Sublingual tacrolimus as an alternative to oral administration for solid organ transplant recipients [Clinical Consultation]

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Sublingual tacrolimus as an alternative to oral administration for solid organ transplant recipients Catherine A. Pennington and Jeong M. Park?

Catherine A. Pennington, M.S., Pharm.D., BCPS, is Clinical Hospital Pharmacist, Jackson Memorial Hospital, Miami, FL. Jeong M. Park, M.S., Pharm.D., BCPS, is Clinical Pharmacist Specialist, University of Michigan Hospitals and Health Centers, Ann Arbor, and Clinical Associate Professor, College of Pharmacy, University of Michigan, Ann Arbor. Address correspondence to Dr. Park (jeongp{at}med.umich.edu). Abstract Purpose Available data regarding sublingual tacrolimus were analyzed to provide recommendations for solid organ transplant recipients.

Summary Tacrolimus is an immunosuppressive agent with a narrow therapeutic range that is commonly used in solid organ transplantation. Achieving and maintaining appropriate tacrolimus exposure are critical for preventing rejection and minimizing toxicity. A variety of clinical situations requiring nonoral medication delivery arise, presenting the need for reliable alternative routes of tacrolimus administration. A review of the currently available literature revealed nine reports of sublingual tacrolimus use in human subjects. Seven reported that sublingual administration could achieve comparable tacrolimus trough concentrations to oral administration, but none investigated the correlation between tacrolimus trough concentration and exposure. One study of lung transplant recipients found that approximately 50% of the oral dose was needed to obtain therapeutic trough concentrations when converted to sublingual administration. Another study of patients with end-stage renal disease identified a similar sublingual:oral dosing ratio of 1:2. When converted from oral tacrolimus in combination with clotrimazole to sublingual administration, the sublingual:oral dosing ratio was 1:1.

Conclusion In addition to enteral tube and i.v. tacrolimus dosing, sublingual administration may be considered for short-term use in patients who are unable to receive medications orally. Based on the available data, it is reasonable to initiate sublingual tacrolimus at 50% of the current or anticipated oral dose in the absence of interacting medications. Dosing must be individualized, taking into consideration concomitant interacting medications, and adjusted to target levels based on therapeutic drug monitoring.

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? Previous | Next Article ? Table of Contents This Article doi: 10.2146/ajhp140322 American Journal of Health-System Pharmacy February 15, 2015 vol. 72 no. 4 277-284 ? Abstract Full Text Full Text (PDF) Classifications Print Content Clinical Consultation Services Email this article to a colleague Alert me when this article is cited Alert me if a correction is posted Alert me when eLetters are published Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Download to citation manager eLetters Submit an eLetter No eLetters published Citing Articles Load citing article information Google Scholar Articles by Pennington, C. A. Articles by Park, J. M. PubMed PubMed citation Articles by Pennington, C. A. Articles by Park, J. M. Related Content Load related web page information Social Bookmarking CiteULike Delicious Digg Facebook Google+ Reddit Twitter What's this?

Current Issue February 15, 2015, 72 (4) Alert me to new issues of American Journal of Health-System Pharmacy From the Cover RhOD immune globulin products for prevention of alloimmunization during pregnancy Sublingual tacrolimus as an alternative to oral administration for solid organ transplant recipients Economic burden of recurrent venous thromboembolism: Analysis from a U.S. hospital perspective Comparative analytics of infusion pump data across multiple hospital systems ABOUT AJHP SUBSCRIPTIONS FOR AUTHORS/REVIEWERS PERMISSION REQUESTS ADVERTISING EMAIL ALERTS (FREE) RSS FEEDS (FREE) HELP CONTACT US/FEEDBACK American Society of Health System Pharmacists Learning Center (CE) Store Meetings & Conferences ASHP Foundation MOST READ ARTICLES (Last 30 Days) Clinical practice guidelines for antimicrobial prophylaxis in surgery Therapeutic monitoring of vancomycin in adult patients: A consensus review of the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, and the Society of Infectious Diseases Pharmacists How to write a patient case report Treatment of poisoning caused by {beta}-adrenergic and calcium-channel blockers ? View all Most Read articles Advertisement ? 2015 by the American Society of Health-System Pharmacists. Terms of Use | Copyright Online ISSN: 1535-2900 Print ISSN: 1079-2082

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