Tacrolimus

WARNING: MALIGNANCIES AND SERIOUS INFECTIONS IN TRANSPLANT PATIENTS; AND INCREASED MORTALITY IN FEMALE LIVER TRANSPLANT PATIENTS Increased risk for developing serious infections and malignancies with tacrolimus extended-release capsules or other immunosuppressants that may lead to hospitalization or death. [see Warnings and Precautions ( 5.1 , 5.2 )] Increased mortality in female liver transplant patients with tacrolimus extended-release capsules. Tacrolimus extended-release capsules is not approved for use in liver transplantation. [see Warnings and Precautions (5.3) ] WARNING: MALIGNANCIES AND SERIOUS INFECTIONS IN TRANSPLANT PATIENTS; AND INCREASED MORTALITY IN FEMALE LIVER TRANSPLANT PATIENTS See full prescribing information for complete boxed warning. Increased risk for developing serious infections and malignancies with tacrolimus extended-release capsules or other immunosuppressants that may lead to hospitalization or death. ( 5.1 , 5.2 ) Increased mortality in female liver transplant patients with tacrolimus extended-release capsules. Not approved for use in liver transplantation. ( 5.3 )

5 WARNINGS AND PRECAUTIONS Not Interchangeable with Other Tacrolimus Products-Medication Errors: Instruct patients or caregivers to recognize the appearance of tacrolimusextended-release capsules. ( 5.4 ) New onset diabetes after transplant: Monitor blood glucose. ( 5.5 ) Nephrotoxicity (acute and/or chronic): May occur due to tacrolimus extended-release capsules, drug interactions, concomitant nephrotoxic drugs. Monitor renal function; consider dosage reduction. ( 5.6 ) Neurotoxicity: Including risk of posterior reversible encephalopathy syndrome (PRES), monitor for neurologic abnormalities; reduce dosage or discontinue tacrolimus extended-release capsules. ( 5.7 ) Hyperkalemia: Risk may be increased with other agents associated with hyperkalemia; monitor serum potassium levels. ( 5.8 ) Hypertension: May require antihypertensive therapy; monitor relevant drug interactions. ( 5.9 ) QT prolongation: Consider obtaining electrocardiograms and monitoring electrolytes in patients at high risk. ( 5.11 ) Immunizations: Avoid live vaccines. ( 5.12 ) Pure red cell aplasia: Consider discontinuation of tacrolimus extended-release capsules. ( 5.13 ) Thrombotic Microangiopathy, Including Hemolytic Uremic Syndrome and Thrombotic Thrombocytopenic Purpura: May occur, especially in patients with infections and certain concomitant medications. ( 5.14 ) 5.1 Lymphoma and Other Malignancies Immunosuppressants, including tacrolimus extended-release capsules, increase the risk of developing lymphomas and other malignancies, particularly of the skin . The risk appears to be related to the intensity and duration of immunosuppression rather than to the use of any specific agent. Examine patients for skin changes and advise to avoid or limit exposure to sunlight and UV light by wearing protective clothing and using a broad-spectrum sunscreen with a high protection factor. Post-transplant lymphoproliferative disorder (PTLD), associated with Epstein-Barr Virus (EBV), has been reported in immunosuppressed organ transplant patients. The risk of PTLD appears greatest in patients who are EBV seronegative, a population which includes many young children. Monitor EBV serology during treatment. 5.2 Serious Infections Immunosuppressants, including tacrolimus extended-release capsules, increase the risk of developing bacterial, viral, fungal, and protozoal infections, including opportunistic infections. These infections may lead to serious, including fatal, outcomes. Serious viral infections reported include: Polyomavirus-associated nephropathy (especially due to BK virus infection) JC virus-associated progressive multifocal leukoencephalopathy (PML) Cytomegalovirus (CMV) infections: CMV seronegative transplant patients who receive an organ from a CMV seropositive donor are at highest risk of CMV viremia and CMV disease. Monitor for the development of infection and adjust the immunosuppressive regimen to balance the risk of rejection with the risk of infection [see Adverse Reactions ( 6.1 , 6.2 )] . 5.3 Increased Mortality in Female Liver Transplant Patients In a clinical trial of 471 liver transplant patients randomized to tacrolimus extended-release capsules or tacrolimus immediate-release product, mortality at 12 months was 10% higher among the 76 female patients (18%) treated with tacrolimus extended-release capsules compared to the 64 female patients (8%) treated with tacrolimus immediate-release product. Tacrolimus extended-release capsules is not approved for the prophylaxis of organ rejection in patients who received a liver transplant. 5.4 Not Interchangeable with Other Tacrolimus Products - Medication Errors Medication errors, including substitution and dispensing errors, between tacrolimus immediate-release products and tacrolimus extended-release capsules were reported outside the U.S. This led to serious adverse reactions, including graft rejection, or other adverse reactions due to under- or over-exposure to tacrolimus. Tacrolimus extended-release capsules is not interchangeable or substitutable for tacrolimus extended-release tablets, tacrolimus immediate-release capsules or tacrolimus for oral suspension. Changes between tacrolimus immediate-release and extended-release dosage forms must occur under physician supervision. Instruct patients and caregivers to recognize the appearance of tacrolimus extended-release capsules [see Dosage Forms and Strengths (3) ] and to confirm with the healthcare provider if a different product is dispensed or if dosing instructions have changed. 5.5 New Onset Diabetes After Transplant Tacrolimus extended-release capsules caused new onset diabetes after transplant (NODAT) in kidney transplant patients, which may be reversible in some patients. African-American and Hispanic kidney transplant patients are at an increased risk. Monitor blood glucose concentrations and treat appropriately [see Adverse Reactions (6.1) and Use in Specific Populations (8.8) ] . 5.6 Nephrotoxicity due to Tacrolimus Extended-Release Capsules and Drug Interactions Tacrolimus extended-release capsules, like other calcineurin-inhibitors, can cause acute or chronic nephrotoxicity in transplant patients due to its vasoconstrictive effect on renal vasculature, toxic tubulopathy and tubular-interstitial effects. Acute renal impairment associated with tacrolimus toxicity can result in high serum creatinine, hyperkalemia, decreased secretion of urea and hyperuricemia, and is usually reversible. In patients with elevated serum creatinine and tacrolimus whole blood trough concentrations greater than the recommended range, consider dosage reduction or temporary interruption of tacrolimus administration. The risk for nephrotoxicity may increase when tacrolimus extended-release capsules is concomitantly administered with CYP3A inhibitors (by increasing tacrolimus whole blood concentrations) or drugs associated with nephrotoxicity (e.g., aminoglycosides, ganciclovir, amphotericin B, cisplatin, nucleotide reverse transcriptase inhibitors, protease inhibitors). When tacrolimus is used concurrently with other known nephrotoxic drugs, monitor renal function and tacrolimus blood concentrations, and adjust dose of both tacrolimus and/or concomitant medications during concurrent use [see Adverse Reactions ( 6.1 , 6.2 ) and Drug Interactions (7.2) ]. 5.7 Neurotoxicity Tacrolimus extended-release capsules may cause a spectrum of neurotoxicities. The most severe neurotoxicities include posterior reversible encephalopathy syndrome (PRES), delirium, seizure and coma; others include tremors, paresthesias, headache, mental status changes, and changes in motor and sensory functions [see Adverse Reactions ( 6.1 , 6.2 )] . As symptoms may be associated with tacrolimus whole blood trough concentrations at or above the recommended range, monitor for neurologic symptoms and consider dosage reduction or discontinuation of tacrolimus extended-release capsules if neurotoxicity occurs. 5.8 Hyperkalemia Mild to severe hyperkalemia, which may require treatment, has been reported with tacrolimus including tacrolimus extended-release capsules. Concomitant use of agents associated with hyperkalemia (e.g., potassium-sparing diuretics, ACE inhibitors, angiotensin receptor blockers) may increase the risk for hyperkalemia [see Adverse Reactions (6.1) ] . Monitor serum potassium levels periodically during treatment. 5.9 Hypertension Hypertension is a common adverse reaction of tacrolimus extended-release capsules therapy and may require antihypertensive therapy [see Adverse Reactions (6.1) ] . Some antihypertensive drugs can increase the risk for hyperkalemia [see Warnings and Precautions (5.8) ] . Calcium-channel blocking agents may increase tacrolimus blood concentrations and require dosage reduction of tacrolimus extended-release capsules [see Drug Interactions (7.2) ] . 5.10 Risk of Rejection with Strong CYP3A Inducers and Risk of Serious Adverse Reactions with Strong CYP3A Inhibitors The concomitant use of strong CYP3A inducers may increase the metabolism of tacrolimus, leading to lower whole blood trough concentrations and greater risk of rejection. In contrast, the concomitant use of strong CYP3A inhibitors may decrease the metabolism of tacrolimus, leading to higher whole blood trough concentrations and greater risk of serious adverse reactions (e.g., neurotoxicity, QT prolongation) [see Warnings and Precautions ( 5.7 , 5.11 )] . Therefore, adjust tacrolimus extended-release capsules dose and monitor tacrolimus whole blood trough concentrations when co-administering tacrolimus extended-release capsules with strong CYP3A inhibitors (e.g., including, but not limited to, telaprevir, boceprevir, ritonavir, ketoconazole, itraconazole, voriconazole, clarithromycin) or strong CYP3A inducers (e.g., including, but not limited to, rifampin, rifabutin) [see Dosage and Administration (2.4) and Drug Interactions (7.2) ] . A rapid, sharp rise in tacrolimus levels has been reported after co-administration with a strong CYP3A4 inhibitor, clarithromycin, despite an initial reduction of tacrolimus dose. Early and frequent monitoring of tacrolimus whole blood trough levels is recommended [see Drug Interactions (7.2) ]. 5.11 QT Prolongation Tacrolimus extended-release capsules may prolong the QT/QTc interval and cause Torsades de pointes. Avoid tacrolimus extended-release capsules in patients with congenital long QT syndrome. Consider obtaining electrocardiograms and monitoring electrolytes (magnesium, potassium, calcium) periodically during treatment in patients with congestive heart failure, bradyarrhythmias, those taking certain antiarrhythmic medications or other products that lead to QT prolongation, and those with electrolyte disturbances (e.g., hypokalemia, hypocalcemia, or hypomagnesemia). When co-administering tacrolimus extended-release capsules with other substrates and/or inhibitors of CYP3A, especially those that also have the potential to prolong the QT interval, a reduction in tacrolimus extended-release capsules dosage, monitoring of tacrolimus whole blood concentrations, and monitoring for QT prolongation is recommended [see Dosage and Administration (2.4) and Drug Interactions (7.2) ] . 5.12 Immunizations Whenever possible, administer the complete complement of vaccines before transplantation and treatment with tacrolimus extended-release capsules. Avoid the use of live attenuated vaccines during treatment with tacrolimus extended-release capsules (e.g., intranasal influenza, measles, mumps, rubella, oral polio, BCG, yellow fever, varicella, and TY21a typhoid vaccines). Inactivated vaccines noted to be safe for administration after transplantation may not be sufficiently immunogenic during treatment with tacrolimus extended-release capsules. 5.13 Pure Red Cell Aplasia Cases of pure red cell aplasia (PRCA) have been reported in patients treated with tacrolimus. All of these patients reported risk factors for PRCA such as parvovirus B19 infection, underlying disease, or concomitant medications associated with PRCA. A mechanism for tacrolimus-induced PRCA has not been elucidated. If PRCA is diagnosed, consider discontinuation of tacrolimus extended-release capsules. 5.14 Thrombotic Microangiopathy (TMA) Including Hemolytic Uremic Syndrome and Thrombotic Thrombocytopenic Purpura Cases of thrombotic microangiopathy (TMA), including hemolytic uremic syndrome (HUS) and thrombotic thrombocytopenic purpura (TTP), have been reported in patients treated with tacrolimus extended-release capsules TMA may have a multifactorial etiology. Risk factors for TMA that can occur in transplant patients include, for example, severe infections, graft-versus-host disease (GVHD), Human Leukocyte Antigen (HLA) mismatch, the use of calcineurin inhibitors and mammalian target of rapamycin (mTOR) inhibitors. These risk factors may, either alone or combined, contribute to the risk of TMA. In patients with signs and symptoms of TMA, consider tacrolimus as a risk factor. Concurrent use of tacrolimus and mTOR inhibitors may contribute to the risk of TMA. 5.15 Cannabidiol Drug Interactions When cannabidiol and tacrolimus extended-release capsules are co-administered, closely monitor for an increase in tacrolimus blood levels and for adverse reactions suggestive of tacrolimus toxicity. A dose reduction of tacrolimus extended-release capsules should be considered as needed when tacrolimus extended-release capsules is co-administered with cannabidiol [see Dosage and Administration (2.4) and Drug Interactions (7.3) ] .

6 ADVERSE REACTIONS The following clinically significant adverse drug reactions are discussed in greater detail in other sections of labeling: Lymphoma and Other Malignancies [see Warnings and Precautions (5.1) ] Serious Infections [see Warnings and Precautions (5.2) ] Increased Mortality in Female Liver Transplant Patients [see Warnings and Precautions (5.3) ] New Onset Diabetes after Transplant [see Warnings and Precautions (5.5) ] Nephrotoxicity due to Tacrolimus Extended-Release Capsules and Drug Interactions [see Warnings and Precautions (5.6) ] Neurotoxicity [see Warnings and Precautions (5.7) ] Hyperkalemia [see Warnings and Precautions (5.8) ] Hypertension [see Warnings and Precautions (5.9) ] QT Prolongation [see Warnings and Precautions (5.11) ] Pure Red Cell Aplasia [see Warnings and Precautions (5.13) ] Thrombotic Microangiopathy, Including Hemolytic Uremic Syndrome and Thrombotic Thrombocytopenic Purpura [see Warnings and Precautions (5.14) ] The most common adverse reactions (≥ 30%) are: diarrhea, constipation, nausea, peripheral edema, tremor and anemia. ( 6.1 ) To report SUSPECTED ADVERSE REACTIONS, contact Amneal Pharmaceuticals at 1-877-835-5472 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch . 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 patients were treated with tacrolimus extended-release capsules (N=214) or tacrolimus immediate- release product (N=212) and concomitant immunosuppressants (median duration of exposure of 12 months) in a randomized, open-label, active-controlled trial of mostly U.S. patients (Study 1) [see Clinical Studies (14.1) ] . The types of adverse reactions seen in Study 1 were similar to the adverse reactions seen in Study 2 [non-U.S. trial in kidney transplant patients treated with tacrolimus extended-release capsules (N=331) or tacrolimus immediate-release product (N=336) and concomitant immunosuppressants] [see Clinical Studies (14.2) ] . In Study 1, the proportion of patients who discontinued treatment due to adverse reactions was 9% and 11% in the tacrolimus extended-release capsules and tacrolimus immediate-release treatment groups, respectively, through 12 months of treatment. The most common adverse reactions leading to discontinuation in tacrolimus extended-release capsules-treated patients were related to infections or renal/urinary disorders. Infections The overall incidence of infections, serious infections, and infections with identified etiology reported in patients treated with the tacrolimus extended-release capsules or tacrolimus immediate-release product in Study 1 are shown in Table 2 . Table 2: Percentage of Patients with Infections in Study 1 a Through One Year Post-Kidney Transplant Tacrolimus extended-release capsules, MMF, steroids, basiliximab induction N=214 Tacrolimus immediate-release product, MMF, steroids, basiliximab induction N=212 All Infections 69% 69% Respiratory Infections 34% 31% Urinary Tract Infections 16% 25% Cytomegalovirus Infections 10% 11% Bacterial Infections 8% 12% Gastroenteritis 7% 3% Polyomavirus Infections 3% 5% Serious Infections 22% 23% a Study 1 was not designed to support comparative claims of tacrolimus extended-release capsules compared to tacrolimus immediate-release product for the adverse reactions reported in this table. New Onset Diabetes After Transplant (NODAT) The incidence of new onset diabetes after transplantation (defined by the composite occurrence of ≥ 2 fasting plasma glucose values that were more than 126 mg/dL at ≥ 30 days apart, insulin use for≥ 30 consecutive days, oral hypoglycemic use for ≥ 30 consecutive days, and/or HbA 1C ≥ 6.5%) is summarized in Table 3 below for Study 1 through one year post-transplant [see Warnings and Precautions (5.5) ]. Table 3: Percentage of Patients with NODAT Through One Year Post-Kidney Transplant in Study 1 a Tacrolimus extended-release capsules, MMF, steroids, basiliximab induction N=162 Tacrolimus immediate-release product, MMF, steroids, basiliximab induction N=151 Composite NODAT 36% 35% ≥ 2 Fasting Plasma Glucose Values ≥ 126 mg/dL ≥ 30 days apart 26% 23% HbA 1C ≥ 6.5% 19% 22% Oral hypoglycemic use ≥ 30 consecutive days 14% 9% Insulin use ≥ 30 consecutive days 6% 8% a Study 1 was not designed to support comparative claims of tacrolimus extended-release capsules compared to tacrolimus immediate-release product for the adverse reactions reported in this table. Hyperkalemia In Study 1 [see Clinical Studies (14.1) ] , 73 of 214 (34.1%) patients on tacrolimus extended-release capsules had a serum potassium level greater than 5.4 up to 6.4 mEq/L, and 8 out of 214 (3.7%) patients had a serum potassium level greater than 6.4 mEq/L [see Warnings and Precautions (5.8) ] . Common Adverse Reactions The most common (≥ 30%) adverse reactions observed with tacrolimus extended-release capsules in Study 1 were: diarrhea, constipation, nausea, peripheral edema, tremor, and anemia. The incidence of adverse reactions that occurred in ≥ 15% of tacrolimus extended-release capsules-treated patients compared to tacrolimus immediate-release product through one year of treatment in Study 1 is shown by treatment groups in Table 4 . Table 4: Adverse Reactions (≥ 15%) in Kidney Transplant Patients Through One Year Post-Transplant in Study 1 a Tacrolimus extended-release capsules, MMF, steroids, basiliximab induction N=214 Tacrolimus immediate-release product, MMF, steroids, basiliximab induction N=212 Diarrhea 45% 44% Constipation 40% 32% Nausea 36% 35% Peripheral Edema 36% 34% Tremor 35% 34% Anemia 33% 29% Hypertension 28% 30% Vomiting 25% 25% Hypomagnesemia 24% 27% Insomnia 24% 28% Hypophosphatemia 23% 28% Headache 22% 24% Hyperkalemia 20% 23% Increased Blood Creatinine 19% 23% Fatigue 16% 10% Leukopenia 16% 16% Hyperlipidemia 16% 17% Hyperglycemia 16% 18% a Study 1 was not designed to support comparative claims of tacrolimus extended-release capsules compared to tacrolimus immediate-release for the adverse reactions reported in this table. Less Frequently Reported Adverse Reactions (less than 15% in tacrolimus extended-release capsules-treated patients) by System Organ Class The following adverse reactions were reported in clinical studies of kidney transplant patients who were treated with tacrolimus extended-release capsules, MMF, and steroids (Studies 1 and 2): Blood and Lymphatic System Disorders: Hemolytic anemia, leukocytosis, neutropenia, thrombocytopenia, thrombotic microangiopathy Cardiac Disorders: Atrial fibrillation, atrial flutter, tachycardia Ear Disorders: Tinnitus Eye Disorders: Vision blurred, conjunctivitis Gastrointestinal Disorders: Abdominal distension, abdominal pain, aphthous stomatitis, dyspepsia, esophagitis, flatulence, gastritis, gastroesophageal reflux disease General Disorders and Administration Site Conditions: Anasarca, asthenia, edema, pyrexia Hepatobiliary Disorders: Abnormal hepatic function, cholestasis, hepatitis (acute and chronic), hepatotoxicity Infections and Infestations: Condyloma acuminatum, tinea versicolor Injury: Fall Investigations: Increased blood lactate dehydrogenase, increased blood urea, increased hepatic enzyme Metabolism and Nutrition Disorders: Anorexia, hyperphosphatemia, hyperuricemia, hypokalemia, hyponatremia, metabolic acidosis Musculoskeletal and Connective Tissue Disorders: Arthralgia, osteopenia, osteoporosis Neoplasms: Kaposi’s sarcoma Nervous System Disorders: Convulsion, dizziness, hypoesthesia, neurotoxicity, paresthesia, peripheral neuropathy Psychiatric Disorders: Agitation, anxiety, confusional state, depression, hallucination, mood swings, nightmare Renal and Urinary Disorders: Anuria, oliguria, proteinuria, renal failure, renal tubular necrosis, toxic nephropathy Respiratory, Thoracic and Mediastinal Disorders: Acute respiratory distress syndrome, dyspnea, pulmonary edema, productive cough Skin and Subcutaneous Tissue Disorders: Acne, alopecia, dermatitis, hyperhidrosis, hypotrichosis, pruritus, rash Vascular Disorders: Deep vein thrombosis, flushing Pediatrics De Novo Pediatric Transplant Patients A study was conducted in 44 de novo pediatric transplant patients (including 25 kidney transplant patients; 13 randomized to tacrolimus extended-release capsules and 12 randomized to Prograf), who were started on 0.3 mg/kg daily of tacrolimus product, given once daily for tacrolimus extended-release capsules and divided into two doses for Prograf. Two kidney transplant patients on Prograf discontinued the study (withdrawn consent, sapovirus enteritis). Thirteen (13) pediatric kidney transplant patients completed 52 weeks on tacrolimus extended-release capsules. The most common adverse reactions were diarrhea [7/13 (54%)], increased blood creatinine [6/13 (46%)], hypertension [3/13 (23%)], cough [4/13 (31%)], and upper respiratory tract infection [4/13 (31%)]. Stable Pediatric Transplant Patients Another study was conducted in 81 stable pediatric allograft recipients (including 48 kidney transplant patients) 5 to 16 years of age converted 1:1 (mg:mg) from Prograf to tacrolimus extended-release capsules. Seventy-six (76) pediatric patients completed at least one year of tacrolimus extended-release capsules-based treatment. Treatment-related adverse reactions were reported in 35%, including 13% serious adverse reactions. The most frequent adverse reactions by system organ class were infections (55.7%), followed by gastrointestinal disorders (27.8%), skin and subcutaneous tissue disorders (21.5%), respiratory, thoracic and mediastinal disorders (20.3% each). The most common adverse reactions were diarrhea (13.9%), headache (13.9%) and cough (11.4%). 6.2 Postmarketing Experience The following adverse reactions have been reported from marketing experience with tacrolimus in the U.S. and outside the U.S. 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. These reactions have been chosen for inclusion due to either their seriousness, frequency of reporting or causal connection to tacrolimus extended-release capsules: Blood and Lymphatic System Disorders: Agranulocytosis, disseminated intravascular coagulation, hemolytic uremic syndrome, febrile neutropenia, pancytopenia, pure red cell aplasia [see Warnings and Precautions (5.13) ] , coagulopathy, thrombotic thrombocytopenic purpura, prolonged activated partial thromboplastin time, decreased blood fibrinogen Cardiac Disorders: Cardiac arrest, myocardial infarction, ventricular fibrillation, congestive cardiac failure, hypertrophic cardiomyopathy, pericardial effusion, angina pectoris, supraventricular extrasystoles, supraventricular tachycardia, bradycardia, Torsades de pointes , QT prolongation Ear Disorders: Hearing loss Eye Disorders: Blindness, optic neuropathy, optic atrophy, photophobia Gastrointestinal Disorders: Gastrointestinal hemorrhage, gastrointestinal perforation, pancreatitis, peritonitis, stomach ulcer, intestinal obstruction, ascites, colitis, ileus, impaired gastric emptying, dysphagia Hepatobiliary Disorders: Hepatic failure, hepatic necrosis, cirrhosis, cholangitis, venoocclusive liver disease, bile duct stenosis, hepatic steatosis, jaundice Hypersensitivity Reactions: Hypersensitivity, Stevens-Johnson syndrome, toxic epidermal necrolysis, urticaria Immune System Disorders: Graft versus host disease (acute and chronic) Investigations: Increased international normalized ratio Metabolism and Nutrition Disorders: Hypoproteinemia Musculoskeletal and Connective Tissue Disorders: Rhabdomyolysis, myalgia, polyarthritis, pain in extremity including Calcineurin-Inhibitor Induced Pain Syndrome (CIPS) Neoplasms: Lymphoma including EBV-associated lymphoproliferative disorder, hepatosplenic T-cell lymphoma, PTLD [see Warnings and Precautions (5.1) ] , leukemia, melanoma Nervous System Disorders: Cerebral infarction, progressive multifocal leukoencephalopathy (PML) sometimes fatal [see Warnings and Precautions (5.2) ] , posterior reversible encephalopathy syndrome (PRES) [see Warnings and Precautions (5.7) ], coma, status epilepticus, quadriplegia, flaccid paralysis, hemiparesis, aphasia, syncope, carpal tunnel syndrome, nerve compression, mutism, dysarthria, somnolence Psychiatric Disorders: Mental status changes Renal and Urinary Disorders: Hemorrhagic cystitis, hematuria, urinary retention, urinary incontinence Respiratory, Thoracic and Mediastinal Disorders: Interstitial lung disease, pulmonary hypertension, lung infiltration, rhinitis allergic, hiccups Skin and Subcutaneous Tissue Disorders: Hyperpigmentation, photosensitivity Vascular Disorders: Hemorrhage

<table><col/><col/><col/><tbody><tr><td styleCode=" Botrule Toprule Lrule Rrule"> </td><td styleCode=" Botrule Toprule Lrule Rrule"><paragraph><content styleCode="bold">Tacrolimus</content> <content styleCode="bold">extended-release capsules, MMF,</content></paragraph><paragraph><content styleCode="bold">steroids, basiliximab induction</content></paragraph><paragraph><content styleCode="bold">N=214</content></paragraph> </td><td styleCode=" Botrule Toprule Lrule Rrule"> <paragraph><content styleCode="bold">Tacrolimus immediate-release product, MMF, steroids, basiliximab induction</content></paragraph><paragraph><content styleCode="bold">N=212</content></paragraph></td></tr><tr><td styleCode=" Botrule Toprule Lrule Rrule"> All Infections</td><td styleCode=" Botrule Toprule Lrule Rrule"> 69%</td><td styleCode=" Botrule Toprule Lrule Rrule"> 69%</td></tr><tr><td styleCode=" Botrule Toprule Lrule Rrule"> Respiratory Infections</td><td styleCode=" Botrule Toprule Lrule Rrule"> 34%</td><td styleCode=" Botrule Toprule Lrule Rrule"> 31%</td></tr><tr><td styleCode=" Botrule Toprule Lrule Rrule"> Urinary Tract Infections</td><td styleCode=" Botrule Toprule Lrule Rrule"> 16%</td><td styleCode=" Botrule Toprule Lrule Rrule"> 25%</td></tr><tr><td styleCode=" Botrule Toprule Lrule Rrule"> Cytomegalovirus Infections</td><td styleCode=" Botrule Toprule Lrule Rrule"> 10%</td><td styleCode=" Botrule Toprule Lrule Rrule"> 11%</td></tr><tr><td styleCode=" Botrule Toprule Lrule Rrule"> Bacterial Infections</td><td styleCode=" Botrule Toprule Lrule Rrule"> 8%</td><td styleCode=" Botrule Toprule Lrule Rrule"> 12%</td></tr><tr><td styleCode=" Botrule Toprule Lrule Rrule"> Gastroenteritis</td><td styleCode=" Botrule Toprule Lrule Rrule"> 7%</td><td styleCode=" Botrule Toprule Lrule Rrule"> 3%</td></tr><tr><td styleCode=" Botrule Toprule Lrule Rrule"> Polyomavirus Infections</td><td styleCode=" Botrule Toprule Lrule Rrule"> 3%</td><td styleCode=" Botrule Toprule Lrule Rrule"> 5%</td></tr><tr><td styleCode=" Botrule Toprule Lrule Rrule">Serious Infections</td><td styleCode=" Botrule Toprule Lrule Rrule"> 22%</td><td styleCode=" Botrule Toprule Lrule Rrule"> 23%</td></tr></tbody></table>

<table><col/><col/><col/><tbody><tr><td styleCode=" Botrule Toprule Lrule Rrule"> </td><td styleCode=" Botrule Toprule Lrule Rrule"><paragraph><content styleCode="bold">Tacrolimus extended-release capsules, MMF,</content><content styleCode="bold"> steroids, basiliximab induction</content></paragraph><paragraph><content styleCode="bold">N=162</content></paragraph> </td><td styleCode=" Botrule Toprule Lrule Rrule"><paragraph><content styleCode="bold">Tacrolimus immediate-release product, MMF, steroids, basiliximab induction</content></paragraph><paragraph><content styleCode="bold">N=151</content></paragraph> </td></tr><tr><td styleCode=" Botrule Toprule Lrule Rrule"> Composite NODAT</td><td styleCode=" Botrule Toprule Lrule Rrule"> 36%</td><td styleCode=" Botrule Toprule Lrule Rrule"> 35%</td></tr><tr><td styleCode=" Botrule Toprule Lrule Rrule"> <paragraph>&#x2265; 2 Fasting Plasma Glucose Values</paragraph><paragraph>&#x2265; 126 mg/dL &#x2265; 30 days apart</paragraph></td><td styleCode=" Botrule Toprule Lrule Rrule"> 26%</td><td styleCode=" Botrule Toprule Lrule Rrule"> 23%</td></tr><tr><td styleCode=" Botrule Toprule Lrule Rrule"> HbA_1C&#x2265; 6.5%</td><td styleCode=" Botrule Toprule Lrule Rrule"> 19%</td><td styleCode=" Botrule Toprule Lrule Rrule"> 22%</td></tr><tr><td styleCode=" Botrule Toprule Lrule Rrule"> Oral hypoglycemic use &#x2265; 30 consecutive days</td><td styleCode=" Botrule Toprule Lrule Rrule"> 14%</td><td styleCode=" Botrule Toprule Lrule Rrule"> 9%</td></tr><tr><td styleCode=" Botrule Toprule Lrule Rrule"> Insulin use &#x2265; 30 consecutive days</td><td styleCode=" Botrule Toprule Lrule Rrule"> 6%</td><td styleCode=" Botrule Toprule Lrule Rrule"> 8%</td></tr></tbody></table>

<table><col/><col/><col/><tbody><tr><td styleCode=" Botrule Toprule Lrule Rrule"> </td><td styleCode=" Botrule Toprule Lrule Rrule"><paragraph><content styleCode="bold">Tacrolimus extended-release capsules, MMF,</content></paragraph><paragraph><content styleCode="bold">steroids, basiliximab induction</content></paragraph><paragraph><content styleCode="bold">N=214</content></paragraph> </td><td styleCode=" Botrule Toprule Lrule Rrule"><paragraph><content styleCode="bold">Tacrolimus immediate-release product, MMF, steroids, basiliximab induction</content></paragraph><paragraph><content styleCode="bold">N=212</content></paragraph> </td></tr><tr><td styleCode=" Botrule Toprule Lrule Rrule">Diarrhea </td><td styleCode=" Botrule Toprule Lrule Rrule"> 45%</td><td styleCode=" Botrule Toprule Lrule Rrule"> 44%</td></tr><tr><td styleCode=" Botrule Toprule Lrule Rrule"> Constipation</td><td styleCode=" Botrule Toprule Lrule Rrule"> 40%</td><td styleCode=" Botrule Toprule Lrule Rrule"> 32%</td></tr><tr><td styleCode=" Botrule Toprule Lrule Rrule"> Nausea</td><td styleCode=" Botrule Toprule Lrule Rrule"> 36%</td><td styleCode=" Botrule Toprule Lrule Rrule"> 35%</td></tr><tr><td styleCode=" Botrule Toprule Lrule Rrule"> Peripheral Edema</td><td styleCode=" Botrule Toprule Lrule Rrule"> 36%</td><td styleCode=" Botrule Toprule Lrule Rrule"> 34%</td></tr><tr><td styleCode=" Botrule Toprule Lrule Rrule"> Tremor</td><td styleCode=" Botrule Toprule Lrule Rrule"> 35%</td><td styleCode=" Botrule Toprule Lrule Rrule"> 34%</td></tr><tr><td styleCode=" Botrule Toprule Lrule Rrule"> Anemia</td><td styleCode=" Botrule Toprule Lrule Rrule"> 33%</td><td styleCode=" Botrule Toprule Lrule Rrule"> 29%</td></tr><tr><td styleCode=" Botrule Toprule Lrule Rrule"> Hypertension</td><td styleCode=" Botrule Toprule Lrule Rrule"> 28%</td><td styleCode=" Botrule Toprule Lrule Rrule"> 30%</td></tr><tr><td styleCode=" Botrule Toprule Lrule Rrule"> Vomiting</td><td styleCode=" Botrule Toprule Lrule Rrule"> 25%</td><td styleCode=" Botrule Toprule Lrule Rrule"> 25%</td></tr><tr><td styleCode=" Botrule Toprule Lrule Rrule"> Hypomagnesemia</td><td styleCode=" Botrule Toprule Lrule Rrule"> 24%</td><td styleCode=" Botrule Toprule Lrule Rrule"> 27%</td></tr><tr><td styleCode=" Botrule Toprule Lrule Rrule"> Insomnia</td><td styleCode=" Botrule Toprule Lrule Rrule"> 24%</td><td styleCode=" Botrule Toprule Lrule Rrule"> 28%</td></tr><tr><td styleCode=" Botrule Toprule Lrule Rrule"> Hypophosphatemia</td><td styleCode=" Botrule Toprule Lrule Rrule"> 23%</td><td styleCode=" Botrule Toprule Lrule Rrule"> 28%</td></tr><tr><td styleCode=" Botrule Toprule Lrule Rrule"> Headache</td><td styleCode=" Botrule Toprule Lrule Rrule"> 22%</td><td styleCode=" Botrule Toprule Lrule Rrule"> 24%</td></tr><tr><td styleCode=" Botrule Toprule Lrule Rrule"> Hyperkalemia</td><td styleCode=" Botrule Toprule Lrule Rrule"> 20%</td><td styleCode=" Botrule Toprule Lrule Rrule"> 23%</td></tr><tr><td styleCode=" Botrule Toprule Lrule Rrule"> Increased Blood Creatinine</td><td styleCode=" Botrule Toprule Lrule Rrule"> 19%</td><td styleCode=" Botrule Toprule Lrule Rrule"> 23%</td></tr><tr><td styleCode=" Botrule Toprule Lrule Rrule"> Fatigue</td><td styleCode=" Botrule Toprule Lrule Rrule"> 16%</td><td styleCode=" Botrule Toprule Lrule Rrule"> 10%</td></tr><tr><td styleCode=" Botrule Toprule Lrule Rrule"> Leukopenia</td><td styleCode=" Botrule Toprule Lrule Rrule"> 16%</td><td styleCode=" Botrule Toprule Lrule Rrule"> 16%</td></tr><tr><td styleCode=" Botrule Toprule Lrule Rrule"> Hyperlipidemia</td><td styleCode=" Botrule Toprule Lrule Rrule"> 16%</td><td styleCode=" Botrule Toprule Lrule Rrule"> 17%</td></tr><tr><td styleCode=" Botrule Toprule Lrule Rrule"> Hyperglycemia</td><td styleCode=" Botrule Toprule Lrule Rrule"> 16%</td><td styleCode=" Botrule Toprule Lrule Rrule"> 18%</td></tr></tbody></table>