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Astagraf XL

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Astagraf XL

Side Effects
Interactions

SIDE EFFECTS

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

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.

The data described below reflect exposure to ASTAGRAF XL in 545 renal transplant recipients exposed to ASTAGRAF XL for periods up to two years [see Clinical Studies].

The most frequent diseases leading to transplantation were glomerulonephritis, polycystic kidney disease, nephrosclerosis/hypertensive nephropathy, and diabetic nephropathy in both studies.

Study 1: With Basiliximab Induction

The proportion of patients who discontinued treatment due to adverse reactions was 9% in the ASTAGRAF XL arm and 11% in the Prograf control arm through 12 months of treatment. The most common adverse reactions leading to discontinuation in ASTAGRAF XL-treated patients were related to infections or renal/urinary disorders. The most common ( ≥ 30%) adverse reactions observed in the ASTAGRAF XL group were: diarrhea, constipation, nausea, peripheral edema, tremor and anemia.

Study 2: Without Induction

The proportion of patients who discontinued treatment due to adverse reactions was 13% in the ASTAGRAF XL arm and 11% in the Prograf control arm through 12 months of treatment. The most common adverse reactions leading to discontinuation in ASTAGRAF XL-treated patients were related to infections, graft dysfunction, renal vascular/ischemic conditions and diabetes. The most common ( ≥ 30%) adverse reaction observed in the ASTAGRAF XL group was anemia.

Information on selected significant adverse reactions observed during Studies 1 and 2 are summarized below.

New Onset Diabetes After Transplant (NODAT)

New onset diabetes after transplantation (defined by the composite occurrence of ≥ 2 fasting plasma glucose values that were > 126 mg/dL at ≥ 30 days apart, insulin use for ≥ 30 consecutive days, oral hypoglycemic use for ≥ 30 consecutive days, and/or HbA1C ≥ 6.5%) is summarized in Table 2 below for Study 1 and Study 2 through one year post-transplant.

Table 2: Composite NODAT Through 1 Year Post-Transplant in Studies 1 and 2

  Study 1 Study 2
ASTAGRAF XL
n (%)
(N=162)
Prograf
n (%)
(N=151)
ASTAGRAF XL
n (%)
(N=288)
Prograf
n (%)
(N=299)
Composite NODAT 58 (36) 53 (35) 105 (37) 90 (30)
   ≥ 2 Fasting Plasma Glucose Values ≥ 126 mg/dL ≥ 30 days apart 42 (26) 35 (23) 51 (18) 47 (16)
  Insulin use ≥ 30 consecutive days 10 (6) 12 (8) 29 (10) 29 (10)
  Oral hypoglycemic use ≥ 30 consecutive days 22 (14) 13 (9) 20 (7) 23 (8)
  HbA1C ≥ 6.5% 31 (19) 33 (22) 48 (17) 39 (13)

Infections

Adverse reactions of infectious etiology were reported based on clinical assessment by physicians. The causative organisms for these reactions are identified when provided by the physician. The overall number of infections, serious infections, and select infections with identified etiology reported in patients treated with ASTAGRAF XL or the control in Studies 1 and 2 are shown in Table 3.

Table 3: Overall Infections and Select Infections by Treatment Group in Studies 1 and 2 Through One Year Post-Transplant

  Study 1 Study 2
ASTAGRAF XL
n (%)
(N=214)
Prograf
n (%)
(N=212)
ASTAGRAF XL
n (%)
(N=331)
Prograf
n (%)
(N=336)
All Infections 148 (69) 146 (69) 228 (69) 216 (64)
  Serious Infections 48 (22) 49 (23) 79 (24) 64 (19)
  Bacterial Infections 18 (8) 25 (12) 125 (38) 137 (41)
  Respiratory Infections 73 (34) 65 (31) 75 (23) 74 (22)
  Cytomegalovirus Infections 21 (10) 24 (11) 38 (12) 21 (6)
  Polyomavirus Infections 6 (3) 10 (5) 7 (2) 1 (0)
  Gastroenteritis 16 (7) 6 (3) 16 (5) 8 (2)
Studies 1 and 2 were not designed to support comparative claims for ASTAGRAF XL for the adverse reactions reported in this table.

Glomerular Filtration Rate

The estimated mean glomerular filtration rates, using the Modification of Diet in Renal Disease (MDRD) formula, by treatment group at Month 12 in the ITT population in Studies 1 and 2 are shown in Table 4.

Table 4: Estimated Glomerular Filtration Rate (mL/min/1.73m²) by MDRD Formula at 12 Months Post-Transplant

  Study 1 Study 2
ASTAGRAF XL
(n=201)
Prograf
(n=202)
ASTAGRAF XL
(n=287)
Prograf
(n=300)
Month 1 Baseline Mean (SD) 56 (20) 56 (21) 51 (19) 52 (20)
Month 12 LOCFa
Mean (Standard deviation) 58 (21) 56 (23) 52 (20) 55 (19)
Median (Min-Max) 56 (0, 177) 57 (0, 120) 54 (0, 116) 54 (0, 134)
Mean Difference XL-Prografb +2.3 (-1.2, +5.8) -1.8 (-4.6, +0.8)
a Subject's last observation carried forward (LOCF) for missing data at Month 1; patients who died, lost the graft or were lost to follow-up are imputed as zeroes
b Tacrolimus XL-Prograf treatment mean difference results of analysis of covariance model with Month 1 Baseline as a covariate.

The incidence of adverse reactions that occurred in ≥ 15% of ASTAGRAF XL-treated patients compared to control through one year of treatment in Studies 1 and 2 are shown in Table 5.

Table 5: Adverse Events Occurring in ≥ 15% of ASTAGRAF XL-Treated Kidney Transplant Patients Through One year Post Transplant in Studies 1 or 2a

  Study 1 Study 2
ASTAGRAF XL
n (%)
(N=214)
Prograf
n (%)
(N=212)
ASTAGRAF XL
n (%)
(N=331)
Prograf
n (%)
(N=336)
Anemia 70 (33) 61 (29) 103 (31) 87 (26)
Constipation 85 (40) 68 (32) 45 (14) 60 (18)
Diarrhea 96 (45) 94 (44) 88 (27) 103 (31)
Fatigue 34 (16) 22 (10) 7 (2) 6 (2)
Graft Dysfunction 29 (14) 45 (21) 57 (17) 56 (17)
Headache 46 (22) 50 (24) 39 (12) 33 (10)
Hyperglycemia 34 (16) 39 (18) 61 (18) 65 (19)
Hyperkalemia 43 (20) 49 (23) 50 (15) 49 (15)
Hyperlipidemia 35 (16) 36 (17) 23 (7) 28 (8)
Hypertension 59 (28) 63 (30) 80 (24) 76 (23)
Hypomagnesemia 52 (24) 57 (27) 9 (3) 12 (4)
Hypophosphatemia 50 (23) 59 (28) 15 (5) 22 (7)
Increased Blood Creatinine 40 (19) 49 (23) 54 (16) 63 (19)
Insomnia 52 (24) 60 (28) 29 (9) 34 (10)
Leukopenia 35 (16) 33 (16) 51 (15) 37 (11)
Nausea 76 (36) 75 (35) 51 (15) 42 (13)
Peripheral Edema 76 (36) 73 (34) 38 (12) 49 (15)
Tremor 75 (35) 73 (34) 58 (18) 58 (17)
Urinary Tract Infection 34 (16) 53 (25) 7 (2) 10 (3)
Urinary Tract Infection (bacterial) 1 (1) 6 (3) 86 (26) 102 (30)
Vomiting 53 (25) 53 (25) 42 (13) 43 (13)
aStudies 1 and 2 were not designed to support comparative claims for ASTAGRAF XL for the adverse reactions reported in this table.

Less Frequently Reported Adverse Reactions ( < 15%) by System Organ Class

The following adverse reactions were also reported in clinical studies of kidney transplant recipients who were treated with ASTAGRAF XL.

Blood and Lymphatic System Disorders

Coagulopathy, hemolytic anemia, leukocytosis, neutropenia, pancytopenia, thrombocytopenia, thrombotic microangiopathy

Cardiac Disorders

Angina pectoris, atrial fibrillation, atrial flutter, bradycardia, cardiac arrest, congestive cardiac failure, hypertrophic cardiomyopathy, myocardial ischemia, myocardial infarction, pericardial effusion, tachycardia, ventricular extrasystoles

Ear Disorders

Hearing loss, otitis (media and externa), tinnitus

Eye Disorders

Vision blurred, conjunctivitis

Gastrointestinal Disorders

Abdominal distension, abdominal pain, aphthous stomatitis, ascites, colitis, dyspepsia, esophagitis, flatulence, gastritis, gastroesophageal reflux disease, gastrointestinal hemorrhage, ileus, impaired gastric emptying, pancreatitis, stomach ulcer

General Disorders and Administration Site Conditions

Anasarca, asthenia, edema

Hepatobiliary Disorders

Abnormal hepatic function, cholestasis, hepatitis (acute and chronic), hepatotoxicity

Infections and Infestations

Condyloma acuminatum, Epstein-Barr virus infection, tinea versicolor

Injury, Poisoning and Procedural Complications

Fall

Investigations

Abnormal electrocardiogram T wave, increased blood lactate dehydrogenase, increased blood urea, increased hematocrit, increased hepatic enzyme, increased international normalized ratio, weight fluctuation

Metabolism and Nutrition Disorders

Anorexia, dehydration, fluid overload, hypercalcemia, hyperphosphatemia, hyperuricemia, hypocalcemia, hypoglycemia, hypokalemia, hyponatremia, hypoproteinemia, metabolic acidosis

Musculoskeletal and Connective Tissue Disorders

Arthralgia, osteopenia, osteoporosis

Neoplasms

Bladder cancer, Kaposi's sarcoma, non-melanoma skin cancer, papillary thyroid cancer

Nervous System Disorders

Aphasia, carpal tunnel syndrome, cerebral infarction, cerebral ischemia, convulsion, dizziness, hypoesthesia, neurotoxicity, paresthesia, peripheral neuropathy, somnolence, syncope

Psychiatric Disorders

Agitation, anxiety, confusional state, depression, hallucination, mental status changes, mood swings, nightmare

Renal and Urinary Disorders

Anuria, hematuria, oliguria, proteinuria, renal failure, renal graft dysfunction, renal tubular necrosis, toxic nephropathy, urinary incontinence, urinary retention

Respiratory, Thoracic and Mediastinal Disorders

Acute respiratory distress syndrome, allergic rhinitis, dyspnea, emphysema, hiccups, lung infiltration, pulmonary edema, productive cough, respiratory failure

Skin and Subcutaneous Tissue Disorders

Acne, alopecia, dermatitis, hyperhidrosis, hypotrichosis, pruritus, rash

Vascular Disorders

Deep vein thrombosis, flushing, hemorrhage, hypotension, orthostatic hypotension

Postmarketing Experience

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.

Blood and Lymphatic System Disorders

Agranulocytosis, decreased blood fibrinogen, disseminated intravascular coagulation, hemolytic uremic syndrome, prolonged activated partial thromboplastin time, pure red cell aplasia [see WARNINGS AND PRECAUTIONS], thrombotic thrombocytopenic purpura

Cardiac Disorders

QT prolongation, supraventricular extrasystoles, supraventricular tachycardia, Torsade de Pointes, ventricular fibrillation

Eye Disorders

Blindness, photophobia, optic atrophy

Gastrointestinal Disorders

Dysphagia, gastrointestinal perforation [see WARNINGS AND PRECAUTIONS], intestinal obstruction, peritonitis

General Disorders

Multi-organ failure

Hepatobiliary Disorders

Bile duct stenosis, cholangitis, cirrhosis, hepatic failure, hepatic necrosis, hepatic steatosis, jaundice, venoocclusive liver disease

Immune disorders

Graft versus host disease (acute and chronic)

Musculoskeletal and Connective Tissue Disorders

Myalgia, polyarthritis, rhabdomyolysis

Neoplasms

Lymphoma including EBV-associated lymphoproliferative disorder, hepatosplenic T-cell lymphoma, PTLD [see WARNINGS AND PRECAUTIONS]; leukemia, melanoma

Nervous System Disorders

Coma, dysarthria, flaccid paralysis, hemiparesis, mutism, nerve compression, posterior reversible encephalopathy syndrome (PRES) [see WARNINGS AND PRECAUTIONS], progressive multifocal leukoencephalopathy (PML) sometimes fatal [see WARNINGS AND PRECAUTIONS], quadriplegia, status epilepticus

Renal and Urinary Disorders

Hemorrhagic cystitis

Respiratory, Thoracic and Mediastinal Disorders

Interstitial lung disease, pulmonary hypertension

Skin and Subcutaneous Tissue Disorders

Hyperpigmentation, photosensitivity, Stevens-Johnson syndrome, toxic epidermal necrolysis, urticaria

Read the Astagraf XL (tacrolimus extended-release capsules) Side Effects Center for a complete guide to possible side effects

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 AND PRECAUTIONS, CLINICAL PHARMACOLOGY]. Dose adjustments may be needed along with frequent monitoring of tacrolimus whole blood trough concentrations when ASTAGRAF XL 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].

Mycophenolic Acid Products

With a given dose of mycophenolic acid (MPA) products, exposure to MPA is higher with ASTAGRAF XL coadministration than with cyclosporine coadministration because cyclosporine interrupts the enterohepatic recirculation of MPA while tacrolimus does not. Clinicians should monitor for MPA associated adverse events and reduce the dose of concomitantly administered mycophenolic acid products, if needed.

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 in combination with ASTAGRAF XL [see DOSAGE AND ADMINISTRATION].

Alcohol

Consumption of alcohol with ASTAGRAF XL may increase the rate of release of tacrolimus and/or adversely alter the pharmacokinetic properties and the effectiveness and safety of ASTAGRAF XL. Therefore, alcoholic beverages should not be consumed with ASTAGRAF XL [see DOSAGE AND ADMINISTRATION].

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]. Whole blood concentrations of tacrolimus are markedly increased when coadministered with telaprevir or with boceprevir. 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.

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].

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.

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.

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.

Antimycobacterials

Rifampin [see CLINICAL PHARMACOLOGY] 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.

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 of phenytoin plasma concentrations and adjusting the phenytoin dose as needed are recommended when tacrolimus and phenytoin are administered concomitantly.

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 coadministered.

Gastric Acid Suppressors/Neutralizers

Lansoprazole and omeprazole, the proton pump inhibitors (PPIs), as CYP2C19 and CYP3A4 substrates, share the same CYP3A4 system with tacrolimus for their hepatic elimination, and may potentially competitively 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 in which the PPIs metabolic pathway shifts from 2C19 to 3A4, as compared to those patients who are efficient CYP2C19 metabolizers.

Cimetidine, a CYP2C19 and CYP3A4 inhibitor, may also inhibit the CYP3A4 metabolism of tacrolimus and thereby substantially increase tacrolimus whole blood concentrations.

Coadministration with magnesium and aluminum hydroxide antacids increase 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.

Other Drugs

Amiodarone, bromocriptine, nefazodone, metoclopramide, danazol, ethinyl estradiol and methylprednisolone 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 coadministered.

Last reviewed on RxList: 3/18/2014
This monograph has been modified to include the generic and brand name in many instances.

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