Tacrolimus

About Tacrolimus

Tacrolimus is a calcineurin inhibitor that blocks the activation of T cells, the immune cells that drive rejection. With other anti-rejection medicines, Prograf and generic capsules are labeled for kidney, liver, heart and lung transplants, and Envarsus XR and Astagraf XL for kidney transplants. The transplant team sets the dose from blood trough levels, since too little risks rejection and too much risks serious side effects.

Oral tacrolimus has a boxed warning that serious infections and cancers may lead to hospitalization or death; the label singles out lymphoma and skin cancer. Astagraf XL’s boxed warning adds higher death rates in women after liver transplant, for which it is not approved. Other warnings include kidney damage, new diabetes, tremor, high potassium and high blood pressure.

Envarsus XR and Astagraf XL are taken once a day and release the drug differently from Prograf and its generics. The labels report that substitution and dispensing errors between these products have caused rejection and other serious harm, and any change must happen under a doctor’s supervision.

The ointment is second-line treatment for moderate to severe eczema in people whose immune systems are not weakened; the 0.1 percent strength is for adults and the 0.03 percent strength also for children aged 2 to 15. Its boxed warning notes rare reports of skin cancer and lymphoma with this class, without a proven link, so it is used only on affected skin, not continuously, and not under age 2. Burning and itching are common at first.

Taking Tacrolimus

How to take it

Capsules and granules: every 12 hours, taken consistently with or without food; mix a granule packet with 1 to 2 tablespoons of room-temperature water and take it at once. Envarsus XR and Astagraf XL: each morning on an empty stomach, at least 1 hour before or 2 hours after a meal, swallowed whole. Ointment: a thin layer on affected skin twice a day, uncovered.

If you miss a dose

Capsules, granules and ointment: use it when you remember, unless the next dose is nearly due; then skip it. Astagraf XL can be taken up to 14 hours late and Envarsus XR up to 15 hours late.

Storage

At room temperature, tightly closed, away from excess heat and moisture (not in a bathroom), and out of reach of children.

Interactions to know about

Azole antifungals, clarithromycin, erythromycin, ritonavir, diltiazem and nifedipine can raise its level; rifampin, carbamazepine, phenytoin and St. John’s wort can lower it. Avoid grapefruit, and alcohol with the extended-release forms. Potassium-sparing diuretics, ACE inhibitors and ARBs add to the risk of high potassium. Limit sun exposure; with the ointment, avoid sun lamps and tanning beds, and alcohol can cause flushing.

This summarizes the official prescribing information. Your prescriber’s and pharmacist’s instructions, and the leaflet that comes with your medicine, take priority.

Why the cash price for Tacrolimus differs from pharmacy to pharmacy

Generic capsules come from many makers, so quotes differ mostly by markup. Envarsus XR and the granules have no generic and the extended-release capsules few makers, so they are priced nearer brand levels and may need ordering. The ointment comes in 30, 60 and 100 g tubes, and the tube size prescribed drives the quote.

Ways to pay less for Tacrolimus without insurance

• If Medicare helped pay for your transplant, Part B covers anti-rejection drugs; if your Medicare ended 36 months after a kidney transplant and you have no other coverage, ask Social Security about Medicare’s extended immunosuppressive drug benefit.
• For capsules, ask the transplant team to allow generics, and the pharmacy to keep you on one maker and warn you of changes.
• For Envarsus XR or the granules, ask the maker about patient assistance.
• Upload the prescription to Script Unlock so licensed pharmacies can quote their cash price. You pay the pharmacy directly.

Questions to ask your pharmacist about Tacrolimus

1. 1.Is this exactly the tacrolimus product my transplant team prescribed?
2. 2.How should I time it around meals?
3. 3.Do any new medicines or supplements interact with it?
4. 4.For the ointment, how much should I apply, and where?

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