tacrolimus (Rx)

Brand and Other Names:Prograf, Astagraf XL, more...Hecoria, Envarsus XR
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Dosing & Uses

AdultPediatric

Dosage Forms & Strengths

capsule, immediate-release (Prograf, Hecoria)

  • 0.5mg
  • 1mg
  • 5mg

capsule, extended-release (Astagraf XL)

  • 0.5mg
  • 1mg
  • 5mg

tablet, extended-release (Envarsus XR)

  • 0.75mg
  • 1mg
  • 4mg

injectable solution (Prograf)

  • 5mg/mL

granules for oral suspension (Prograf)

  • 0.2mg/packet
  • 1mg/packet

Heart Transplant

Prophylaxis of organ rejection in patients receiving allogeneic transplants; use with azathioprine or mycophenolate mofetil (MMF) recommended

IV: 0.01 mg/kg/day by continuous infusion initially  

PO (immediate-release): 0.075 mg/kg/day divided q12hr initially  

Administer initial dose no sooner than 6 hr after transplantation

Liver Transplant

Prophylaxis of organ rejection in patients receiving allogeneic transplants

IV: 0.03-0.05 mg/kg/day by continuous infusion initially  

PO (immediate-release), with corticosteroids only: 0.1-0.15 mg/kg/day divided q12hr initially  

Administer initial dose no sooner than 6 hr after transplantation

Kidney Transplant

Prograf

  • Prophylaxis of organ rejection in patients receiving allogeneic kidney transplants; used concomitantly with azathioprine or MMF or interleukin (IL)-2 receptor antagonist (eg, basiliximab or daclizumab) and corticosteroids
  • IV: 0.03-0.05 mg/kg/day IV by continuous infusion initially  
  • PO (with azathioprine): 0.2 mg/kg/day divided q12hr initially  
  • PO (with MMF/IL-2 receptor antagonist): 0.1 mg/kg/day divided q12hr initially

Astagraf XL

  • Prophylaxis of organ rejection in patients receiving kidney transplants; used concomitantly with MMF and corticosteroids, with or without basiliximab induction
  • With basiliximab induction
    • MMF, corticosteroids, and initial tacrolimus dose may be administered before or within 48 hr after completion of renal transplantation but may be delayed until renal function has recovered
    • 15 mg/kg PO once daily
  • Without induction
    • When agent is used with MMF and corticosteroids, preoperative dose should be given as single dose within 12 hr before reperfusion; initial postoperative dose should be given ≥4 hr after preoperative dose and ≤12 hr after reperfusion
    • Preoperative: 0.1 mg/kg PO once daily
    • Postoperative: 0.2 mg/kg PO once daily
    • Postoperative oliguria: Initial postoperative dose should be administered ≥6 hr and ≤48 hr after transplantation but may be delayed until renal function shows evidence of recovery

Envarsus XR

  • Conversion from immediate-release tacrolimus
    • Indicated for prophylaxis of organ rejection in kidney transplant patients converted from tacrolimus immediate-release formulations in combination with other immunosuppressants
    • Administer an Envarsus XR dose that is 80% of the total daily dose of the tacrolimus immediate-release product
    • Monitor whole blood tacrolimus levels and titrate to achieve target whole blood trough concentration ranges of 4-11 ng/mL
  • De novo kidney transplant
    • Indication for prophylaxis of organ rejection in de novo kidney transplant patients in combination with other immunosuppressants
    • Initiate at 0.14 mg/kg/day
    • Monitor whole blood tacrolimus levels and titrate to achieve target whole blood trough concentration ranges of 6-11 ng/mL (month 1) and 4-11 ng/mL (>month 1)

Lung Transplant

Prograf

Prophylaxis of organ rejection in patients receiving lung transplants in combination with other immunosuppressants

IV: 0.01-0.03 mg/kg/day by continuous infusion initially  

PO (with azathioprine or MMF): 0.075 mg/kg/day divided q12hr initially  

Patients with cystic fibrosis may require higher doses owing to lower bioavailability

Dosage Modifications

CYP3A5*1 allele

  • African-American patients, compared to Caucasian patients, may need to be titrated to higher dosages to attain comparable trough concentrations
  • ~80% of the African-American patients are carriers of the active, wild type CYP3A5*1 allele, resulting in a higher rate of tacrolimus clearance because of rapid metabolism

Coadministration with CYP3A4 inducers or inhibitors

  • Dosage adjustment of Envarsus XR may be necessary
  • Monitor tacrolimus trough concentrations ≥2 times on separate days during first week after initiation of dosing and after any change in dosage, after a change in coadministration of CYP3A inducers and/or inhibitors

Renal impairment

  • Use lower end of dosing range
  • Monitor renal function and adjust dose according to whole blood concentrations and tolerability

Hepatic impairment

  • Mild: No dosage adjustment required
  • Moderate: Monitor whole blood concentrations and adjust dose accordingly
  • Severe (mean Child-Pugh score >10): Mean clearance of tacrolimus was substantially lower compared with normal hepatic function; dosage reduction recommended; administer 80% of preconversion daily dose of immediate release dosage form when converting from tacrolimus immediate release to extended release

Dosing Considerations

Capsules and granules are not interchangeable or substitutable with other tacrolimus extended-release products; owing to the rate of absorption following administration an extended-release tacrolimus is not equivalent to immediate-release tacrolimus drug product

Under- or overexposure to tacrolimus may result in graft rejection or other serious adverse reactions

African-American patients may need to be titrated to higher dosages to attain comparable trough concentrations compared to Caucasian patients

Monitor serum potassium

Dosage adjusted according to clinical response and observed tacrolimus whole-blood trough concentrations

  • Kidney transplant
    • Trough level, Prograf with azathioprine (months 1-3): 7-20 ng/mL
    • Trough level, Prograf with azathioprine (months 4-12): 5-15 ng/mL
    • Trough level, Prograf with MMF/IL-2 receptor antagonist (months 1-12): 4-11 ng/mL
    • Trough level, Astragraf XL with basiliximab induction (during month 1): 7-15 ng/mL
    • Trough level, Astragraf XL with basiliximab induction (months 2-6): 5-15 ng/mL
    • Trough level, Astragraf XL with basiliximab induction (months >6): 5-10 ng/mL
    • Trough level, Astragraf XL without induction (during month 1): 10-15 ng/mL
    • Trough level, Astragraf XL without induction (months 2-6): 5-15 ng/mL
    • Trough level, Astragraf XL without induction (months >6): 5-10 ng/mL
    • Trough level, Envarsus XR: 4-11 ng/mL
  • Liver transplant
    • Trough level, Prograf with corticosteroids only (months 1-12): 5-20 ng/mL
  • Heart transplant
    • Trough level, Prograf with azathioprine or MMF (months 1-3): 10-20 ng/mL
    • Trough level, Prograf with azathioprine or MMF (months ≥4): 5-15 ng/mL
  • Lung transplant
    • Trough level, Prograf with azathioprine or MMR (months 1-3): 10-15 ng/mL
    • Trough level, Prograf with azathioprine or MMF (months ≥4): 8-12 ng/mL

Graft-Versus-Host Disease (Orphan)

Prophylaxis of GVHD

Orphan indication sponsor

  • Fujisawa USA, Inc, 3 Parkway North Center, Deerfield, IL 60015

Pulmonary Arterial Hypertension (Orphan)

Orphan designation for treatment of pulmonary arterial hypertension

Sponsor

  • Selten Pharma, Inc; 14435C Big Basin Way #246; Saratoga, CA 95070

Hemorrhagic Cystitis (Orphan)

Orphan designation for treatment of hemorrhagic cystitis

Sponsor

  • Lipella Pharmaceuticals Inc; 400 N. Lexington Ave, LL105; Pittsburgh, Pennsylvania 15208

Dosage Forms & Strengths

capsule, immediate-release (Prograf)

  • 0.5mg
  • 1mg
  • 5mg

injectable solution (Prograf)

  • 5mg/mL

granules for oral suspension (Prograf)

  • 0.2mg/packet
  • 1mg/packet

Liver Transplant

Prograf

Prophylaxis of organ rejection in patients receiving liver transplants without preexisting renal or hepatic impairment

Administer initial dose no sooner than 6 hr after transplantation

IV: 0.03-0.05 mg/kg/day by continuous infusion initially  

Oral

  • Capsules: 0.15-0.2 mg/kg/day divided q12hr initially  
  • Granules: 0.2 mg/kg/day divided in 2 doses, administered q12hr initially  

Heart Transplant

Prograf

Prophylaxis of organ rejection in patients receiving allogeneic transplants, in combination with other immunosuppression

Initial dose

Administer initial dose no sooner than 6 hr after transplantation

IV: 0.01 mg/kg/day by continuous infusion initially  

Oral capsules and granules: 0.3 mg/kg/day divided in 2 doses, administered q12hr initially  

Kidney Transplant

Prograf

Prophylaxis of organ rejection in patients receiving allogeneic transplants, in combination with other immunosuppression

Administer initial dose no sooner than 24 hr after transplantation

IV: 0.03-0.05 mg/kg/day by continuous infusion initially  

Oral capsules and granules: 0.3 mg/kg/day divided in 2 doses, administered q12hr initially  

Lung Transplant

Prograf

Prophylaxis of organ rejection in patients receiving lung transplants in combination with other immunosuppressants

IV: 0.01-0.03 mg/kg/day by continuous infusion initially  

Oral capsules or granules: 0.03 mg/kg/day divided q12hr initially  

Dosage Modifications

CYP3A5*1 allele

  • African-American patients, compared to Caucasian patients, may need to be titrated to higher dosages to attain comparable trough concentrations ~80% of the African-American patients are carriers of the active, wild type CYP3A5*1 allele, resulting in a higher rate of tacrolimus clearance because of rapid metabolism

Renal impairment

  • Consider using lower end of dosing range in patients who have received a liver or heart transplant and have pre-existing renal impairment; may require further dose reductions below the targeted range
  • In kidney transplant patients with post-operative oliguria, administer initial dose no sooner than 6 hr and within 24 hr of transplantation, but may be delayed until renal function shows evidence of recovery

Hepatic impairment

  • Mild: No dosage adjustment required
  • Moderate: Monitor whole blood concentrations and adjust dose accordingly
  • Severe (mean Child-Pugh score >10): Mean clearance of tacrolimus was substantially lower compared with normal hepatic function; dosage reduction recommended; administer 80% of preconversion daily dose of immediate release dosage form when converting from tacrolimus immediate release to extended release

Dosing Considerations

When converting between Prograf granules and Prograf capsules, the total daily dose should remain the same

Prograf capsules and granules are not interchangeable or substitutable with other tacrolimus extended-release products; owing to the rate of absorption following administration an extended-release tacrolimus is not equivalent to immediate-release tacrolimus drug product

Under- or overexposure to tacrolimus may result in graft rejection or other serious adverse reactions

Do not use without supervision of a physician with experience in immunosuppressive therapy

African-American patients may need to be titrated to higher dosages to attain comparable trough concentrations compared to Caucasian patients

IV formulation

  • Intravenous use is recommended for patients who cannot tolerate oral formulations, and conversion from IV to PO tacrolimus is recommended as soon as oral therapy can be tolerated to minimize the risk of anaphylactic reactions that occurred with injectables containing castor oil derivatives
  • Patients receiving the 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, stop the infusion
  • Aqueous epinephrine solution and a source of oxygen should be available at the bedside

Adjust oral dose according to clinical response and whole blood trough concentration

  • Pediatric kidney, liver, or heart transplant recipients: Prograf trough level (months 1-12): 5-20 ng/mL
  • Pediatric lung transplant recipients: Prograf trough level (weeks 1-2: 10-20 ng/mL)

  • Pediatric lung transplant recipients: Prograf trough level (week 2 to month 12: 10-15 ng/mL)

  • Lung transplant recipients with cystic fibrosis
    • May require higher doses to achieve target trough concentration owing to lower oral bioavailability
    • Monitor and adjust dose accordingly
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Interactions

Interaction Checker

and tacrolimus

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            Contraindicated (7)

            • amphotericin B deoxycholate

              amphotericin B deoxycholate and tacrolimus both increase nephrotoxicity and/or ototoxicity. Contraindicated.

            • cidofovir

              cidofovir and tacrolimus both increase nephrotoxicity and/or ototoxicity. Contraindicated.

            • elagolix

              tacrolimus will increase the level or effect of elagolix by Other (see comment). Contraindicated. Concomitant use of elagolix and strong OATP1B1 inhibitors is contraindicated.

            • lefamulin

              lefamulin will increase the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated. Lefamulin is contraindicated with CYP3A substrates know to prolong the QT interval.

            • mifepristone

              mifepristone increases levels of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated. Contraindicated with CYP3A substrates that have a narrow therapeutic index .

            • neomycin PO

              neomycin PO and tacrolimus both increase nephrotoxicity and/or ototoxicity. Contraindicated.

            • saquinavir

              saquinavir will increase the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            Serious - Use Alternative (153)

            • abametapir

              abametapir will increase the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. For 2 weeks after abametapir application, avoid taking drugs that are CYP3A4 substrates. If not feasible, avoid use of abametapir.

            • adalimumab

              adalimumab and tacrolimus both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

            • adenovirus types 4 and 7 live, oral

              tacrolimus decreases effects of adenovirus types 4 and 7 live, oral by pharmacodynamic antagonism. Avoid or Use Alternate Drug. Immunosuppressives may diminish therapeutic effects of vaccines and increase risk of adverse effects (increased risk of infection). Live-attenuated vaccines should be avoided for at least 3mo after cessation of immunosuppressive therapy.

            • afatinib

              tacrolimus increases levels of afatinib by P-glycoprotein (MDR1) efflux transporter. Avoid or Use Alternate Drug. Reduce afatinib daily dose by 10 mg if not tolerated when coadministered with P-gp inhibitors.

            • alefacept

              alefacept and tacrolimus both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

            • alpelisib

              tacrolimus will increase the level or effect of alpelisib by Other (see comment). Avoid or Use Alternate Drug. Coadministration of alpelisib (BCRP substrate) with a BCRP inhibitor may increase alpelisib concentration, which may increase the risk of toxicities. If unable to avoid or use alternant drugs, closely monitor for increased adverse reactions.

            • amikacin

              amikacin and tacrolimus both increase nephrotoxicity and/or ototoxicity. Avoid or Use Alternate Drug.

            • anakinra

              anakinra and tacrolimus both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

            • anthrax vaccine

              tacrolimus decreases effects of anthrax vaccine by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

            • antithymocyte globulin equine

              antithymocyte globulin equine and tacrolimus both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

            • antithymocyte globulin rabbit

              antithymocyte globulin rabbit and tacrolimus both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

            • apalutamide

              apalutamide will decrease the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Coadministration of apalutamide, a strong CYP3A4 inducer, with drugs that are CYP3A4 substrates can result in lower exposure to these medications. Avoid or substitute another drug for these medications when possible. Evaluate for loss of therapeutic effect if medication must be coadministered. Adjust dose according to prescribing information if needed.

            • artemether

              artemether and tacrolimus both increase QTc interval. Avoid or Use Alternate Drug.

            • azathioprine

              azathioprine and tacrolimus both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

            • bacitracin

              tacrolimus and bacitracin both increase nephrotoxicity and/or ototoxicity. Avoid or Use Alternate Drug. Avoid concurrent use of bacitracin with other nephrotoxic drugs

            • baricitinib

              baricitinib, tacrolimus. Either increases toxicity of the other by immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug. Baricitinib is not recommended in combination with other JAK inhibitors, biologic DMARDs, or potent immunosuppressives.

            • basiliximab

              basiliximab and tacrolimus both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

            • BCG vaccine live

              tacrolimus decreases effects of BCG vaccine live by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

            • bosutinib

              tacrolimus increases levels of bosutinib by P-glycoprotein (MDR1) efflux transporter. Avoid or Use Alternate Drug.

            • bremelanotide

              bremelanotide will decrease the level or effect of tacrolimus by Other (see comment). Avoid or Use Alternate Drug. Bremelanotide may slow gastric emptying and potentially reduces the rate and extent of absorption of concomitantly administered oral medications. Avoid use when taking any oral drug that is dependent on threshold concentrations for efficacy. Interactions listed are representative examples and do not include all possible clinical examples.

            • brigatinib

              brigatinib will decrease the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Brigatinib induces CYP3A4 in vitro. Coadministration with CYP3A4 substrates, particularly those with a narrow therapeutic index, can result in decreased concentrations and loss of efficacy. If unable to avoid coadministration, monitor CYP3A4 substrate levels and adjust dose as needed.

            • canakinumab

              canakinumab and tacrolimus both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

            • carbamazepine

              carbamazepine will decrease the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Monitor tacrolimus levels and adjust dose accordingly

            • ceritinib

              ceritinib increases levels of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Avoid concurrent use of CYP3A substrates known to have narrow therapeutic indices or substrates primarily metabolized by CYP3A during treatment with ceritinib; if use of these medications is unavoidable, consider dose.

              ceritinib and tacrolimus both increase QTc interval. Avoid or Use Alternate Drug.

            • chloramphenicol

              chloramphenicol will increase the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • cimetidine

              cimetidine will increase the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • clarithromycin

              clarithromycin will increase the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

              clarithromycin and tacrolimus both increase QTc interval. Avoid or Use Alternate Drug.

            • contrast media (iodinated)

              contrast media (iodinated) and tacrolimus both increase nephrotoxicity and/or ototoxicity. Avoid or Use Alternate Drug.

            • crizotinib

              crizotinib increases levels of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Coadministration of crizotinib with CYP3A substrates with narrow therapeutic indices should be avoided. ECG monitoring is recommended, along with drugs that may prolong the QT interval.

              crizotinib and tacrolimus both increase QTc interval. Avoid or Use Alternate Drug.

            • cyclosporine

              cyclosporine, tacrolimus. Other (see comment). Avoid or Use Alternate Drug. Comment: Coadministration of tacrolimus with cyclosporine may increase the risk of nephrotoxicity and immunosuppressive effects. Additionally, both agents are CYP3A4 and P-gp substrates and may elevate serum levels of either agent when coadministered. Discontinue tacrolimus or cyclosporine therapy at least 24 hours before initiating therapy with the other agent.

            • dabrafenib

              dabrafenib will decrease the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • desflurane

              desflurane and tacrolimus both increase QTc interval. Avoid or Use Alternate Drug.

            • diclofenac

              diclofenac, tacrolimus. Either increases toxicity of the other by Other (see comment). Avoid or Use Alternate Drug. Comment: Concomitant administration increases risk of nephrotoxicity.

            • diflunisal

              diflunisal, tacrolimus. Either increases toxicity of the other by Other (see comment). Avoid or Use Alternate Drug. Comment: Concomitant administration increases risk of nephrotoxicity.

            • diphtheria & tetanus toxoids

              tacrolimus decreases effects of diphtheria & tetanus toxoids by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

            • diphtheria & tetanus toxoids/ acellular pertussis vaccine

              tacrolimus decreases effects of diphtheria & tetanus toxoids/ acellular pertussis vaccine by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

            • diphtheria & tetanus toxoids/acellular pertussis/poliovirus, inactivated vaccine

              tacrolimus decreases effects of diphtheria & tetanus toxoids/acellular pertussis/poliovirus, inactivated vaccine by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

            • dronedarone

              dronedarone will increase the level or effect of tacrolimus by P-glycoprotein (MDR1) efflux transporter. Avoid or Use Alternate Drug. The use of dronedarone in combination with other medications that can prolong the QT interval is considered contraindicated.

            • edoxaban

              tacrolimus will increase the level or effect of edoxaban by P-glycoprotein (MDR1) efflux transporter. Avoid or Use Alternate Drug. Dose adjustment may be required with strong P-gp inhibitors. DVT/PE treatment: Decrease dose to 30 mg PO once daily. NVAF: No dose reduction recommended

            • efavirenz

              efavirenz will decrease the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • eluxadoline

              tacrolimus increases levels of eluxadoline by decreasing metabolism. Avoid or Use Alternate Drug. Decrease eluxadoline dose to 75 mg PO BID if coadministered with OATP1B1 inhibitors. .

            • enzalutamide

              enzalutamide will decrease the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • erdafitinib

              erdafitinib, tacrolimus. affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Avoid coadministration with erdafitinib and sensitive CYP3A4 substrates with narrow therapeutic indices. Erdafitinib may altered plasma concentrations of CYP3A4 substrates, leading to either loss of activity or increased toxicity of the substrate.

              erdafitinib will increase the level or effect of tacrolimus by P-glycoprotein (MDR1) efflux transporter. Avoid or Use Alternate Drug. If coadministration unavoidable, separate administration by at least 6 hr before or after administration of P-gp substrates with narrow therapeutic index.

            • erythromycin base

              erythromycin base will increase the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • erythromycin ethylsuccinate

              erythromycin ethylsuccinate will increase the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • erythromycin lactobionate

              erythromycin lactobionate will increase the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • erythromycin stearate

              erythromycin stearate will increase the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • etanercept

              etanercept and tacrolimus both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

            • etodolac

              etodolac, tacrolimus. Either increases toxicity of the other by Other (see comment). Avoid or Use Alternate Drug. Comment: Concomitant administration increases risk of nephrotoxicity.

            • fenoprofen

              fenoprofen, tacrolimus. Either increases toxicity of the other by Other (see comment). Avoid or Use Alternate Drug. Comment: Concomitant administration increases risk of nephrotoxicity.

            • fexinidazole

              fexinidazole and tacrolimus both increase QTc interval. Avoid or Use Alternate Drug. Avoid coadministration of fexinidazole with drugs known to block potassium channels or prolong QT interval.

              fexinidazole will increase the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Fexinidazole inhibits CYP3A4. Coadministration may increase risk for adverse effects of CYP3A4 substrates.

            • flurbiprofen

              flurbiprofen, tacrolimus. Either increases toxicity of the other by Other (see comment). Avoid or Use Alternate Drug. Comment: Concomitant administration increases risk of nephrotoxicity.

            • glatiramer

              glatiramer and tacrolimus both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

            • golimumab

              golimumab and tacrolimus both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

            • hepatitis A vaccine inactivated

              tacrolimus decreases effects of hepatitis A vaccine inactivated by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

            • hepatitis a/b vaccine

              tacrolimus decreases effects of hepatitis a/b vaccine by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

            • hepatitis a/typhoid vaccine

              tacrolimus decreases effects of hepatitis a/typhoid vaccine by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

            • hepatitis b vaccine

              tacrolimus decreases effects of hepatitis b vaccine by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

            • human papillomavirus vaccine, nonavalent

              tacrolimus decreases effects of human papillomavirus vaccine, nonavalent by pharmacodynamic antagonism. Avoid or Use Alternate Drug. Immunosuppressive therapies, including irradiation, antimetabolites, alkylating agents, cytotoxic drugs, and corticosteroids (used in greater than physiologic doses), may reduce the immune responses to vaccines.

            • human papillomavirus vaccine, quadrivalent

              tacrolimus decreases effects of human papillomavirus vaccine, quadrivalent by pharmacodynamic antagonism. Avoid or Use Alternate Drug. Immunosuppressive therapies, including irradiation, antimetabolites, alkylating agents, cytotoxic drugs, and corticosteroids (used in greater than physiologic doses), may reduce the immune responses to vaccines.

            • hydroxychloroquine sulfate

              hydroxychloroquine sulfate and tacrolimus both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

              hydroxychloroquine sulfate and tacrolimus both increase QTc interval. Avoid or Use Alternate Drug.

            • ibuprofen

              ibuprofen, tacrolimus. Either increases toxicity of the other by Other (see comment). Avoid or Use Alternate Drug. Comment: Concomitant administration increases risk of nephrotoxicity.

            • ibuprofen IV

              ibuprofen IV, tacrolimus. Either increases toxicity of the other by Other (see comment). Avoid or Use Alternate Drug. Comment: Concomitant administration increases risk of nephrotoxicity.

            • idelalisib

              idelalisib will increase the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Idelalisib is a strong CYP3A inhibitor; avoid coadministration with sensitive CYP3A substrates

            • ifosfamide

              ifosfamide, tacrolimus. Either increases effects of the other by immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

            • indomethacin

              indomethacin, tacrolimus. Either increases toxicity of the other by Other (see comment). Avoid or Use Alternate Drug. Comment: Concomitant administration increases risk of nephrotoxicity.

            • infliximab

              infliximab and tacrolimus both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

            • influenza virus vaccine quadrivalent

              tacrolimus decreases effects of influenza virus vaccine quadrivalent by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

            • influenza virus vaccine quadrivalent, adjuvanted

              tacrolimus decreases effects of influenza virus vaccine quadrivalent, adjuvanted by pharmacodynamic antagonism. Avoid or Use Alternate Drug. Immunosuppressive drugs may reduce the immune response to influenza vaccine.

            • influenza virus vaccine quadrivalent, cell-cultured

              tacrolimus decreases effects of influenza virus vaccine quadrivalent, cell-cultured by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

            • influenza virus vaccine quadrivalent, intranasal

              tacrolimus decreases effects of influenza virus vaccine quadrivalent, intranasal by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

            • influenza virus vaccine trivalent

              tacrolimus decreases effects of influenza virus vaccine trivalent by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

            • influenza virus vaccine trivalent, adjuvanted

              tacrolimus decreases effects of influenza virus vaccine trivalent, adjuvanted by pharmacodynamic antagonism. Avoid or Use Alternate Drug. Immunosuppressive drugs may reduce the immune response to influenza vaccine.

            • ioversol

              ioversol and tacrolimus both increase nephrotoxicity and/or ototoxicity. Avoid or Use Alternate Drug.

            • ivosidenib

              ivosidenib and tacrolimus both increase QTc interval. Avoid or Use Alternate Drug. Avoid coadministration of QTc prolonging drugs with ivosidenib or replace with alternate therapies. If coadministration of a QTc prolonging drug is unavoidable, monitor for increased risk of QTc interval prolongation.

              ivosidenib will decrease the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Avoid coadministration of sensitive CYP3A4 substrates with ivosidenib or replace with alternative therapies. If coadministration is unavoidable, monitor patients for loss of therapeutic effect of these drugs.

            • Japanese encephalitis virus vaccine

              tacrolimus decreases effects of Japanese encephalitis virus vaccine by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

            • ketoconazole

              ketoconazole will increase the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • ketoprofen

              ketoprofen, tacrolimus. Either increases toxicity of the other by Other (see comment). Avoid or Use Alternate Drug. Comment: Concomitant administration increases risk of nephrotoxicity.

            • ketorolac

              ketorolac, tacrolimus. Either increases toxicity of the other by Other (see comment). Avoid or Use Alternate Drug. Comment: Concomitant administration increases risk of nephrotoxicity.

            • lasmiditan

              lasmiditan increases levels of tacrolimus by P-glycoprotein (MDR1) efflux transporter. Avoid or Use Alternate Drug.

            • leflunomide

              leflunomide and tacrolimus both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

            • lonafarnib

              lonafarnib will increase the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Avoid coadministration with sensitive CYP3A substrates. If coadministration unavoidable, monitor for adverse reactions and reduce CYP3A substrate dose in accordance with product labeling.

            • lopinavir

              lopinavir will increase the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • lorlatinib

              lorlatinib will decrease the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Avoid use of lorlatinib with CYP3A substrates, where minimal concentration changes may lead to serious therapeutic failures of the substrate. If concomitant use is unavoidable, increase CYP3A substrate dosage in accordance with approved product labeling.

            • lumacaftor/ivacaftor

              lumacaftor/ivacaftor will decrease the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Lumacaftor is a strong inducer of CYP3A. Avoid coadministration with sensitive CYP3A substrates or CYP3A substrates with a narrow therapeutic index.

            • macimorelin

              macimorelin and tacrolimus both increase QTc interval. Avoid or Use Alternate Drug. Macimorelin causes an increase of ~11 msec in the corrected QT interval. Avoid coadministration with drugs that prolong QT interval, which could increase risk for developing torsade de pointes-type ventricular tachycardia. Allow sufficient washout time of drugs that are known to prolong the QT interval before administering macimorelin.

            • measles (rubeola) vaccine

              tacrolimus decreases effects of measles (rubeola) vaccine by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

            • measles mumps and rubella vaccine, live

              tacrolimus decreases effects of measles mumps and rubella vaccine, live by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

            • measles, mumps, rubella and varicella vaccine, live

              tacrolimus decreases effects of measles, mumps, rubella and varicella vaccine, live by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

            • meclofenamate

              meclofenamate, tacrolimus. Either increases toxicity of the other by Other (see comment). Avoid or Use Alternate Drug. Comment: Concomitant administration increases risk of nephrotoxicity.

            • mefenamic acid

              mefenamic acid, tacrolimus. Either increases toxicity of the other by Other (see comment). Avoid or Use Alternate Drug. Comment: Concomitant administration increases risk of nephrotoxicity.

            • mefloquine

              mefloquine increases toxicity of tacrolimus by QTc interval. Avoid or Use Alternate Drug. Mefloquine may enhance the QTc prolonging effect of high risk QTc prolonging agents.

            • meloxicam

              meloxicam, tacrolimus. Either increases toxicity of the other by Other (see comment). Avoid or Use Alternate Drug. Comment: Concomitant administration increases risk of nephrotoxicity.

            • melphalan

              melphalan, tacrolimus. Either decreases effects of the other by immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug. Concomitant therapy is expected to increase the risk of immunosuppression. Use caution when switching patients from long-acting therapies with immune effects.

            • meningococcal A C Y and W-135 polysaccharide vaccine combined

              tacrolimus decreases effects of meningococcal A C Y and W-135 polysaccharide vaccine combined by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

            • mobocertinib

              mobocertinib will decrease the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. If use is unavoidable, increase CYP3A4 substrate dosage in accordance with its prescribing information.

              mobocertinib and tacrolimus both increase QTc interval. Avoid or Use Alternate Drug. If coadministration unavoidable, reduce mobocertinib dose and monitor QTc interval more frequently.

            • muromonab CD3

              muromonab CD3 and tacrolimus both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

            • mycophenolate

              mycophenolate and tacrolimus both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

            • nabumetone

              nabumetone, tacrolimus. Either increases toxicity of the other by Other (see comment). Avoid or Use Alternate Drug. Comment: Concomitant administration increases risk of nephrotoxicity.

            • naproxen

              naproxen, tacrolimus. Either increases toxicity of the other by Other (see comment). Avoid or Use Alternate Drug. Comment: Concomitant administration increases risk of nephrotoxicity.

            • nefazodone

              nefazodone will increase the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • ondansetron

              ondansetron and tacrolimus both increase QTc interval. Avoid or Use Alternate Drug. Avoid with congenital long QT syndrome; ECG monitoring recommended with concomitant medications that prolong QT interval, electrolyte abnormalities, CHF, or bradyarrhythmias.

            • oxaliplatin

              oxaliplatin and tacrolimus both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug. Concomitant therapy is expected to increase the risk of immunosuppression. Use caution when switching patients from long-acting therapies with immune effects.

            • oxaprozin

              oxaprozin, tacrolimus. Either increases toxicity of the other by Other (see comment). Avoid or Use Alternate Drug. Comment: Concomitant administration increases risk of nephrotoxicity.

            • pasireotide

              tacrolimus and pasireotide both increase QTc interval. Avoid or Use Alternate Drug.

            • pexidartinib

              pexidartinib will decrease the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Coadministration of pexidartinib (a CYP3A4 inducer) with sensitive CYP3A substrates may lead to serious therapeutic failures. If concomitant use is unavoidable, increase the CYP3A substrate dosage in accordance with approved product labeling.

            • piroxicam

              piroxicam, tacrolimus. Either increases toxicity of the other by Other (see comment). Avoid or Use Alternate Drug. Comment: Concomitant administration increases risk of nephrotoxicity.

            • pneumococcal vaccine 13-valent

              tacrolimus decreases effects of pneumococcal vaccine 13-valent by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

            • pneumococcal vaccine heptavalent

              tacrolimus decreases effects of pneumococcal vaccine heptavalent by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

            • pneumococcal vaccine polyvalent

              tacrolimus decreases effects of pneumococcal vaccine polyvalent by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

            • pomalidomide

              tacrolimus increases levels of pomalidomide by P-glycoprotein (MDR1) efflux transporter. Avoid or Use Alternate Drug.

            • potassium phosphates, IV

              tacrolimus and potassium phosphates, IV both increase serum potassium. Avoid or Use Alternate Drug.

            • quinidine

              quinidine will increase the level or effect of tacrolimus by P-glycoprotein (MDR1) efflux transporter. Avoid or Use Alternate Drug.

            • rabies vaccine

              tacrolimus decreases effects of rabies vaccine by pharmacodynamic antagonism. Contraindicated. Immunosuppressants may interfere with development of active immunity.

            • rabies vaccine chick embryo cell derived

              tacrolimus decreases effects of rabies vaccine chick embryo cell derived by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

            • revefenacin

              tacrolimus increases levels of revefenacin by Other (see comment). Avoid or Use Alternate Drug. Comment: OATP1B1 and OATP1B3 transport inhibitors may increase systemic exposure of revefenacin's active metabolite. Coadministration not recommended.

            • ribociclib

              ribociclib increases toxicity of tacrolimus by QTc interval. Avoid or Use Alternate Drug.

            • rifabutin

              rifabutin will decrease the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • rifampin

              rifampin will decrease the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • rilonacept

              rilonacept and tacrolimus both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

            • rimegepant

              tacrolimus will increase the level or effect of rimegepant by P-glycoprotein (MDR1) efflux transporter. Avoid or Use Alternate Drug.

            • riociguat

              tacrolimus will increase the level or effect of riociguat by decreasing metabolism. Avoid or Use Alternate Drug. Coadministration of riociguat (substrate of CYP isoenzymes 1A1, 2C8, 3A, 2J2) with strong CYP inhibitors may require a decreased initial dose of 0.5 mg PO TID; monitor for signs of hypotension and reduce dose if needed

            • rotavirus oral vaccine, live

              tacrolimus decreases effects of rotavirus oral vaccine, live by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

            • rubella vaccine

              tacrolimus decreases effects of rubella vaccine by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

            • sirolimus

              sirolimus and tacrolimus both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

            • smallpox (vaccinia) vaccine, live

              tacrolimus decreases effects of smallpox (vaccinia) vaccine, live by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

            • sotorasib

              sotorasib will decrease the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. If use is unavoidable, refer to the prescribing information of the CYP3A4 substrate for dosage modifications

              sotorasib will decrease the level or effect of tacrolimus by P-glycoprotein (MDR1) efflux transporter. Avoid or Use Alternate Drug. If use is unavoidable, refer to the prescribing information of the P-gp substrate for dosage modifications.

            • St John's Wort

              St John's Wort will decrease the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

              St John's Wort decreases levels of tacrolimus by increasing metabolism. Avoid or Use Alternate Drug.

            • sulindac

              sulindac, tacrolimus. Either increases toxicity of the other by Other (see comment). Avoid or Use Alternate Drug. Comment: Concomitant administration increases risk of nephrotoxicity.

            • teicoplanin

              tacrolimus and teicoplanin both increase nephrotoxicity and/or ototoxicity. Avoid or Use Alternate Drug.

            • temsirolimus

              tacrolimus and temsirolimus both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

            • tetanus toxoid adsorbed or fluid

              tacrolimus decreases effects of tetanus toxoid adsorbed or fluid by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

            • tick-borne encephalitis vaccine

              tacrolimus decreases effects of tick-borne encephalitis vaccine by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

            • tipranavir

              tipranavir will increase the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • tocilizumab

              tocilizumab and tacrolimus both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

            • tofacitinib

              tacrolimus, tofacitinib. Either increases toxicity of the other by immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

            • tolmetin

              tolmetin, tacrolimus. Either increases toxicity of the other by Other (see comment). Avoid or Use Alternate Drug. Comment: Concomitant administration increases risk of nephrotoxicity.

            • tongkat ali

              tacrolimus and tongkat ali both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

            • topotecan

              tacrolimus will increase the level or effect of topotecan by P-glycoprotein (MDR1) efflux transporter. Avoid or Use Alternate Drug. Product labeling for PO topotecan recommends avoiding concomitant use of P-gp inhibitors; the interaction with IV topotecan may be less severe but is still likely of clinical significance

            • toremifene

              tacrolimus and toremifene both increase QTc interval. Avoid or Use Alternate Drug. Concurrent use of toremifene with agents causing QT prolongation should be avoided. If concomitant use is required it's recommended that toremifene be interrupted. If interruption not possible, patients requiring therapy with a drug that prolongs QT should be closely monitored. ECGs should be obtained for high risk patients.

            • travelers diarrhea and cholera vaccine inactivated

              tacrolimus decreases effects of travelers diarrhea and cholera vaccine inactivated by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

            • tucatinib

              tucatinib will increase the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Avoid concomitant use of tucatinib with CYP3A substrates, where minimal concentration changes may lead to serious or life-threatening toxicities. If unavoidable, reduce CYP3A substrate dose according to product labeling.

            • typhoid polysaccharide vaccine

              tacrolimus decreases effects of typhoid polysaccharide vaccine by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

            • typhoid vaccine live

              tacrolimus decreases effects of typhoid vaccine live by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

            • umeclidinium bromide/vilanterol inhaled

              tacrolimus increases toxicity of umeclidinium bromide/vilanterol inhaled by QTc interval. Avoid or Use Alternate Drug. Exercise extreme caution when vilanterol coadministered with drugs that prolong QTc interval; adrenergic agonist effects on the cardiovascular system may be potentiated.

            • ustekinumab

              tacrolimus and ustekinumab both increase immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug.

            • vandetanib

              tacrolimus, vandetanib. Either increases toxicity of the other by QTc interval. Avoid or Use Alternate Drug. Avoid coadministration with drugs known to prolong QT interval; if a drug known to prolong QT interval must be used, more frequent ECG monitoring is recommended.

            • varicella virus vaccine live

              tacrolimus decreases effects of varicella virus vaccine live by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

            • venetoclax

              tacrolimus will increase the level or effect of venetoclax by P-glycoprotein (MDR1) efflux transporter. Avoid or Use Alternate Drug. If a P-gp inhibitor must be used, reduce the venetoclax dose by at least 50%. Monitor more closely for signs of venetoclax toxicities.

              venetoclax will increase the level or effect of tacrolimus by P-glycoprotein (MDR1) efflux transporter. Avoid or Use Alternate Drug. In vitro data suggest venetoclax may inhibit P-gp substrates at therapeutic dose levels in the gut. Avoid coadministration of narrow therapeutic index P-gp substrates with venetoclax. If a narrow therapeutic index P-gp substrate must be used, it should be taken at least 6 hr before venetoclax.

            • vilanterol/fluticasone furoate inhaled

              tacrolimus increases toxicity of vilanterol/fluticasone furoate inhaled by QTc interval. Avoid or Use Alternate Drug. Exercise extreme caution when vilanterol coadministered with drugs that prolong QTc interval; adrenergic agonist effects on the cardiovascular system may be potentiated.

            • voxelotor

              voxelotor will increase the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Voxelotor increases systemic exposure of sensitive CYP3A4 substrates. Avoid coadministration with sensitive CYP3A4 substrates with a narrow therapeutic index. Consider dose reduction of the sensitive CYP3A4 substrate(s) if unable to avoid.

            • yellow fever vaccine

              tacrolimus decreases effects of yellow fever vaccine by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

            • zoster vaccine live

              tacrolimus decreases effects of zoster vaccine live by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.

            Monitor Closely (282)

            • acyclovir

              acyclovir and tacrolimus both increase nephrotoxicity and/or ototoxicity. Modify Therapy/Monitor Closely.

            • adefovir

              adefovir and tacrolimus both increase nephrotoxicity and/or ototoxicity. Use Caution/Monitor.

            • albuterol

              albuterol and tacrolimus both increase QTc interval. Use Caution/Monitor.

            • alfuzosin

              tacrolimus and alfuzosin both increase QTc interval. Use Caution/Monitor.

              alfuzosin and tacrolimus both increase QTc interval. Use Caution/Monitor.

            • amikacin

              tacrolimus will increase the level or effect of amikacin by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • amiodarone

              amiodarone will increase the level or effect of tacrolimus by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • amitriptyline

              tacrolimus will increase the level or effect of amitriptyline by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • amlodipine

              amlodipine will increase the level or effect of tacrolimus by unspecified interaction mechanism. Modify Therapy/Monitor Closely. Adjust dose when appropriate.

            • amobarbital

              amobarbital will decrease the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • apomorphine

              apomorphine and tacrolimus both increase QTc interval. Use Caution/Monitor.

            • aprepitant

              aprepitant will increase the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • arformoterol

              arformoterol and tacrolimus both increase QTc interval. Use Caution/Monitor.

            • aripiprazole

              aripiprazole and tacrolimus both increase QTc interval. Use Caution/Monitor.

            • armodafinil

              armodafinil will decrease the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • artemether/lumefantrine

              artemether/lumefantrine will decrease the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • astragalus

              tacrolimus increases and astragalus decreases immunosuppressive effects; risk of infection. Effect of interaction is not clear, use caution. Use Caution/Monitor.

            • atazanavir

              atazanavir will increase the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • atomoxetine

              atomoxetine and tacrolimus both increase QTc interval. Use Caution/Monitor.

            • atorvastatin

              atorvastatin will increase the level or effect of tacrolimus by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              tacrolimus increases toxicity of atorvastatin by Other (see comment). Use Caution/Monitor. Comment: OATP1B1 inhibitors may increase risk of myopathy.

            • azithromycin

              azithromycin will increase the level or effect of tacrolimus by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • bazedoxifene/conjugated estrogens

              tacrolimus will increase the level or effect of bazedoxifene/conjugated estrogens by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • bedaquiline

              tacrolimus and bedaquiline both increase QTc interval. Modify Therapy/Monitor Closely. ECG should be monitored closely

            • belatacept

              belatacept and tacrolimus both increase immunosuppressive effects; risk of infection. Use Caution/Monitor.

            • berotralstat

              berotralstat will increase the level or effect of tacrolimus by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor. Monitor or titrate P-gp substrate dose if coadministered.

              berotralstat will increase the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Monitor or titrate substrate dose when berotralstat is coadministered with narrow therapeutic index drugs that are CYP3A substrates.

            • betrixaban

              tacrolimus increases levels of betrixaban by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor. Decrease betrixaban dose to 80 mg PO once, then 40 mg PO qDay if coadministered with a P-gp inhibitor.

            • blinatumomab

              blinatumomab increases levels of tacrolimus by decreasing metabolism. Modify Therapy/Monitor Closely. Treatment initiation causes transient release of cytokines that may suppress CYP450 enzymes; highest drug-drug interaction risk is during the first 9 days of the first cycle and the first 2 days of the 2nd cycle in patients who are receiving concomitant CYP450 substrates, particularly those with a narrow therapeutic index.

            • bosentan

              bosentan will decrease the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • bosutinib

              bosutinib increases levels of tacrolimus by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • brodalumab

              brodalumab, tacrolimus. Other (see comment). Use Caution/Monitor. Comment: Formation of CYP450 enzymes can be altered by increased levels of certain cytokines during chronic inflammation; thus, brodalumab could normalize the formation of CYP450 enzymes. Upon initiation or discontinuation of brodalumab in patients who are receiving concomitant CYP450 substrates, particularly those with a narrow therapeutic index, consider monitoring for therapeutic effect.

            • bromocriptine

              bromocriptine increases levels of tacrolimus by decreasing metabolism. Use Caution/Monitor.

            • budesonide

              budesonide will decrease the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              tacrolimus will increase the level or effect of budesonide by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • butabarbital

              butabarbital will decrease the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • butalbital

              butalbital will decrease the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • canagliflozin

              tacrolimus and canagliflozin both increase serum potassium. Use Caution/Monitor.

            • cannabidiol

              cannabidiol will increase the level or effect of tacrolimus by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor. Therapeutic drug monitoring and dose reduction of P-gp substrates should be considered when given orally and concurrently with cannabidiol

            • capreomycin

              capreomycin and tacrolimus both increase nephrotoxicity and/or ototoxicity. Modify Therapy/Monitor Closely.

            • carboplatin

              carboplatin and tacrolimus both increase nephrotoxicity and/or ototoxicity. Use Caution/Monitor.

            • cenobamate

              cenobamate will decrease the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Increase dose of CYP3A4 substrate, as needed, when coadministered with cenobamate.

            • cephaloridine

              cephaloridine and tacrolimus both increase nephrotoxicity and/or ototoxicity. Modify Therapy/Monitor Closely.

            • ceritinib

              tacrolimus increases levels of ceritinib by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • chloroquine

              chloroquine increases toxicity of tacrolimus by QTc interval. Use Caution/Monitor.

            • cholera vaccine

              tacrolimus decreases effects of cholera vaccine by immunosuppressive effects; risk of infection. Modify Therapy/Monitor Closely. Immunosuppressive therapies, including irradiation, antimetabolites, alkylating agents, cytotoxic drugs and corticosteroids (used in greater than physiologic doses), may reduce the immune response to cholera vaccine.

            • cisplatin

              cisplatin and tacrolimus both increase nephrotoxicity and/or ototoxicity. Use Caution/Monitor.

            • citalopram

              tacrolimus and citalopram both increase QTc interval. Use Caution/Monitor. ECG monitoring is recommended, along with drugs that may prolong the QT interval.

            • clarithromycin

              clarithromycin will increase the level or effect of tacrolimus by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • clobetasone

              tacrolimus will increase the level or effect of clobetasone by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • clotrimazole

              clotrimazole will decrease the level or effect of tacrolimus by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • clozapine

              clozapine and tacrolimus both increase QTc interval. Use Caution/Monitor.

            • cobicistat

              cobicistat will increase the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely.

            • colistin

              colistin and tacrolimus both increase nephrotoxicity and/or ototoxicity. Modify Therapy/Monitor Closely.

            • conivaptan

              conivaptan will increase the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • conjugated estrogens

              tacrolimus will increase the level or effect of conjugated estrogens by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • conjugated estrogens, vaginal

              tacrolimus will increase the level or effect of conjugated estrogens, vaginal by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • cortisone

              cortisone will decrease the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              tacrolimus will increase the level or effect of cortisone by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • crizotinib

              crizotinib increases levels of tacrolimus by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • crofelemer

              crofelemer increases levels of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Crofelemer has the potential to inhibit CYP3A4 at concentrations expected in the gut; unlikely to inhibit systemically because minimally absorbed.

            • dabigatran

              tacrolimus will increase the level or effect of dabigatran by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor. Atrial fibrillation: Avoid coadministering dabigatran with P-gp inhibitors if CrCl <30 mL/min. DVT/PE treatment: Avoid coadministering dabigatran with P-gp inhibitors if CrCl <50 mL/min

            • darifenacin

              darifenacin will increase the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • darunavir

              darunavir will increase the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely.

            • dasatinib

              dasatinib will increase the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              dasatinib and tacrolimus both increase QTc interval. Use Caution/Monitor.

            • daunorubicin

              tacrolimus will increase the level or effect of daunorubicin by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • deferasirox

              deferasirox will decrease the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Coadministration of deferasirox with potentially nephrotoxic drugs, including tacrolimus, may increase the risk of this toxicity. Monitor serum creatinine and/or creatinine clearance in patients.

            • deflazacort

              tacrolimus will increase the level or effect of deflazacort by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • degarelix

              degarelix and tacrolimus both increase QTc interval. Use Caution/Monitor.

            • dengue vaccine

              tacrolimus decreases effects of dengue vaccine by immunosuppressive effects; risk of infection. Use Caution/Monitor. Immunosuppressive therapies (eg, irradiation, antimetabolites, alkylating agents, cytotoxic drugs, corticosteroids [greater than physiologic doses]) may reduce immune response to dengue vaccine.

            • denosumab

              tacrolimus, denosumab. Other (see comment). Use Caution/Monitor. Comment: Caution should be taken in patients on concomitant immunosuppressants or with impaired immune systems because of increased risk for serious infections.

            • desipramine

              desipramine and tacrolimus both increase QTc interval. Use Caution/Monitor.

            • dexamethasone

              dexamethasone will decrease the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              tacrolimus will increase the level or effect of dexamethasone by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • dexlansoprazole

              dexlansoprazole will increase the level or effect of tacrolimus by affecting hepatic enzyme CYP2C19 metabolism. Use Caution/Monitor. Dexlansoprazole and tacrolimus compete for CYP2C19 metabolism. Concomitant administration may increase tacrolimus whole blood concentrations, particularly in intermediate or poor metabolizers of CYP2C19

            • DHEA, herbal

              DHEA, herbal will increase the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • dichlorphenamide

              dichlorphenamide and tacrolimus both decrease serum potassium. Use Caution/Monitor.

              dichlorphenamide, tacrolimus. Either increases toxicity of the other by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Both drugs can cause metabolic acidosis.

            • digoxin

              tacrolimus will increase the level or effect of digoxin by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • diltiazem

              diltiazem will increase the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • docetaxel

              tacrolimus will increase the level or effect of docetaxel by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • dofetilide

              dofetilide increases toxicity of tacrolimus by QTc interval. Use Caution/Monitor.

            • doxorubicin

              tacrolimus will increase the level or effect of doxorubicin by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • doxorubicin liposomal

              tacrolimus will increase the level or effect of doxorubicin liposomal by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • dronabinol

              dronabinol increases levels of tacrolimus by plasma protein binding competition. Modify Therapy/Monitor Closely. Dronabinol is highly bound to plasma proteins and may displace and increase the free fraction of other concomitantly administered highly protein-bound drugs. This has not been confirmed in vivo. Caution with narrow therapeutic index drugs that are highly protein bound when initiating or increasing the dose of dronabinol.

            • dronedarone

              dronedarone will increase the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • dulaglutide

              dulaglutide, tacrolimus. Other (see comment). Use Caution/Monitor. Comment: Dulaglutide slows gastric emptying and may impact absorption of concomitantly administered oral medications; be particularly cautious when coadministered with drugs that have a narrow therapeutic index.

            • dupilumab

              dupilumab, tacrolimus. Other (see comment). Use Caution/Monitor. Comment: Formation of CYP450 enzymes can be altered by increased levels of certain cytokines during chronic inflammation; thus, dupilumab could normalize the formation of CYP450 enzymes. Upon initiation or discontinuation of dupilumab in patients who are receiving concomitant CYP450 substrates, particularly those with a narrow therapeutic index, consider monitoring for therapeutic effect.

            • duvelisib

              duvelisib will increase the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Coadministration with duvelisib increases AUC of a sensitive CYP3A4 substrate which may increase the risk of toxicities of these drugs. Consider reducing the dose of the sensitive CYP3A4 substrate and monitor for signs of toxicities of the coadministered sensitive CYP3A substrate.

            • echinacea

              tacrolimus increases and echinacea decreases immunosuppressive effects; risk of infection. Effect of interaction is not clear, use caution. Use Caution/Monitor.

            • elagolix

              elagolix will increase the level or effect of tacrolimus by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              elagolix decreases levels of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Elagolix is a weak-to-moderate CYP3A4 inducer. Monitor CYP3A substrates if coadministered. Consider increasing CYP3A substrate dose if needed.

            • elbasvir/grazoprevir

              elbasvir/grazoprevir increases levels of tacrolimus by unknown mechanism. Modify Therapy/Monitor Closely. Frequently monitor tacrolimus whole blood concentrations, renal function, and tacrolimus-associated adverse events if coadministered with elbasvir/grazoprevir.

            • eliglustat

              eliglustat increases levels of tacrolimus by P-glycoprotein (MDR1) efflux transporter. Modify Therapy/Monitor Closely. Monitor therapeutic drug concentrations, as indicated, or consider reducing the dosage of the P-gp substrate and titrate to clinical effect.

            • eluxadoline

              eluxadoline increases levels of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Caution when CYP3A substrates that have a narrow therapeutic index are coadministered with eluxadoline.

            • elvitegravir/cobicistat/emtricitabine/tenofovir DF

              elvitegravir/cobicistat/emtricitabine/tenofovir DF increases levels of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Cobicistat is a CYP3A4 inhibitor; contraindicated with CYP3A4 substrates for which elevated plasma concentrations are associated with serious and/or life-threatening events.

              tacrolimus and elvitegravir/cobicistat/emtricitabine/tenofovir DF both increase nephrotoxicity and/or ototoxicity. Use Caution/Monitor.

            • encorafenib

              encorafenib, tacrolimus. affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Encorafenib both inhibits and induces CYP3A4 at clinically relevant plasma concentrations. Coadministration of encorafenib with sensitive CYP3A4 substrates may result in increased toxicity or decreased efficacy of these agents.

            • erythromycin base

              erythromycin base will increase the level or effect of tacrolimus by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • erythromycin ethylsuccinate

              erythromycin ethylsuccinate will increase the level or effect of tacrolimus by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • erythromycin lactobionate

              erythromycin lactobionate will increase the level or effect of tacrolimus by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • erythromycin stearate

              erythromycin stearate will increase the level or effect of tacrolimus by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • escitalopram

              escitalopram increases toxicity of tacrolimus by QTc interval. Use Caution/Monitor.

            • eslicarbazepine acetate

              eslicarbazepine acetate will decrease the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • esomeprazole

              esomeprazole will increase the level or effect of tacrolimus by affecting hepatic enzyme CYP2C19 metabolism. Use Caution/Monitor. Concomitant administration may increase tacrolimus whole blood concentrations, particularly in intermediate or poor metabolizers of CYP2C19

            • estradiol

              tacrolimus will increase the level or effect of estradiol by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • estrogens conjugated synthetic

              tacrolimus will increase the level or effect of estrogens conjugated synthetic by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • estrogens esterified

              tacrolimus will increase the level or effect of estrogens esterified by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • estropipate

              tacrolimus will increase the level or effect of estropipate by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • ethinylestradiol

              ethinylestradiol will increase the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • etoposide

              tacrolimus will increase the level or effect of etoposide by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • etravirine

              etravirine will decrease the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • everolimus

              tacrolimus and everolimus both increase nephrotoxicity and/or ototoxicity. Modify Therapy/Monitor Closely. If used for liver transplant immunosuppression (Zortress), reduce tacrolimus dose and use target serum concentration to reduce nephrotoxicity.

            • ezogabine

              ezogabine, tacrolimus. Either increases toxicity of the other by QTc interval. Use Caution/Monitor. Slight and transient QT-prolongation observed with ezogabine, particularly when dose titrated to 1200 mg/day. QT interval should be monitored when ezogabine is prescribed with agents known to increase QT interval.

            • fedratinib

              fedratinib will increase the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Adjust dose of drugs that are CYP3A4 substrates as necessary.

            • felodipine

              felodipine will increase the level or effect of tacrolimus by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • ferric maltol

              ferric maltol, tacrolimus. Either increases levels of the other by unspecified interaction mechanism. Modify Therapy/Monitor Closely. Coadministration of ferric maltol with certain oral medications may decrease the bioavailability of either ferric maltol and some oral drugs. For oral drugs where reductions in bioavailability may cause clinically significant effects on its safety or efficacy, separate administration of ferric maltol from these drugs. Duration of separation may depend on the absorption of the medication concomitantly administered (eg, time to peak concentration, whether the drug is an immediate or extended release product).

            • finerenone

              tacrolimus will increase the level or effect of finerenone by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Monitor serum potassium during initiation and dosage adjustment of either finererone or weak CYP3A4 inhibitors. Adjust finererone dosage as needed.

              tacrolimus and finerenone both increase serum potassium. Modify Therapy/Monitor Closely. Finerenone dose adjustment based on current serum potassium concentration. Monitor serum potassium and adjust finerenone dose as described in the prescribing information as necessary.

            • fingolimod

              tacrolimus increases effects of fingolimod by immunosuppressive effects; risk of infection. Modify Therapy/Monitor Closely. Concomitant therapy is expected to increase the risk of immunosuppression. Use caution when switching patients from long-acting therapies with immune effects. .

            • flibanserin

              tacrolimus will increase the level or effect of flibanserin by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Increased flibanserin adverse effects may occur if coadministered with multiple weak CYP3A4 inhibitors.

            • fluconazole

              fluconazole will increase the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • fludrocortisone

              fludrocortisone will decrease the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              tacrolimus will increase the level or effect of fludrocortisone by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • fluvastatin

              tacrolimus increases toxicity of fluvastatin by Other (see comment). Use Caution/Monitor. Comment: OATP1B1 inhibitors may increase risk of myopathy.

            • fluvoxamine

              fluvoxamine will increase the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • fosamprenavir

              fosamprenavir will increase the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • foscarnet

              foscarnet and tacrolimus both increase nephrotoxicity and/or ototoxicity. Use Caution/Monitor.

            • fosphenytoin

              fosphenytoin will decrease the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              fosphenytoin will decrease the level or effect of tacrolimus by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • fostamatinib

              fostamatinib will increase the level or effect of tacrolimus by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor. Concomitant use of fostamatinib may increase concentrations of P-gp substrates. Monitor for toxicities of the P-gp substrate drug that may require dosage reduction when given concurrently with fostamatinib.

            • fostemsavir

              tacrolimus and fostemsavir both increase QTc interval. Use Caution/Monitor. QTc prolongation reported with higher than recommended doses of fostemsavir.

            • gentamicin

              tacrolimus will increase the level or effect of gentamicin by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              gentamicin and tacrolimus both increase nephrotoxicity and/or ototoxicity. Modify Therapy/Monitor Closely.

            • glecaprevir/pibrentasvir

              tacrolimus will increase the level or effect of glecaprevir/pibrentasvir by decreasing metabolism. Use Caution/Monitor. Caution when coadministering glecaprevir/pibrentasvir with OATP1B1/OATP1B3 inhibitors

              glecaprevir/pibrentasvir will increase the level or effect of tacrolimus by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • glycerol phenylbutyrate

              glycerol phenylbutyrate will decrease the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Glycerol phenylbutyrate is a weak inducer of CYP3A4. Monitor for decreased efficacy of CYP3A4 substrates that have a narrow therapeutic index.

            • grapefruit

              grapefruit will increase the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • griseofulvin

              griseofulvin will decrease the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • guselkumab

              guselkumab, tacrolimus. Other (see comment). Use Caution/Monitor. Comment: Formation of CYP450 enzymes can be altered by increased levels of certain cytokines during chronic inflammation; thus, normalizing the formation of CYP450 enzymes. Upon initiation or discontinuation of guselkumab in patients who are receiving concomitant CYP450 substrates, particularly those with a narrow therapeutic index, consider monitoring for therapeutic effect.

            • haemophilus influenzae type b vaccine

              tacrolimus decreases effects of haemophilus influenzae type b vaccine by pharmacodynamic antagonism. Modify Therapy/Monitor Closely. Avoid vaccination during chemotherapy or radiation therapy if possible because antibody response might be suboptimal. Patients vaccinated within a 14-day period before starting or during immunosuppressive therapy should be revaccinated =3 months after therapy is discontinued if immune competence has been restored. .

            • haloperidol

              haloperidol and tacrolimus both increase QTc interval. Use Caution/Monitor.

            • hydrocortisone

              hydrocortisone will decrease the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              tacrolimus will increase the level or effect of hydrocortisone by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • ifosfamide

              ifosfamide, tacrolimus. Either increases toxicity of the other by pharmacodynamic synergism. Use Caution/Monitor. Ifosfamide may enhance the toxicities of myelosuppressive agents. Monitor for increased risk of myelosuppression.

            • iloperidone

              iloperidone increases levels of tacrolimus by affecting hepatic enzyme CYP2E1 metabolism. Use Caution/Monitor. Iloperidone is a time-dependent CYP3A inhibitor and may lead to increased plasma levels of drugs predominantly eliminated by CYP3A4.

            • imatinib

              tacrolimus will increase the level or effect of imatinib by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • indacaterol, inhaled

              indacaterol, inhaled, tacrolimus. QTc interval. Use Caution/Monitor. Drugs that are known to prolong the QTc interval may have an increased the risk of ventricular arrhythmias.

            • indinavir

              indinavir will increase the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              indinavir will increase the level or effect of tacrolimus by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • influenza virus vaccine quadrivalent, recombinant

              tacrolimus decreases effects of influenza virus vaccine quadrivalent, recombinant by pharmacodynamic antagonism. Use Caution/Monitor. Immune response to vaccine may be decreased in immunocompromised individuals.

            • influenza virus vaccine trivalent, recombinant

              tacrolimus decreases effects of influenza virus vaccine trivalent, recombinant by pharmacodynamic antagonism. Use Caution/Monitor. Immune response to vaccine may be decreased in immunocompromised individuals.

            • irinotecan

              tacrolimus will increase the level or effect of irinotecan by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • irinotecan liposomal

              tacrolimus will increase the level or effect of irinotecan liposomal by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • isavuconazonium sulfate

              tacrolimus will increase the level or effect of isavuconazonium sulfate by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • isoniazid

              isoniazid will increase the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • istradefylline

              istradefylline will increase the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Istradefylline 40 mg/day increased peak levels and AUC of CYP3A4 substrates in clinical trials. This effect was not observed with istradefylline 20 mg/day. Consider dose reduction of sensitive CYP3A4 substrates.

              istradefylline will increase the level or effect of tacrolimus by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor. Istradefylline 40 mg/day increased peak levels and AUC of P-gp substrates in clinical trials. Consider dose reduction of sensitive P-gp substrates.

            • ivacaftor

              ivacaftor increases levels of tacrolimus by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor. Ivacaftor and its M1 metabolite has the potential to inhibit P-gp; may significantly increase systemic exposure to sensitive P-gp substrates with a narrow therapeutic index.

            • ivermectin

              tacrolimus will increase the level or effect of ivermectin by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • ixekizumab

              ixekizumab, tacrolimus. Other (see comment). Use Caution/Monitor. Comment: Formation of CYP450 enzymes can be altered by increased levels of certain cytokines during chronic inflammation; thus, ixekizumab could normalize the formation of CYP450 enzymes. Upon initiation or discontinuation of ixekizumab in patients who are receiving concomitant CYP450 substrates, particularly those with a narrow therapeutic index, consider monitoring for therapeutic effect.

            • ketoconazole

              ketoconazole will increase the level or effect of tacrolimus by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • lansoprazole

              lansoprazole will increase the level or effect of tacrolimus by affecting hepatic enzyme CYP2C19 metabolism. Use Caution/Monitor. Concomitant administration may increase tacrolimus whole blood concentrations, particularly in intermediate or poor metabolizers of CYP2C19

            • lapatinib

              lapatinib will increase the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              lapatinib will increase the level or effect of tacrolimus by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • letermovir

              tacrolimus increases levels of letermovir by decreasing metabolism. Use Caution/Monitor. Coadminstration of letermovir, an OATP1B1/3 substrate, with OATP1B1/3 inhibitors may increase letermovir plasma concentrations.

              letermovir increases levels of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Monitor tacrolimus plasma concentrations during treatment and after discontinuation of letemovir and adjust dose of tacrolimus accordingly.

            • levamlodipine

              levamlodipine will increase the level or effect of tacrolimus by unspecified interaction mechanism. Modify Therapy/Monitor Closely. Amlodipine may increase the systemic exposure of cyclosporine or tacrolimus when coadministered. Frequent monitoring of trough blood levels of cyclosporine and tacrolimus is recommended and adjust the dose when appropriate.

            • lomitapide

              lomitapide increases levels of tacrolimus by P-glycoprotein (MDR1) efflux transporter. Modify Therapy/Monitor Closely. Consider reducing dose when used concomitantly with lomitapide.

            • lomustine

              lomustine and tacrolimus both increase immunosuppressive effects; risk of infection. Use Caution/Monitor. Concomitant therapy is expected to increase the risk of immunosuppression. Use caution when switching patients from long-acting therapies with immune effects.

            • lonafarnib

              lonafarnib will increase the level or effect of tacrolimus by P-glycoprotein (MDR1) efflux transporter. Modify Therapy/Monitor Closely. Lonafarnib is a weak P-gp inhibitor. Monitor for adverse reactions if coadministered with P-gp substrates where minimal concentration changes may lead to serious or life-threatening toxicities. Reduce P-gp substrate dose if needed.

            • loperamide

              tacrolimus will increase the level or effect of loperamide by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • loratadine

              loratadine will increase the level or effect of tacrolimus by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • lovastatin

              lovastatin will increase the level or effect of tacrolimus by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • lumefantrine

              lumefantrine will decrease the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • maitake

              tacrolimus increases and maitake decreases immunosuppressive effects; risk of infection. Effect of interaction is not clear, use caution. Use Caution/Monitor.

            • maraviroc

              tacrolimus will increase the level or effect of maraviroc by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • marijuana

              marijuana will increase the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • meningococcal group B vaccine

              tacrolimus decreases effects of meningococcal group B vaccine by pharmacodynamic antagonism. Use Caution/Monitor. Individuals with altered immunocompetence may have reduced immune responses to the vaccine.

            • mercaptopurine

              mercaptopurine and tacrolimus both increase immunosuppressive effects; risk of infection. Use Caution/Monitor.

            • mestranol

              tacrolimus will increase the level or effect of mestranol by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • metformin

              tacrolimus decreases effects of metformin by pharmacodynamic antagonism. Use Caution/Monitor.

            • methotrexate

              methotrexate and tacrolimus both increase immunosuppressive effects; risk of infection. Use Caution/Monitor. Combination may increase risk of myelosuppression.

            • methoxyflurane

              methoxyflurane and tacrolimus both increase nephrotoxicity and/or ototoxicity. Use Caution/Monitor.

            • methylprednisolone

              methylprednisolone will decrease the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              tacrolimus will increase the level or effect of methylprednisolone by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • methyltestosterone

              methyltestosterone increases effects of tacrolimus by decreasing metabolism. Use Caution/Monitor.

            • metoclopramide intranasal

              metoclopramide intranasal will increase the level or effect of tacrolimus by Other (see comment). Use Caution/Monitor. Metoclopramide may increase the absorption of tacrolimus. Monitor therapeutic drug concentrations and adjust the dose as needed.

            • metronidazole

              metronidazole will increase the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • miconazole vaginal

              miconazole vaginal will increase the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • mitotane

              mitotane decreases levels of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Mitotane is a strong inducer of cytochrome P-4503A4; monitor when coadministered with CYP3A4 substrates for possible dosage adjustments.

            • modafinil

              modafinil will decrease the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • nafcillin

              nafcillin will decrease the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • naldemedine

              tacrolimus increases levels of naldemedine by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor. Monitor naldemedine for potential adverse effects if coadministered with P-gp inhibitors.

            • nefazodone

              nefazodone will increase the level or effect of tacrolimus by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • nelfinavir

              nelfinavir will increase the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              tacrolimus will increase the level or effect of nelfinavir by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • neomycin PO

              tacrolimus will increase the level or effect of neomycin PO by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • nevirapine

              nevirapine will decrease the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • nicardipine

              nicardipine will increase the level or effect of tacrolimus by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              nicardipine increases levels of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • nifedipine

              nifedipine will increase the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              nifedipine will decrease the level or effect of tacrolimus by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • nilotinib

              nilotinib will increase the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              nilotinib will increase the level or effect of tacrolimus by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • nintedanib

              tacrolimus increases levels of nintedanib by P-glycoprotein (MDR1) efflux transporter. Modify Therapy/Monitor Closely. If nintedanib adverse effects occur, management may require interruption, dose reduction, or discontinuation of therapy .

            • nitazoxanide

              nitazoxanide, tacrolimus. Either increases levels of the other by Mechanism: plasma protein binding competition. Use Caution/Monitor.

            • ocrelizumab

              tacrolimus and ocrelizumab both increase immunosuppressive effects; risk of infection. Use Caution/Monitor. Coadministration of ocrelizumab with immunosuppressants may increase the risk of immunosuppression.

            • ofatumumab SC

              ofatumumab SC, tacrolimus. Either increases effects of the other by immunosuppressive effects; risk of infection. Use Caution/Monitor. Consider the risk of additive immune system effects when coadministering immunosuppressive therapies with coadministration. When switching from therapies with immune effects, take into account the duration and mechanism of action of these therapies when initiating ofatumumab SC.

            • olaparib

              tacrolimus and olaparib both increase pharmacodynamic synergism. Use Caution/Monitor. Coadministration with other other myelosuppressive anticancer agents, including DNA damaging agents, may potentiate and prolongate the myelosuppressive toxicity.

            • olodaterol inhaled

              tacrolimus and olodaterol inhaled both increase QTc interval. Use Caution/Monitor. Drugs that prolong the QTc interval and may potentiate the effects of beta2 agonists on the cardiovascular system; increased risk of ventricular arrhythmias

            • ombitasvir/paritaprevir/ritonavir & dasabuvir

              ombitasvir/paritaprevir/ritonavir & dasabuvir will increase the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. When initiating therapy with Viekira Pak, the dose of tacrolimus needs to be reduced; do not administer tacrolimus on the day Viekira Pak is initiated; beginning the day after Viekira Pak is initiated, reinitiate tacrolimus at a reduced dose based on tacrolimus blood concentrations; typical tacrolimus dosing is 0.5 mg q7days; measure tacrolimus blood concentrations and adjust dose or dosing frequency to determine subsequent dose modifications; upon completion of Viekira Pak, the appropriate time to resume pre-Viekira Pak dose of tacrolimus should be guided by assessment of blood concentrations

            • omeprazole

              omeprazole will increase the level or effect of tacrolimus by affecting hepatic enzyme CYP2C19 metabolism. Use Caution/Monitor. Concomitant administration may increase tacrolimus whole blood concentrations, particularly in intermediate or poor metabolizers of CYP2C19

            • oritavancin

              oritavancin will decrease the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Oritavancin is a weak CYP3A4 inducer; caution if coadministered with CYP3A4 substrates that have a narrow therapeutic index

            • osilodrostat

              osilodrostat and tacrolimus both increase QTc interval. Use Caution/Monitor.

            • osimertinib

              osimertinib and tacrolimus both increase QTc interval. Use Caution/Monitor. Conduct periodic monitoring with ECGs and electrolytes in patients taking drugs known to prolong the QTc interval.

            • ospemifene

              tacrolimus, ospemifene. Either increases levels of the other by plasma protein binding competition. Modify Therapy/Monitor Closely.

            • oxaliplatin

              oxaliplatin and tacrolimus both increase nephrotoxicity and/or ototoxicity. Use Caution/Monitor.

            • oxcarbazepine

              oxcarbazepine will decrease the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • ozanimod

              ozanimod and tacrolimus both increase QTc interval. Modify Therapy/Monitor Closely. The potential additive effects on heart rate, treatment with ozanimod should generally not be initiated in patients who are concurrently treated with QT prolonging drugs with known arrhythmogenic properties.

              ozanimod, tacrolimus. Either increases effects of the other by immunosuppressive effects; risk of infection. Use Caution/Monitor. Coadministration with immunosuppressive therapies may increase the risk of additive immune effects during therapy and in the weeks following administration. When switching from drugs with prolonged immune effects, consider the half-life and mode of action of these drugs in order to avoid unintended additive immunosuppressive effects.

            • paclitaxel

              tacrolimus will increase the level or effect of paclitaxel by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • paclitaxel protein bound

              tacrolimus will increase the level or effect of paclitaxel protein bound by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • palbociclib

              palbociclib will increase the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. The dose of sensitive CYP3A substrates with a narrow therapeutic index may need to be reduced if coadministered with palbociclib

            • paliperidone

              tacrolimus will increase the level or effect of paliperidone by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • pantoprazole

              pantoprazole will increase the level or effect of tacrolimus by affecting hepatic enzyme CYP2C19 metabolism. Use Caution/Monitor. Concomitant administration may increase tacrolimus whole blood concentrations, particularly in intermediate or poor metabolizers of CYP2C19

            • paromomycin

              tacrolimus will increase the level or effect of paromomycin by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              paromomycin and tacrolimus both increase nephrotoxicity and/or ototoxicity. Use Caution/Monitor.

            • pentamidine

              pentamidine and tacrolimus both increase nephrotoxicity and/or ototoxicity. Use Caution/Monitor.

            • pentobarbital

              pentobarbital will decrease the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • peramivir

              tacrolimus increases levels of peramivir by decreasing renal clearance. Use Caution/Monitor. Caution when peramivir coadministered with nephrotoxic drugs.

            • phenobarbital

              phenobarbital will decrease the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              phenobarbital will decrease the level or effect of tacrolimus by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • phenytoin

              phenytoin will decrease the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              phenytoin will decrease the level or effect of tacrolimus by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor. Tacrolimus dosage requirements may be greater when administered concurrently with phenytoin.

            • pitavastatin

              tacrolimus increases toxicity of pitavastatin by Other (see comment). Use Caution/Monitor. Comment: OATP1B1 inhibitors may increase risk of myopathy.

            • pitolisant

              pitolisant will decrease the level or effect of tacrolimus by Other (see comment). Use Caution/Monitor. Pitolisant is a borderline/weak inducer of CYP3A4. Monitor sensitive CYP3A4 substrates for reduced effectiveness if coadministered.

            • poliovirus vaccine inactivated

              tacrolimus decreases effects of poliovirus vaccine inactivated by pharmacodynamic antagonism. Modify Therapy/Monitor Closely. Avoid vaccination during chemotherapy or radiation therapy if possible because antibody response might be suboptimal. Patients vaccinated within a 14-day period before starting or during immunosuppressive therapy should be revaccinated =3 months after therapy is discontinued if immune competence has been restored. .

            • polymyxin B

              polymyxin B and tacrolimus both increase nephrotoxicity and/or ototoxicity. Modify Therapy/Monitor Closely.

            • ponatinib

              ponatinib increases levels of tacrolimus by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • ponesimod

              ponesimod and tacrolimus both increase immunosuppressive effects; risk of infection. Use Caution/Monitor. Caution if coadministered because of additive immunosuppressive effects during such therapy and in the weeks following administration. When switching from drugs with prolonged immune effects, consider the half-life and mode of action of these drugs to avoid unintended additive immunosuppressive effects.

            • posaconazole

              posaconazole will increase the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              tacrolimus will increase the level or effect of posaconazole by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • potassium citrate

              tacrolimus and potassium citrate both increase serum potassium. Use Caution/Monitor.

            • potassium citrate/citric acid

              tacrolimus and potassium citrate/citric acid both increase serum potassium. Use Caution/Monitor.

            • pravastatin

              tacrolimus increases toxicity of pravastatin by Other (see comment). Use Caution/Monitor. Comment: OATP1B1 inhibitors may increase risk of myopathy.

            • prednisolone

              tacrolimus will increase the level or effect of prednisolone by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • prednisone

              prednisone will decrease the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              tacrolimus will increase the level or effect of prednisone by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • primidone

              primidone will decrease the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • quercetin

              quercetin will decrease the level or effect of tacrolimus by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • quetiapine

              quetiapine, tacrolimus. Either increases toxicity of the other by QTc interval. Use Caution/Monitor. Avoid use with drugs that prolong QT and in patients with risk factors for prolonged QT interval. Postmarketing cases show QT prolongation with overdose in patients with concomitant illness or with drugs known to cause electrolyte imbalance or prolong QT.

            • quinine

              tacrolimus and quinine both increase QTc interval. Use Caution/Monitor.

            • quinupristin/dalfopristin

              quinupristin/dalfopristin will increase the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • rabeprazole

              rabeprazole will increase the level or effect of tacrolimus by affecting hepatic enzyme CYP2C19 metabolism. Use Caution/Monitor. Concomitant administration may increase tacrolimus whole blood concentrations, particularly in intermediate or poor metabolizers of CYP2C19

              rabeprazole, tacrolimus. Either increases toxicity of the other by Other (see comment). Use Caution/Monitor. Comment: Contomitant use of agents that can cause magnesium loss can result in hypomagnesemia.

            • ranolazine

              ranolazine will increase the level or effect of tacrolimus by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • ribociclib

              ribociclib will increase the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Caution if ribociclib is coadministered with sensitive CYP3A4 substrates that have a narrow therapeutic index. Dose reduction for sensitive CYP3A4 substrates may be needed.

            • rifampin

              rifampin will decrease the level or effect of tacrolimus by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • rifapentine

              rifapentine will decrease the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • rifaximin

              tacrolimus increases levels of rifaximin by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • rilpivirine

              rilpivirine increases toxicity of tacrolimus by QTc interval. Use Caution/Monitor. Rilpivirine should be used with caution when co-administered with a drug with a known risk of Torsade de Pointes.

            • risperidone

              tacrolimus will increase the level or effect of risperidone by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • ritonavir

              ritonavir will increase the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              ritonavir will increase the level or effect of tacrolimus by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • romidepsin

              tacrolimus will increase the level or effect of romidepsin by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • roxithromycin

              roxithromycin increases levels of tacrolimus by decreasing metabolism. Use Caution/Monitor.

            • rucaparib

              rucaparib will increase the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Adjust dosage of CYP3A4 substrates, if clinically indicated.

            • rufinamide

              rufinamide will decrease the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • sacubitril/valsartan

              tacrolimus will increase the level or effect of sacubitril/valsartan by Other (see comment). Use Caution/Monitor. The results from an in vitro study with human liver tissue indicate that valsartan is a substrate of the hepatic uptake transporter OATP1B1; coadministration with OATP1B1 inhibitors may increase valsartan systemic exposure

            • saquinavir

              tacrolimus will increase the level or effect of saquinavir by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • sarecycline

              sarecycline will increase the level or effect of tacrolimus by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor. Monitor for toxicities of P-gp substrates that may require dosage reduction when coadministered with P-gp inhibitors.

            • sarilumab

              sarilumab, tacrolimus. Other (see comment). Use Caution/Monitor. Comment: Formation of CYP450 enzymes can be altered by increased levels of cytokines such as IL-6. Elevated IL-6 concentration may down-regulate CYP activity, such as in patients with RA, and, hence, increase drug levels compared with subjects without RA. Blockade of IL-6 signaling by IL-6 antagonists (eg, sarilumab) might reverse the inhibitory effect of IL-6 and restore CYP activity, leading to decreased drug concentrations. Caution when initiating or discontinuing sarilumab if coadministered with CYP450 substrates, especially those with a narrow therapeutic index.

            • schisandra

              schisandra will increase the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • secobarbital

              secobarbital will decrease the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • secukinumab

              secukinumab, tacrolimus. Other (see comment). Use Caution/Monitor. Comment: Formation of CYP450 enzymes can be altered by increased levels of certain cytokines during chronic inflammation; thus, secukinumab could normalize the formation of CYP450 enzymes. Upon initiation or discontinuation of secukinumab in patients who are receiving concomitant CYP450 substrates, particularly those with a narrow therapeutic index, consider monitoring for therapeutic effect.

            • selpercatinib

              selpercatinib increases toxicity of tacrolimus by QTc interval. Use Caution/Monitor.

            • silodosin

              tacrolimus will increase the level or effect of silodosin by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • siltuximab

              siltuximab, tacrolimus. Other (see comment). Use Caution/Monitor. Comment: CYP450 activity in the liver is down regulated by infection and inflammation stimuli including cytokines (eg, IL-6); inhibition of IL-6 by siltuximab may restore CYP450 enzymatic activity; caution if coadministered with CYP substrates that have a narrow therapeutic index.

            • simvastatin

              simvastatin will increase the level or effect of tacrolimus by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              tacrolimus increases toxicity of simvastatin by Other (see comment). Use Caution/Monitor. Comment: OATP1B1 inhibitors may increase risk of myopathy.

            • siponimod

              siponimod and tacrolimus both increase immunosuppressive effects; risk of infection. Use Caution/Monitor. Caution if coadministered because of additive immunosuppressive effects during such therapy and in the weeks following administration. When switching from drugs with prolonged immune effects, consider the half-life and mode of action of these drugs to avoid unintended additive immunosuppressive effects.

            • sipuleucel-T

              tacrolimus decreases effects of sipuleucel-T by pharmacodynamic antagonism. Modify Therapy/Monitor Closely.

            • sirolimus

              sirolimus will increase the level or effect of tacrolimus by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • sorafenib

              sorafenib and tacrolimus both increase QTc interval. Use Caution/Monitor.

            • spironolactone

              spironolactone will increase the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. tacrolimus dose may need to be adjusted

            • St John's Wort

              St John's Wort will decrease the level or effect of tacrolimus by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • stiripentol

              stiripentol, tacrolimus. affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Stiripentol is a CYP3A4 inhibitor and inducer. Monitor CYP3A4 substrates coadministered with stiripentol for increased or decreased effects. CYP3A4 substrates may require dosage adjustment.

              stiripentol will increase the level or effect of tacrolimus by P-glycoprotein (MDR1) efflux transporter. Modify Therapy/Monitor Closely. Consider reducing the dose of P-glycoprotein (P-gp) substrates, if adverse reactions are experienced when administered concomitantly with stiripentol.

            • streptomycin

              tacrolimus will increase the level or effect of streptomycin by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              streptomycin and tacrolimus both increase nephrotoxicity and/or ototoxicity. Use Caution/Monitor.

            • streptozocin

              streptozocin and tacrolimus both increase nephrotoxicity and/or ototoxicity. Use Caution/Monitor.

            • tazemetostat

              tazemetostat will decrease the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              tacrolimus will increase the level or effect of tazemetostat by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • tecovirimat

              tecovirimat will decrease the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Tecovirimat is a weak CYP3A4 inducer. Monitor sensitive CYP3A4 substrates for effectiveness if coadministered.

            • teduglutide

              teduglutide increases levels of tacrolimus by Other (see comment). Use Caution/Monitor. Comment: Teduglutide may increase absorption of concomitant PO medications; caution with with drugs requiring titration or those with a narrow therapeutic index; dose adjustment may be necessary.

            • telotristat ethyl

              telotristat ethyl will decrease the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Telotristat ethyl induces CYP3A4 and may reduce systemic exposure of sensitive CYP3A4 substrates. Monitor for suboptimal efficacy and consider increasing the dose of the CYP3A4 substrate.

            • teniposide

              tacrolimus will increase the level or effect of teniposide by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • tenofovir DF

              tacrolimus and tenofovir DF both increase nephrotoxicity and/or ototoxicity. Modify Therapy/Monitor Closely.

            • tinidazole

              tinidazole will increase the level or effect of tacrolimus by unknown mechanism. Use Caution/Monitor. Monitored for signs of calcineurin-inhibitor associated toxicities (eg, nephrotoxicity, cholestasis, paresthesias).

              tacrolimus will increase the level or effect of tinidazole by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • tipranavir

              tipranavir, tacrolimus. Other (see comment). Use Caution/Monitor. Comment: Tacrolimus levels may incr or decr, due to contradictory effects of tipranavir on hepatic CYP3A4 and P glycoprotein.

            • tobramycin

              tacrolimus will increase the level or effect of tobramycin by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              tacrolimus and tobramycin both increase nephrotoxicity and/or ototoxicity. Modify Therapy/Monitor Closely.

            • tolvaptan

              tacrolimus will increase the level or effect of tolvaptan by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              tolvaptan will increase the level or effect of tacrolimus by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • topiramate

              topiramate will decrease the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • trastuzumab

              trastuzumab, tacrolimus. Either increases toxicity of the other by immunosuppressive effects; risk of infection. Use Caution/Monitor. Neutropenia or febrile neutropenia incidence were increased when trastuzumab was coadministered with myelosuppressive chemotherapy.

            • trastuzumab deruxtecan

              trastuzumab deruxtecan, tacrolimus. Either increases toxicity of the other by immunosuppressive effects; risk of infection. Use Caution/Monitor. Neutropenia or febrile neutropenia incidence were increased when trastuzumab was coadministered with myelosuppressive chemotherapy.

            • trazodone

              trazodone will decrease the level or effect of tacrolimus by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • tucatinib

              tucatinib will increase the level or effect of tacrolimus by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor. Consider reducing the dosage of P-gp substrates, where minimal concentration changes may lead to serious or life-threatening toxicities.

            • ustekinumab

              ustekinumab, tacrolimus. Other (see comment). Use Caution/Monitor. Comment: Formation of CYP450 enzymes can be altered by increased levels of certain cytokines during chronic inflammation; thus, normalizing the formation of CYP450 enzymes. Upon initiation or discontinuation of ustekinumab in patients who are receiving concomitant CYP450 substrates, particularly those with a narrow therapeutic index, consider monitoring for therapeutic effect.

            • vancomycin

              tacrolimus and vancomycin both increase nephrotoxicity and/or ototoxicity. Use Caution/Monitor.

            • verapamil

              verapamil will increase the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              verapamil will increase the level or effect of tacrolimus by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • vinblastine

              tacrolimus will increase the level or effect of vinblastine by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • vincristine

              tacrolimus will increase the level or effect of vincristine by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • vincristine liposomal

              tacrolimus will increase the level or effect of vincristine liposomal by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

            • voclosporin

              voclosporin and tacrolimus both increase serum potassium. Use Caution/Monitor.

              voclosporin, tacrolimus. Either increases effects of the other by QTc interval. Use Caution/Monitor.

            • voriconazole

              voriconazole will increase the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • zafirlukast

              zafirlukast will increase the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • zoster vaccine recombinant

              tacrolimus decreases effects of zoster vaccine recombinant by pharmacodynamic antagonism. Use Caution/Monitor. Immunosuppressive therapies may reduce the effectiveness of zoster vaccine recombinant.

            Minor (38)

            • aliskiren

              tacrolimus will increase the level or effect of aliskiren by P-glycoprotein (MDR1) efflux transporter. Minor/Significance Unknown.

            • allopurinol

              allopurinol increases levels of tacrolimus by unknown mechanism. Minor/Significance Unknown.

            • alvimopan

              tacrolimus will increase the level or effect of alvimopan by P-glycoprotein (MDR1) efflux transporter. Minor/Significance Unknown.

            • amiodarone

              amiodarone increases levels of tacrolimus by decreasing renal clearance. Minor/Significance Unknown.

            • armodafinil

              tacrolimus will increase the level or effect of armodafinil by P-glycoprotein (MDR1) efflux transporter. Minor/Significance Unknown.

            • budesonide

              budesonide, tacrolimus. Either increases levels of the other by decreasing metabolism. Minor/Significance Unknown.

            • caspofungin

              caspofungin decreases levels of tacrolimus by unspecified interaction mechanism. Minor/Significance Unknown.

            • chloroquine

              chloroquine increases levels of tacrolimus by decreasing metabolism. Minor/Significance Unknown.

            • chlorpropamide

              chlorpropamide increases levels of tacrolimus by unknown mechanism. Minor/Significance Unknown.

            • clonidine

              clonidine increases levels of tacrolimus by unknown mechanism. Minor/Significance Unknown.

            • clotrimazole

              clotrimazole increases levels of tacrolimus by decreasing metabolism. Minor/Significance Unknown.

            • cortisone

              cortisone, tacrolimus. Either increases levels of the other by decreasing metabolism. Minor/Significance Unknown.

            • danazol

              danazol increases effects of tacrolimus by decreasing metabolism. Minor/Significance Unknown.

            • deflazacort

              deflazacort, tacrolimus. Either increases levels of the other by decreasing metabolism. Minor/Significance Unknown.

            • dexamethasone

              dexamethasone, tacrolimus. Either increases levels of the other by decreasing metabolism. Minor/Significance Unknown.

            • entecavir

              tacrolimus, entecavir. Either increases effects of the other by decreasing renal clearance. Minor/Significance Unknown. Coadministration with drugs that reduce renal function or compete for active tubular secretion may increase serum concentrations of either entecavir or the coadministered drug.

            • fexofenadine

              tacrolimus will increase the level or effect of fexofenadine by P-glycoprotein (MDR1) efflux transporter. Minor/Significance Unknown.

            • fludrocortisone

              fludrocortisone, tacrolimus. Either increases levels of the other by decreasing metabolism. Minor/Significance Unknown.

            • fluoxymesterone

              fluoxymesterone increases effects of tacrolimus by decreasing metabolism. Minor/Significance Unknown.

            • food

              food decreases levels of tacrolimus by inhibition of GI absorption. Applies only to oral form of both agents. Minor/Significance Unknown.

            • glimepiride

              glimepiride increases levels of tacrolimus by unknown mechanism. Minor/Significance Unknown.

            • glipizide

              glipizide increases levels of tacrolimus by unknown mechanism. Minor/Significance Unknown.

            • glyburide

              glyburide increases levels of tacrolimus by unknown mechanism. Minor/Significance Unknown.

            • hydrocortisone

              hydrocortisone, tacrolimus. Either increases levels of the other by decreasing metabolism. Minor/Significance Unknown.

            • loratadine

              tacrolimus will increase the level or effect of loratadine by P-glycoprotein (MDR1) efflux transporter. Minor/Significance Unknown.

            • mesterolone

              mesterolone increases effects of tacrolimus by decreasing metabolism. Minor/Significance Unknown.

            • methylprednisolone

              methylprednisolone, tacrolimus. Either increases levels of the other by decreasing metabolism. Minor/Significance Unknown.

            • oxandrolone

              oxandrolone increases effects of tacrolimus by decreasing metabolism. Minor/Significance Unknown.

            • oxymetholone

              oxymetholone increases effects of tacrolimus by decreasing metabolism. Minor/Significance Unknown.

            • prednisolone

              prednisolone, tacrolimus. Either increases levels of the other by decreasing metabolism. Minor/Significance Unknown.

            • prednisone

              prednisone, tacrolimus. Either increases levels of the other by decreasing metabolism. Minor/Significance Unknown.

            • pyrazinamide

              pyrazinamide decreases levels of tacrolimus by unknown mechanism. Minor/Significance Unknown.

            • testosterone

              testosterone increases effects of tacrolimus by decreasing metabolism. Minor/Significance Unknown.

            • testosterone buccal system

              testosterone buccal system increases effects of tacrolimus by decreasing metabolism. Minor/Significance Unknown.

            • testosterone topical

              testosterone topical increases effects of tacrolimus by decreasing metabolism. Minor/Significance Unknown.

            • tolazamide

              tolazamide increases levels of tacrolimus by unknown mechanism. Minor/Significance Unknown.

            • tolbutamide

              tolbutamide increases levels of tacrolimus by unknown mechanism. Minor/Significance Unknown.

            • triamcinolone acetonide injectable suspension

              triamcinolone acetonide injectable suspension, tacrolimus. Either increases levels of the other by decreasing metabolism. Minor/Significance Unknown.

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            Adverse Effects

            >10% (Prograf)

            Tremor (54%)

            Hypertension (50%)

            Hypophosphatemia (49%)

            Increased creatinine (45%)

            Infection (45%)

            Headache (44%)

            Diarrhea (44%)

            Nausea (38%)

            Peripheral edema (36%)

            Constipation (35%)

            Urinary tract infection (34%)

            Hypomagnesemia (34%)

            Asthenia (34%)

            Abdominal pain (33%)

            Pain (32%)

            Insomnia (32%)

            Hyperlipemia (31%)

            Hyperkalemia (31%)

            Anemia (30%)

            Vomiting (29%)

            Dyspepsia (28%)

            Fever (29%)

            Arthralgia (25%)

            Back pain (24%)

            Diabetes mellitus (24%)

            Paresthesia (23%)

            Hypokalemia (22%)

            Hyperglycemia (22%)

            Dyspnea (22%)

            Dizziness (19%)

            Chest Pain (19%)

            Increased cough (18%)

            Edema (18%)

            Skin rash (17%)

            Pruritus (15%)

            Leukopenia (15%)

            >10% (Envarsus XR)

            All infections (46%)

            Respiratory infections (26%)

            Diarrhea (14%)

            Increased creatinine (12%)

            >10% (Astagraf XL)

            All infections (69%)

            Diarrhea (45%)

            Constipation (40%)

            Nausea (36%)

            Peripheral edema (36%)

            Tremor (35%)

            Respiratory infections (34%)

            Anemia (33%)

            Hypertension (28%)

            Vomiting (25%)

            Hypomagnesemia (24%)

            Insomnia (24%)

            Hypophosphatemia (23%)

            Serious infections (22%)

            Headache (22%)

            Hyperkalemia (20%)

            Increased blood creatinine (19%)

            Urinary tract infections (16%)

            Fatigue (16%)

            Leukopenia (16%)

            Hyperlipidemia (16%)

            Hyperglycemia (16%)

            1-10% (Astagraf XL)

            Cytomegalovirus infection (10%)

            Bacterial infections (8%)

            Gastroenteritis (7%)

            Polyomavirus infections (3%)

            1-10% (Envarsus XR)

            Urinary tract infections (9-10%)

            Nasopharyngitis (9%)

            Headache (9%)

            Serious infections (8%)

            Bacterial infections (7%)

            Upper respiratory tract infection (7%)

            Peripheral edema (7%)

            Hypertension (4%)

            Fungal infections (4%)

            Gastrointestinal infections (2%)

            Cytomegalovirus infections (2%)

            BK virus (2%)

            Postmarketing Reports

            Blood and lymphatic system disorders: Agranulocytosis, disseminated intravascular coagulation, hemolytic uremic syndrome, febrile neutropenia, pancytopenia, pure red cell aplasia, 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, Torsade 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. acute and chronic hepatitis

            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, leukemia, melanoma

            Nervous system disorders: Cerebral infarction, progressive multifocal leukoencephalopathy (PML) sometimes fatal, posterior reversible encephalopathy syndrome (PRES), 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, thrombotic microangiopathy

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            Warnings

            Black Box Warnings

            Serious infections and malignancies

            • Increased risk for developing serious infections and malignancies, including lymphoma and skin malignancies, with tacrolimus or other immunosuppressants that may lead to hospitalization or death

            Increased mortality in female liver transplant patients

            • Astagraf XL
            • Increased mortality in female transplant recipients was observed in clinical trial of liver transplantation; use of extended release formulation in liver transplantation is not recommended

            Experienced physician

            • Only healthcare providers experienced in immunosuppressive therapy and management of organ transplant patients should prescribe the drug; patients therapy should be managed in facilities equipped and staffed with laboratory and supportive medical resources; healthcare provider responsible for maintenance therapy should have complete information required for follow up of patient

            Contraindications

            Hypersensitivity to tacrolimus or any component of the formulation, including castor oil (Prograf)

            Cautions

            Hypersensitivity reactions, including anaphylaxis reported with injection formulation, which contains polyoxyl 60 hydrogenated castor oil (HCO-60), a castor oil derivative; limit IV use to patients unable to take orally; monitor patient for 30 min after initiation of infusion and then at frequent intervals; discontinue infusion if anaphylaxis occurs; transition patient from IV to oral dosing as soon as patient can tolerate oral administration

            Increased risk of infections and lymphoma, including latent virus activation (eg, BK virus-induced nephropathy)

            Patients receiving immunosuppressants are at increased 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, cytomegalovirus infections; CMV seronegative transplant patients who receive an organ from a CMV seropositive donor are at higher risk of developing 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 Black Box Warnings)

            Medication errors (eg, substitution and dispensing errors, between tacrolimus immediate-release products and tacrolimus extended-release products) reported outside the U.S; which led to serious adverse reactions such as graft rejection, or other adverse reactions due to under-or over-exposure to tacrolimus; 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

            Hypertension may occur; may treat with antihypertensives that are non-potassium-sparing diuretics; concurrent use of calcium channel blockers may require tacrolimus dosage adjustment

            Mild-to-severe hyperkalemia may occur; avoid use of potassium sparing diuretics

            Myocardial hypertrophy reported (reversible with dose reduction or discontinuation)

            QT prolongation reported; consider obtaining electrocardiograms and monitoring electrolytes periodically during treatment in patients with congestive heart failure, bradyarrhythmias, patients taking antiarrhythmic medications or other medicinal products that lead to QT prolongation, and those with electrolyte disturbances, including hypokalemia, hypomagnesemia, or hypocalcemia

            Cases of pure red-cell aplasia reported; if this is diagnosed, consider discontinuing tacrolimus

            Gastrointestinal perforation; all reported cases were considered a complication of transplant surgery or accompanied by infection, diverticulum, or malignant neoplasm

            Increased risk of malignancy is related to intensity/duration of therapy; limit or avoid sun and ultraviolet light exposure; use appropriate sun protection; post-transplant lymphoproliferative disorder related to EBV infection reported in immunosuppressed organ transplant patients; risk highest in young children

            African-Americans may need to be titrated to higher dosages to achieve the target tacrolimus concentrations

            Graft rejection and other serious adverse effects have resulted from medication errors with extended release dosage form; patients and caregivers are advised to recognize appearance extended release tablets

            Monitor blood glucose; new onset of diabetes after transplants reported

            Acute and or chronic nephrotoxicity reported with therapy; monitor renal function; consider dosage reduction

            Neurotoxicity including risk of posterior reversible encephalopathy syndrome (PRES) reported; monitor for neurologic abnormalities; reduce dosage or discontinue

            Posttransplant diabetes mellitus

            • Risk of posttransplant diabetes mellitus, especially in black and Hispanic patients; may occur in patients without pretransplant history of diabetes mellitus
            • Insulin dependence may be reversible
            • Black patients may require higher doses in kidney transplant
            • Monitor blood glucose frequently
            • Discontinue cyclosporine 24 hours before starting tacrolimus
            • Combination immunosuppressant therapy

            Drug interactions overview

            • Use with strong CYP3A inhibitors and inducers: a rapid, sharp rise in tacrolimus levels 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 for occurrence of adverse reactions, including QT prolongation recommended
            • Not for use with sirolimus; associated with an excess mortality, graft loss, and hepatic artery thrombosis (HAT); the concomitant administration of sirolimus (2 mg per day) in heart transplant patients associated with increased risk of renal function impairment, wound healing complications, and insulin-dependent post-transplant diabetes mellitus
            • Use caution with concurrent administration of nephrotoxic agents, consider dosage reduction in patients with elevated serum creatinine and tacrolimus whole blood trough concentrations greater than recommended range; risk for nephrotoxicity may increase when drug is concomitantly administered with CYP3A inhibitors (by increasing tacrolimus whole blood concentrations) or drugs associated with nephrotoxicity (eg, aminoglycosides, ganciclovir, amphotericin B, cisplatin, nucleotide reverse transcriptase inhibitors, protease inhibitors)
            • Avoid use of live vaccines during treatment with tacrolimus
            • Inactivated vaccines noted to be safe for administration after transplantation may not be sufficiently immunogenic during treatment
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            Pregnancy & Lactation

            Pregnancy

            There is a pregnancy registry that monitors pregnancy outcomes in women exposed to drug during pregnancy; the transplantation pregnancy registry international (TPRI) is a voluntary pregnancy exposure registry that monitors outcomes of pregnancy in female transplant recipients and those fathered by male transplant recipients exposed to immunosuppressants including tacrolimus; healthcare providers are encouraged to advise their patients to register by contacting the Transplantation Pregnancy Registry International at 1-877-955-6877 or https://www.transplantpregnancyregistry.org/

            Tacrolimus can cause fetal harm when administered to a pregnant woman; data from postmarketing surveillance and TPRI suggest that infants exposed to tacrolimus in utero are at a risk of prematurity, birth defects/congenital anomalies, low birth weight, and fetal distress; advise pregnant women of potential risk to fetus; administration of oral tacrolimus to pregnant rabbits and rats throughout the period of organogenesis was associated with maternal toxicity/lethality, and an increased incidence of abortion, malformation and embryofetal death at clinically relevant doses (0.5 to 6.9 times the recommended clinical dose range [0.2 to 0.075 mg/kg/day], on a mg/m2 basis)

            Risks during pregnancy are increased in organ transplant recipients; the risk of premature delivery following transplantation is increased; pre-existing hypertension and diabetes confer additional risk to the pregnancy of an organ transplant recipient; pre-gestational and gestational diabetes are associated with birth defects/congenital anomalies, hypertension, low birth weight and fetal death; cholestasis of pregnancy (COP) was reported in 7% of liver or liver-kidney (LK) transplant recipients, compared with approximately 1% of pregnancies in the general population; however, COP symptoms resolved postpartum and no long term effect on offsprings was reported

            Tacrolimus may increase hyperglycemia in pregnant women with diabetes (including gestational diabetes); monitor maternal blood glucose levels regularly

            Therapy may exacerbate hypertension in pregnant women and increase pre-eclampsia; monitor and control blood pressure

            Renal dysfunction, transient neonatal hyperkalemia and low birth weight have been reported at time of delivery in infants of mothers taking drug

            There is an increased risk for premature delivery (< 37 weeks) following transplantation and maternal exposure to drug.

            Contraception

            • Therapy can cause fetal harm when administered to pregnant women; advise female and male patients of reproductive potential to speak to their healthcare provider on family planning options including appropriate contraception prior to starting treatment

            Infertility

            • Based on findings in animals, male and female fertility may be compromised by treatment

            Lactation

            Controlled lactation studies have not been conducted in humans; however tacrolimus has been reported to be present in human milk; effects of tacrolimus on breastfed infant, or on milk production have not been assessed

            Tacrolimus is excreted in rat milk and in peri-/postnatal rat studies, exposure to tacrolimus during postnatal period was associated with developmental toxicity in offspring at clinically relevant doses

            The developmental and health benefits of breastfeeding should be considered along with mother’s clinical need for drug and any potential adverse effects on breastfed child from drug or from underlying maternal condition

            Pregnancy Categories

            A: Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.

            B: May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.

            C: Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.

            D: Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.

            X: Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.

            NA: Information not available.

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            Pharmacology

            Mechanism of Action

            Calcineurin inhibitor; inhibits T-cell activation and proliferation, humoral immunity

            Macrolide antibiotic; potent immunosuppressant

            Absorption

            Bioavailability: 7-55% (children); 7-32% (adults)

            Peak plasma time: 0.5-6 hr

            Distribution

            Protein bound: 99%

            Vd: 0.5-4.7 L/kg (children); 0.55-2.47 L/kg (adults)

            Metabolism

            Metabolized in liver by CYP3A4

            Metabolites: 13-O-demethyl tacrolimus (major)

            P-gp substrate

            Elimination

            Half-life: 23-46 hr (immediate release); 34.5-41 hr (extended release)

            Excretion: Feces (94%); urine (<1%)

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            Administration

            IV Incompatibilities

            Y-site: Acyclovir, ganciclovir

            IV Compatibilities

            Solution: D5W, NS

            Additive: Cimetidine

            Y-site (partial list): Ampicillin, ampicillin-sulbactam, calcium gluconate, cefazolin, ciprofloxacin, dopamine, fluconazole, furosemide, heparin, lorazepam, metoclopramide, metronidazole, morphine sulfate, multivitamins, penicillin G potassium, potassium chloride, propranolol, sodium bicarbonate, trimethoprim-sulfamethoxazole, vancomycin

            IV Preparation

            Dilute with NS or D5W to 0.004-0.02 mg/mL

            Do not store diluted solutions in a polyvinyl chloride (PVC) container due to decreased stability and the potential for extraction of phthalates from PVC containers

            Visually inspect product for particulate matter and discoloration prior to administration, whenever solution and container permit

            Due to the chemical instability of tacrolimus in alkaline media, mix or co-infuse with solutions of pH ≥9

            IV Administration

            Administer by IV continuous infusion only (use infusion pump)

            In situations where more dilute solutions are utilized (eg, pediatric dosing.), utilize PVC-free tubing to minimize the potential for significant drug adsorption onto the tubing

            Oral Suspension Preparation

            Can cause fetal harm; follow applicable special handling and disposal procedures

            Calculate required dose; use the minimum whole number of packets that corresponds to the required morning or evening dose

            If morning or evening dose is not covered by the whole number of packets, use one additional 0.2 mg packet to round up the dose

            Do not use tubing, syringes and other equipment (cups) containing PVC to prepare or administer tacrolimus suspension; do not sprinkle on food

            Empty the entire contents of each packet into a glass cup; ensure packet is completely empty and add 1-2 tablespoons (15-30 mL) of room temperature drinking water to cup containing the granules

            Mix and administer the entire contents of the cup; granules will not completely dissolve; give immediately after preparation

            Pediatric patients

            • Draw up and dispense suspension via a non-PVC oral syringe
            • Rinse cup or syringe with the same quantity of water (15-30 mL) and ensure all of the medication is taken

            Oral Administration

            Administer the same time each day, 12 hr apart

            Do not eat too much grapefruit while taking tacrolimus

            Capsules and granules

            • Administer consistently with or without food
            • Do not open capsules

            Extended-release capsules or tablets

            • Take preferably on an empty stomach
            • Swallow whole; do not chew, divide, or crush

            Missed doses

            • Once daily extended-release: Take it as soon as possible within 14 hr (Astagraf XL) or 15 hr (Envarsus XR) after missing the dose; beyond the 14-hr or 15-hr time frame, wait until the usual scheduled time to take the next regular daily dose; do not double the next dose

            Storage

            Envarsus XR: Store at 25°C (68-77°F); excursions permitted to 15-30°C (59-86°F)

            Astagraf XL: Store at 25°C (68-77°F); excursions permitted to 15-30°C (59-86°F)

            Prograf

            • Capsules: Store at 20-25°C (68-77°F); excursions permitted to 15-30°C (59-86°F)
            • Granules
              • Unit dose packets: Store at 20-25°C (68-77°F); excursions permitted to 15-30°C (59-86°F)
            • Injection
              • Unused vials: Store at 5-25°C (41-77°F)
              • Diluted solutions: Discard after 24 hr
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            Images

            BRAND FORM. UNIT PRICE PILL IMAGE
            Prograf oral
            -
            0.2 mg package
            Prograf oral
            -
            1 mg package
            Prograf oral
            -
            1 mg capsule
            Prograf oral
            -
            5 mg capsule
            Prograf oral
            -
            0.5 mg capsule
            tacrolimus oral
            -
            1 mg capsule
            tacrolimus oral
            -
            1 mg capsule
            tacrolimus oral
            -
            5 mg capsule
            tacrolimus oral
            -
            1 mg capsule
            tacrolimus oral
            -
            0.5 mg capsule
            tacrolimus oral
            -
            5 mg capsule
            tacrolimus oral
            -
            1 mg capsule
            tacrolimus oral
            -
            0.5 mg capsule
            tacrolimus oral
            -
            5 mg capsule
            tacrolimus oral
            -
            5 mg capsule
            tacrolimus oral
            -
            0.5 mg capsule
            tacrolimus oral
            -
            1 mg capsule
            tacrolimus oral
            -
            0.5 mg capsule
            tacrolimus oral
            -
            5 mg capsule
            tacrolimus oral
            -
            1 mg capsule
            tacrolimus oral
            -
            5 mg capsule
            tacrolimus oral
            -
            0.5 mg capsule
            Astagraf XL oral
            -
            5 mg capsule
            Astagraf XL oral
            -
            1 mg capsule
            Astagraf XL oral
            -
            0.5 mg capsule
            Prograf intravenous
            -
            5 mg/mL solution
            tacrolimus topical
            -
            0.1 % ointment
            tacrolimus topical
            -
            0.1 % ointment
            tacrolimus topical
            -
            0.1 % ointment
            tacrolimus topical
            -
            0.03 % ointment
            tacrolimus topical
            -
            0.1 % ointment
            tacrolimus topical
            -
            0.1 % ointment
            tacrolimus topical
            -
            0.1 % ointment
            tacrolimus topical
            -
            0.1 % ointment
            tacrolimus topical
            -
            0.1 % ointment
            tacrolimus topical
            -
            0.03 % ointment
            tacrolimus topical
            -
            0.03 % ointment
            tacrolimus topical
            -
            0.03 % ointment
            tacrolimus topical
            -
            0.03 % ointment
            tacrolimus topical
            -
            0.03 % ointment
            tacrolimus topical
            -
            0.1 % ointment
            tacrolimus topical
            -
            0.1 % ointment
            tacrolimus topical
            -
            0.1 % ointment
            tacrolimus topical
            -
            0.1 % ointment
            tacrolimus topical
            -
            0.03 % ointment
            Protopic topical
            -
            0.1 % ointment
            Protopic topical
            -
            0.1 % ointment
            Protopic topical
            -
            0.1 % ointment
            Protopic topical
            -
            0.03 % ointment
            Protopic topical
            -
            0.03 % ointment
            Envarsus XR oral
            -
            0.75 mg tablet
            Envarsus XR oral
            -
            4 mg tablet
            Envarsus XR oral
            -
            1 mg tablet

            Copyright © 2010 First DataBank, Inc.

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            Patient Handout

            Select a drug:
            Patient Education
            tacrolimus oral

            TACROLIMUS EXTENDED-RELEASE - ORAL

            (ta-KROE-li-mus)

            COMMON BRAND NAME(S): Astagraf XL, Envarsus XR

            WARNING: Tacrolimus lowers the body's ability to fight an infection/disease (immunosuppression). This effect may increase your risk of developing an infection or certain types of cancer (such as skin cancer, lymphoma). To reduce the risk of these serious side effects, take this medication at the lowest effective dose as directed by your doctor. Keep all medical and laboratory appointments.Tell your doctor right away if you develop any of the following: unusual skin changes, change in the appearance/size of moles, unusual growths/lumps, swollen glands, night sweats, unexplained weight loss, signs of infection (such as fever, persistent sore throat).This medication may increase the risk of death when it is used by women to prevent organ rejection after a liver transplant. Discuss the risks and benefits of this medication with the doctor.

            USES: Tacrolimus is used with other medications to prevent rejection of a kidney transplant. This medication belongs to a class of drugs known as immunosuppressants. It works by weakening your body's defense system (immune system) to help your body accept the new organ as if it were your own.

            HOW TO USE: Read the Medication Guide and, if available, the Patient Information Leaflet provided by your pharmacist before you start taking tacrolimus and each time you get a refill. If you have any questions, ask your doctor or pharmacist.Take this medication by mouth on an empty stomach (1 hour before or 2 hours after a meal) as directed by your doctor, usually once daily in the morning. Talk to your doctor about how to take this medication if you have nausea or an upset stomach.If you take the extended-release capsules, swallow the capsules whole. Do not crush or chew the capsules. Doing so can release all of the drug at once, increasing the risk of side effects.If you take the extended-release tablets, do not crush or chew the tablets. Doing so can release all of the drug at once, increasing the risk of side effects. Also, do not split the tablets unless they have a score line and your doctor or pharmacist tells you to do so. Swallow the whole or split tablet without crushing or chewing.Dosage is based on your weight, medical condition, blood test results (for example, tacrolimus trough levels), response to treatment, and previous dose of tacrolimus (if switching from the form of this medication that is taken twice daily).Tacrolimus is available in different formulations (such as immediate and extended-release). Do not switch between different forms of tacrolimus without consulting your doctor.Do not increase your dose or take this medication more often without your doctor's approval. Your condition will not improve any faster and the risk of serious side effects may be increased. Also, do not stop taking this medication without your doctor's approval.Take this medication regularly in order to get the most benefit from it. It is important to take all doses on time to keep the amount of medicine in your body at a constant level. Remember to take it at the same time each day.Avoid eating grapefruit or drinking grapefruit juice while being treated with this medication unless your doctor instructs you otherwise. Grapefruit can increase the amount of certain medications in your bloodstream. Consult your doctor or pharmacist for more details.Since this drug can be absorbed through the skin and lungs and may harm an unborn baby, women who are pregnant or who may become pregnant should not handle this medication or breathe the dust from the tablets.Tell your doctor if your condition worsens.

            SIDE EFFECTS: See also Warning section.Shaking, headache, diarrhea, nausea/vomiting, upset stomach, and trouble sleeping may occur. If any of these effects persist or worsen, tell your doctor or pharmacist promptly.Remember that this medication has been prescribed because your doctor has judged that the benefit to you is greater than the risk of side effects. Many people using this medication do not have serious side effects.Tell your doctor right away if you have any serious side effects, including: signs of kidney problems (such as change in the amount of urine), mental/mood changes, hearing problems (such as hearing loss, ringing in the ears), numbness/tingling of the hands/feet, dizziness, pain/redness/swelling of arms or legs, easy bruising/bleeding, yellowing skin/eyes, dark urine, persistent nausea/vomiting, severe stomach/abdominal pain, muscle weakness, severe leg pain, symptoms of heart failure (such as shortness of breath, swelling ankles/feet, unusual tiredness, unusual/sudden weight gain).This medication may also increase your risk of getting a rare but very serious (sometimes fatal) brain infection (progressive multifocal leukoencephalopathy-PML). Get medical help right away if any of these rare but very serious side effects occur: clumsiness, loss of coordination, weakness, sudden change in your thinking (such as confusion, difficulty concentrating), difficulty moving your muscles, problems with speech, seizure, vision changes.Get medical help right away if you have any very serious side effects, including: fainting, fast/irregular heartbeat, severe dizziness, chest/jaw/left arm pain, black stools, vomit that looks like coffee grounds.This medication may raise your blood pressure. Check your blood pressure regularly and tell your doctor if the results are high. Your doctor may control your blood pressure with medication.Tacrolimus may cause diabetes. Tell your doctor or pharmacist if you experience symptoms of high blood sugar such as increased thirst/hunger, frequent urination.A very serious allergic reaction to this drug is rare. However, get medical help right away if you notice any symptoms of a serious allergic reaction, including: rash, itching/swelling (especially of the face/tongue/throat), severe dizziness, trouble breathing.This is not a complete list of possible side effects. If you notice other effects not listed above, contact your doctor or pharmacist.In the US -Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088 or at www.fda.gov/medwatch.In Canada - Call your doctor for medical advice about side effects. You may report side effects to Health Canada at 1-866-234-2345.

            PRECAUTIONS: Before taking tacrolimus, tell your doctor or pharmacist if you are allergic to it; or to other macrolide medications (such as sirolimus); or if you have any other allergies. This product may contain inactive ingredients, which can cause allergic reactions or other problems. Talk to your pharmacist for more details.Before using this medication, tell your doctor or pharmacist your medical history, especially of: mineral imbalances (such as high potassium), kidney disease, any recent/current infections, cancer, liver disease, high blood pressure, diabetes.Tacrolimus may cause a condition that affects the heart rhythm (QT prolongation). QT prolongation can rarely cause serious (rarely fatal) fast/irregular heartbeat and other symptoms (such as severe dizziness, fainting) that need medical attention right away.The risk of QT prolongation may be increased if you have certain medical conditions or are taking other drugs that may cause QT prolongation. Before using tacrolimus, tell your doctor or pharmacist of all the drugs you take and if you have any of the following conditions: certain heart problems (heart failure, slow heartbeat, QT prolongation in the EKG), family history of certain heart problems (QT prolongation in the EKG, sudden cardiac death).Low levels of potassium or magnesium in the blood may also increase your risk of QT prolongation. This risk may increase if you use certain drugs (such as diuretics/"water pills") or if you have conditions such as severe sweating, diarrhea, or vomiting. Talk to your doctor about using tacrolimus safely.This medication may increase your risk of developing skin cancer. Limit your time in the sun. Avoid tanning booths and sunlamps. Use sunscreen and wear protective clothing when outdoors.Tacrolimus can make you more likely to get infections or may worsen any current infections. Avoid contact with people who have infections that may spread to others (such as chickenpox, measles, flu). Consult your doctor if you have been exposed to an infection or for more details.Do not have immunizations/vaccinations without the consent of your doctor. Avoid contact with people who have recently received live vaccines (such as flu vaccine inhaled through the nose).This drug may increase your potassium levels. Before using potassium supplements or salt substitutes that contain potassium, consult your doctor or pharmacist.Before having surgery, tell your doctor or dentist about all the products you use (including prescription drugs, nonprescription drugs, and herbal products).Older adults may be more sensitive to the side effects of this drug, especially QT prolongation (see above).Since this drug can be absorbed through the skin and lungs and may harm an unborn baby, women who are pregnant or who may become pregnant should not handle this medication or breathe the dust from the tablets.Tell your doctor if you are pregnant or plan to become pregnant. You should not become pregnant while using tacrolimus. Tacrolimus may harm an unborn baby. Men and women using this medication should ask about reliable forms of birth control before and while using this medication. If you or your partner become pregnant, talk to your doctor right away about the risks and benefits of this medication. Do not stop taking this medication unless directed by your doctor.This drug passes into breast milk and the effect on a nursing infant is unknown. Discuss the risks and benefits with your doctor before breast-feeding.

            DRUG INTERACTIONS: See also How to Use section.Drug interactions may change how your medications work or increase your risk for serious side effects. This document does not contain all possible drug interactions. Keep a list of all the products you use (including prescription/nonprescription drugs and herbal products) and share it with your doctor and pharmacist. Do not start, stop, or change the dosage of any medicines without your doctor's approval.Some products that may interact with this drug include: aluminum/magnesium antacid, cyclosporine, sirolimus, temsirolimus, ziprasidone, other drugs that may increase the level of potassium in the blood (such as "water pills" including amiloride, spironolactone), other drugs that weaken the immune system/increase the risk of infection (such as natalizumab, rituximab).Avoid alcohol when using this medication because it may cause the medication to be released too quickly and increase the risk of side effects.Other medications can affect the removal of tacrolimus from your body, which may affect how tacrolimus works. Examples include cimetidine, danazol, nefazodone, ethinyl estradiol, methylprednisolone, St. John's wort, azole antifungals (such as itraconazole/voriconazole), HIV and HCV protease inhibitors (such as nelfinavir, ritonavir, boceprevir, telaprevir), rifamycins (such as rifampin, rifabutin), certain anti-seizure drugs (such as phenobarbital, phenytoin), among others.

            OVERDOSE: If someone has overdosed and has serious symptoms such as passing out or trouble breathing, call 911. Otherwise, call a poison control center right away. US residents can call their local poison control center at 1-800-222-1222. Canada residents can call a provincial poison control center.

            NOTES: Laboratory and/or medical tests (such as potassium levels, blood pressure, blood sugar, tacrolimus trough level, kidney/liver function) will be performed periodically to monitor your progress or check for side effects. Consult your doctor for more details.If you have had an organ transplant, it is recommended that you attend a transplant education class or support group. Learn the signs of organ rejection such as a feeling of being ill, fever, or tenderness/pain around the transplanted organ. Tell your doctor right away if you notice any of these signs.

            MISSED DOSE: If you take the extended-release capsules: If you miss a dose, take it as soon as you remember. If it is more than 14 hours after the time you would usually take it, skip the missed dose. Take your next dose at the regular time. Do not double the dose to catch up.If you take the extended-release tablets: If you miss a dose, take it as soon as you remember. If it is more than 15 hours after the time you would usually take it, skip the missed dose. Take your next dose at the regular time. Do not double the dose to catch up.

            STORAGE: Store at room temperature away from light and moisture. Do not store in the bathroom. Keep all medications away from children and pets.Do not flush medications down the toilet or pour them into a drain unless instructed to do so. Properly discard this product when it is expired or no longer needed. Consult your pharmacist or local waste disposal company.

            MEDICAL ALERT: Your condition can cause complications in a medical emergency. For information about enrolling in MedicAlert, call 1-888-633-4298 (US) or 1-800-668-1507 (Canada).

            Information last revised September 2021. Copyright(c) 2021 First Databank, Inc.

            IMPORTANT: HOW TO USE THIS INFORMATION: This is a summary and does NOT have all possible information about this product. This information does not assure that this product is safe, effective, or appropriate for you. This information is not individual medical advice and does not substitute for the advice of your health care professional. Always ask your health care professional for complete information about this product and your specific health needs.

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            Formulary

            FormularyPatient Discounts

            Adding plans allows you to compare formulary status to other drugs in the same class.

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            • View the formulary and any restrictions for each plan.
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            The above information is provided for general informational and educational purposes only. Individual plans may vary and formulary information changes. Contact the applicable plan provider for the most current information.

            Tier Description
            1 This drug is available at the lowest co-pay. Most commonly, these are generic drugs.
            2 This drug is available at a middle level co-pay. Most commonly, these are "preferred" (on formulary) brand drugs.
            3 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs.
            4 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            5 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            6 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            NC NOT COVERED – Drugs that are not covered by the plan.
            Code Definition
            PA Prior Authorization
            Drugs that require prior authorization. This restriction requires that specific clinical criteria be met prior to the approval of the prescription.
            QL Quantity Limits
            Drugs that have quantity limits associated with each prescription. This restriction typically limits the quantity of the drug that will be covered.
            ST Step Therapy
            Drugs that have step therapy associated with each prescription. This restriction typically requires that certain criteria be met prior to approval for the prescription.
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            Medscape prescription drug monographs are based on FDA-approved labeling information, unless otherwise noted, combined with additional data derived from primary medical literature.