrations between 8 to 20 ng/mL and, from 3 months through 18 months post-transplant, approximately 80% of patients maintained trough concentrations between 6 to18 ng/mL.

The U.S. trial contained a third arm of a combination regimen of sirolimus, 2 mg per day, and full-dose tacrolimus; 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 and Precautions( 5.12)].

16 HOW SUPPLIED/STORAGE AND HANDLING

Tacrolimus Capsules USP, 1 mg are white to off white powder filled in hard gelatin capsule of size ‘4’, white opaque cap and white opaque body imprinted “ BP 666" twice on the body and imprinted “1 mg” twice on the cap with red ink.

NDC: 70518-3388-00

NDC: 70518-3388-01

PACKAGING: 100 in 1 BOX

PACKAGING: 1 in 1 POUCH

Note: Tacrolimus capsules are not filled to maximum capsule capacity. Capsule contains labeled amount.

Store at 25°C (77°F); excursions permitted to 15°C-30°C (59°F-86°F).[See USP Controlled Room Temperature].

Repackaged and Distributed By:

Remedy Repack, Inc.

625 Kolter Dr. Suite #4 Indiana, PA 1-724-465-8762

17 PATIENT COUNSELING INFORMATION

Repackaged By / Distributed By: RemedyRepack Inc.

625 Kolter Drive, Indiana, PA 15701

(724) 465-8762

17.1 Administration

Advise patients to:

Take Tacrolimus at the same 12-hour intervals everyday to achieve consistent blood concentrations.

Take Tacrolimus consistently either with or without food because the presence and composition of food decreases the bioavailability of Tacrolimus.

Not to eat grapefruit or drink grapefruit juice in combination with Tacrolimus [ see Drug Interactions( 7.2)].

17.2 Development of Lymphoma and Other Malignancies

Inform patients they are at increased risk of developing lymphomas and other malignancies, particularly of the skin, due to immunosuppression. Advise patients to limit exposure to sunlight and ultraviolet (UV) light by wearing protective clothing and use a sunscreen with a high protection factor [ see Warnings and Precautions( 5.2)].

17.3 Increased Risk of Infection

Inform patients they are at increased risk of developing a variety of infections, including opportunistic infections, due to immunosuppression and to contact their physician if they develop any symptoms of infection [ see Warnings and Precautions( 5.3, 5.4, 5.5, )].

17.4 New Onset Diabetes After Transplant

Inform patients that Tacrolimus can cause diabetes mellitus and should be advised to contact their physician if they develop frequent urination, increased thirst or hunger [ see Warnings and Precautions( 5.6)].

17.5 Nephrotoxicity

Inform patients that tacrolimus can have toxic effects on the kidney that should be monitored. Advise patients to attend all visits and complete all blood tests ordered by their medical team [ see Warnings and Precautions( 5.7)].

17.6 Neurotoxicity

Inform patients that they are at risk of developing adverse neurologic effects including seizure, altered mental status, and tremor. Advise patients to contact their physician should they develop vision changes, deliriums, or tremors [ see Warnings and Precautions( 5.8)].

17.7 Hyperkalemia

Inform patients that Tacrolimus can cause hyperkalemia. Monitoring of potassium levels may be necessary, especially with concomitant use of other drugs known to cause hyperkalemia [ see Warnings and Precautions( 5.9)].

17.8 Hypertension

Inform patients that tacrolimus can cause high blood pressure which may require treatment with anti-hypertensive therapy [ see Warnings andPrecautions( 5.10)].

17.9 Drug Interactions

Instruct patients to tell their health care providers when they start or stop taking all the medicines, including prescription medicines and non-prescription medicines, natural or herbal remedies, nutritional supplements and vitamins [ see Drug Interactions( 7)].

17.10 Pregnant Women and Nursing Mothers

Instruct patients to tell their healthcare provider if they plan to become pregnant or breast-feed their infant [ see Use in Specific Populations( 8.1, 8.3)]

17.11 Immunizations

Inform patients that tacrolimus can interfere with the usual response to immunizations and that they should avoid live vaccines [ see Warnings and Precautions ( 5.16)].

Rx Only

Repackaged and Distributed By:

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625 Kolter Dr. Suite #4 Indiana, PA 1-724-465-8762

PATIENT INFORMATION

Tacrolimus capsules, USP

Read this Patient Information before you start taking tacrolimus and each time you get a refill. There may be new information. This information does not take the place of talking with your doctor about your medical condition or your treatment.

What is the most important information I should know about TACROLIMUS?

Tacrolimus can cause serious side effects, including:

1. Increased risk of cancer. People who take Tacrolimus have an increased risk of getting some kinds of cancer, including skin and lymph gland cancer (lymphoma).

2. Increased risk of infection. TACROLIMUS is a medicine that affects your immune system. Tacrolimus can lower the ability of your immune system to fight infections. Serious infections can happen in people receiving Tacrolimus that can cause death. Call your doctor right away if you have symptoms of an infection such as:

fever

sweats or chills

cough or flu-like symptoms

muscle aches

warm, red, or painful areas on your skin

What is TACROLIMUS?

TACROLIMUS is a prescription medicine used with other medicines to help prevent organ rejection in people who have had a kidney, liver, or heart transplant and TACROLIMUS is not for use with medicines called cyclosporines (Gengraf®, Neoral®, and Sandimune®).

TACROLIMUS is not for use with a medicine called sirolimus (Rapamune®) in people who have had a liver or heart transplants.

It is not known if TACROLIMUS is safe and effective when used with sirolimus in people who have had kidney transplants.

It is not known if TACROLIMUS is safe and effective in children who have had a kidney or heart transplants.

Who Should Not Take TACROLIMUS?

Do not take TACROLIMUS if you are allergic to tacrolimus or any of the ingredients in TACROLIMUS. See the end of this leaflet for a complete list of ingredients in TACROLIMUS.

What should I tell my doctor before taking TACROLIMUS?

Before you take TACROLIMUS, tell your doctor if you:

• Plan to receive any live vaccines
• Have or have had liver, kidney or heart problems
• Are pregnant or plan to become pregnant. TACROLIMUS may harm your unborn baby. Talk to your doctor if you are pregnant or plan to become pregnant.
• Are breastfeeding or plan to breastfeed. TACROLIMUS can pass into your breast milk. You and your doctor should decide if you will take TACROLIMUS or breastfeed. You should not do both.

Tell your doctor about all the medicines you take, including prescription and non-prescription medicines, vitamins, and herbal supplements.

Especially tell your doctor if you take:

• cyclosporine (Gengraf ®, Neoral ®, and Sandimune ®)
• sirolimus (Rapamune ®)
• nelfinavir (Viracept ®)
• telaprevir (Incivek™)
• boceprevir (Victrelis™)
• amiodarone (Cordarone™, Nexterone™, Pacerone™)

Ask your doctor or pharmacist if you are not sure if you take any of the medicines listed above.

TACROLIMUS may affect the way other medicines work, and other medicines may affect how TACROLIMUS works.

Know the medicines you take. Keep a list of your medicines and show it to your doctor and pharmacist when you get a new medicine.

How should I take TACROLIMUS?

• Take TACROLIMUS exactly as your doctor tells you to take it.
• Your doctor will tell you how many TACROLIMUS to take and when to take them.
• Your doctor may change your TACROLIMUS dose if needed. Do not stop taking or change your dose of TACROLIMUS without talking to your doctor.
• Take TACROLIMUS with or without food.
• Take TACROLIMUS the same way everyday. For example, if you choose to take TACROLIMUS with food, you should always take TACROLIMUS with food.
• Take TACROLIMUS at the same time each day, 12 hours apart. For example, if you take your first dose at 7:00 a.m. you should take your second dose at 7:00 p.m.
• Taking TACROLIMUS at the same time each day helps to keep enough medicine in your body to give your transplanted organ the around-the-clock medicine it needs.
• Do not eat grapefruit or drink grapefruit juice while taking TACROLIMUS.
• If you take too much TACROLIMUS, call your doctor or go to the nearest hospital emergency room right away.

What should I avoid while taking TACROLIMUS ?

While you take TACROLIMUS you should not receive any live vaccines such as:

• Flu vaccine through your nose
• Measles
• Mumps
• Rubella
• polio by mouth
• BCG (TB vaccine)
• Yellow fever
• Chicken pox (varicella)
• Typhoid

Avoid exposure to sunlight and UV light such as tanning machines. Wear protective clothing and use a sunscreen.

What are the possible side effects of TACROLIMUS

TACROLIMUS may cause serious side effects, including:

See “What the most important information I should know about TACROLIMUS ?”

High blood sugar (diabetes). Your doctor may do certain tests to check for diabetes while you take TACROLIMUS. Call your doctor right away if you have:

frequent urination

increased thirst or hunger

blurred vision

confusion

drowsiness

loss of appetite

fruity smell on your breath

nausea, vomiting, or stomach pain

Kidney problems. Your doctor may do certain tests to check your kidney function while you take TACROLIMUS.

Nervous system problems. Call your doctor right away if you get any of these symptoms while taking TACROLIMUS. These could be signs of a serious nervous system problem:

confusion

coma

muscle tremors

numbness and tingling

headache

seizures

vision changes

high levels of potassium in your blood.Your doctor may do certain tests to check your potassium level while you take TACROLIMUS.

high blood pressure. Your doctor will monitor your blood pressure while you take TACROLIMUS.

heart problems (myocardial hypertrophy).Tell your doctor right away if you get any of these symptoms of heart problems while taking TACROLIMUS:

• shortness of breath
• chest pain
• feel lightheaded
• feel faint

The most common side effects of TACROLIMUS in people receiving kidney transplant are:

• infection
• tremors (shaking of the body)
• high blood pressure
• kidney problems
• constipation
• diarrhea
• headache
• stomach pain
• trouble sleeping
• nausea
• low levels of phosphate in your blood
• swelling of the hands, ankles, or legs
• weakness
• pain
• high levels of fat in your blood
• high levels of potassium in your blood
• low red blood cell count (anemia)

The most common side effects of TACROLIMUS in people receiving liver transplants are:

• shaking of the body tremors
• headache
• diarrhea
• high blood pressure
• nausea
• kidney problems
• stomach pain
• trouble sleeping
• numbness or tingling in your hands or feet
• anemia
• pain
• fever
• weakness
• high levels of potassium in the blood
• low levels of magnesium in the blood

The most common side effects of TACROLIMUS for heart transplant patients are:

• kidney problems
• high blood pressure

Tell your doctor if you have any side effect that bothers you or that does not go away.

These are not all the possible side effects of TACROLIMUS. For more information, ask your doctor or pharmacist.

Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.

How should I store TACROLIMUS?

• Store tacrolimus at 59°F to 86°F (15°C to 30°C).
• Safely throw away medicine that is out of date or no longer needed.

Keep TACROLIMUS and all medicines out of reach of children.

General information about the safe and effective use of TACROLIMUS

Medicines are sometimes prescribed for purposes other than those listed in a Patient Information leaflet. Do not use TACROLIMUS for a condition for which it was not prescribed. Do not give TACROLIMUS to other people, even if they have the same symptoms that you have. It may harm them.

How Does TACROLIMUS Protect My New Organ?

The body’s immune system protects the body against anything that it does not recognize as part of the body. For example, when the immune system detects a virus or bacteria it tries to get rid of it to prevent infection. When a person has a liver, kidney, or heart transplant, the immune system does not recognize the new organ as a part of the body and tries to get rid of it, too. This is called “rejection”. TACROLIMUS protects your new organ by slowing down the body’s immune system.

This Patient Information leaflet summarizes the most important information about TACROLIMUS. If you would like more information, talk with your doctor. You can ask your pharmacist or doctor for information about TACROLIMUS that is written for health professionals.

For more information,go to www.bpi-labs.comor call 1-727-471-0850.

What are the ingredients in TACROLIMUS?

Active ingredient: TACROLIMUS

Inactive ingredients: Anhydrous Lactose, hypromellose, croscarmellose sodium, magnesium stearate, gelatin, titanium dioxide and ferric oxide.

Non-volatile components of the ink are Shellac Glaze, Iron Oxide Red, and Simethicone USP.

Trademarks are the property of their respective owners.

This Patient Information has been approved by the U.S. Food and Drug Administration.

Repackaged and Distributed By:

Remedy Repack, Inc.

625 Kolter Dr. Suite #4 Indiana, PA 1-724-465-8762

DRUG: Tacrolimus

GENERIC: Tacrolimus

DOSAGE: CAPSULE

ADMINSTRATION: ORAL

NDC: 70518-3388-0

NDC: 70518-3388-1

COLOR: white

SHAPE: CAPSULE

SCORE: No score

SIZE: 14 mm

IMPRINT: 1;mg;BP;666

PACKAGING: 1 in 1 POUCH

OUTER PACKAGING: 100 in 1 BOX

ACTIVE INGREDIENT(S):

• TACROLIMUS 1mg in 1

INACTIVE INGREDIENT(S):

• ANHYDROUS LACTOSE
• HYPROMELLOSE 2208 (100 MPA.S)
• CROSCARMELLOSE SODIUM
• MAGNESIUM STEARATE
• GELATIN
• TITANIUM DIOXIDE
• SHELLAC
• FERRIC OXIDE RED
• DIMETHICONE
• HYDRATED SILICA

TACROLIMUS 
tacrolimus capsule

Product Information
Product Type	HUMAN PRESCRIPTION DRUG	Item Code (Source)	NDC: 70518-3388(NDC: 54288-135)
Route of Administration	ORAL

Active Ingredient/Active Moiety
Ingredient Name	Basis of Strength	Strength
TACROLIMUS (UNII: WM0HAQ4WNM) (TACROLIMUS ANHYDROUS - UNII:Y5L2157C4J)	TACROLIMUS ANHYDROUS	1 mg

Inactive Ingredients
Ingredient Name	Strength
ANHYDROUS LACTOSE (UNII: 3SY5LH9PMK)
HYPROMELLOSE 2208 (100 MPA.S) (UNII: B1QE5P712K)
CROSCARMELLOSE SODIUM (UNII: M28OL1HH48)
MAGNESIUM STEARATE (UNII: 70097M6I30)
GELATIN (UNII: 2G86QN327L)
TITANIUM DIOXIDE (UNII: 15FIX9V2JP)
SHELLAC (UNII: 46N107B71O)
FERRIC OXIDE RED (UNII: 1K09F3G675)
DIMETHICONE (UNII: 92RU3N3Y1O)
HYDRATED SILICA (UNII: Y6O7T4G8P9)

Product Characteristics
Color	white (white opaque body and white oaque cap)	Score	no score
Shape	CAPSULE	Size	14mm
Flavor		Imprint Code	1;mg;BP;666
Contains

Packaging
#	Item Code	Package Description	Marketing Start Date	Marketing End Date
1	NDC: 70518-3388-0	100 in 1 BOX	03/14/2022	03/14/2022
1	NDC: 70518-3388-1	1 in 1 POUCH; Type 0: Not a Combination Product

Marketing Information
Marketing Category	Application Number or Monograph Citation	Marketing Start Date	Marketing End Date
ANDA	ANDA206651	03/14/2022	03/14/2022

Labeler - REMEDYREPACK INC. (829572556)

Revised: 7/2024

Document Id: 1cbe15c5-1e9d-08d0-e063-6394a90aef53

34391-3

Set id: d93e6b15-8bd4-4d0f-9a18-e232e5b1161a

Version: 3

Effective Time: 20240708