DRUGS & SUPPLEMENTS
1 INDICATIONS AND USAGE
Protopic Capsules USP is a calcineurin-inhibitor immunosuppressant indicated for
1.1 Prophylaxis of Organ Rejection in Kidney Transplant
Protopic Capsules USP are indicated for the prophylaxis of organ rejection in patients receiving allogeneic kidney transplants. It is recommended that Protopic be used concomitantly with azathioprine or mycophenolate mofetil (MMF) and adrenal corticosteroids . Therapeutic drug monitoring is recommended for all patients receiving Protopic Capsules USP .
1.2 Prophylaxis of Organ Rejection in Liver Transplant
Protopic Capsules USP are indicated for the prophylaxis of organ rejection in patients receiving allogeneic liver transplants. It is recommended that Protopic be used concomitantly with adrenal corticosteroids . Therapeutic drug monitoring is recommended for all patients receiving Protopic Capsules USP .
1.4 Limitations of Use
Protopic Capsules USP should not be used simultaneously with cyclosporine.
Protopic Injection should be reserved for patients unable to take Protopic Capsules USP orally .
Use with sirolimus is not recommended in liver transplant. The safety and efficacy of Tacrolimus with sirolimus has not been established in kidney transplant .
2 DOSAGE AND ADMINISTRATION
Summary of Initial Oral Dosage Recommendation and Observed Whole Blood Trough Concentrations.
2.1 Dosage in Adult Kidney or Liver Transplant Patients
The initial oral dosage recommendations for adult patients with kidney or liver transplants along with recommendations for whole blood trough concentrations are shown in Table 1. The initial dose of Protopic Capsules USP should be administered no sooner than 6 hours after transplantation in the liver transplant patients. In kidney transplant patients, the initial dose of Protopic Capsules USP may be administered within 24 hours of transplantation, but should be delayed until renal function has recovered. For blood concentration monitoring details see Dosage and Administration (2.6).
Dosing should be titrated based on clinical assessments of rejection and tolerability. Lower Protopic dosages than the recommended initial dosage may be sufficient as maintenance therapy. Adjunct therapy with adrenal corticosteroids is recommended early post-transplant.
The data in kidney transplant patients indicate that the Black patients required a higher dose to attain comparable trough concentrations compared to Caucasian patients (Table 2).
Initial Dose - Injection
Protopic injection should be used only as a continuous IV infusion and when the patient cannot tolerate oral administration of Protopic Capsules USP. Protopic injection should be discontinued as soon as the patient can tolerate oral administration of Protopic Capsules USP, usually within 2-3 days. In a patient receiving an IV infusion, the first dose of oral therapy should be given 8-12 hours after discontinuing the IV infusion.
The observed trough concentrations described above pertain to oral administration of Protopic Capsules USP only; while monitoring Protopic concentrations in patients receiving Protopic injection as a continuous IV infusion may have some utility, the observed concentrations will not represent comparable exposures to those estimated by the trough concentrations observed in patients on oral therapy.
The recommended starting dose of Protopic injection is 0.03-0.05 mg/kg/day in kidney and liver transplant given as a continuous IV infusion. Adult patients should receive doses at the lower end of the dosing range. Concomitant adrenal corticosteroid therapy is recommended early post-transplantation.
Anaphylactic reactions have occurred with injectables containing castor oil derivatives, such as Protopic injection .
2.2 Dosage in Pediatric Liver Transplant Patients
The initial oral dosage recommendations for pediatric patients with liver transplants along with recommendations for whole blood trough concentrations are shown in Table 3. For blood concentration monitoring details see Dosage and Administration (2.6). If necessary, pediatric patients may start on an IV dose of 0.03-0.05 mg/kg/day.
Pediatric liver transplantation patients without pre-existing renal or hepatic dysfunction have required and tolerated higher doses than adults to achieve similar blood concentrations.
Experience in pediatric kidney transplantation patients is limited.
2.3 Dosage Adjustment in Patients with Renal Impairment
Due to its potential for nephrotoxicity, consideration should be given to dosing Protopic Capsules USP at the lower end of the therapeutic dosing range in patients who have received a liver transplant and have pre-existing renal impairment. Further reductions in dose below the targeted range may be required.
In kidney transplant patients with post-operative oliguria, the initial dose of Protopic Capsules USP should be administered no sooner than 6 hours and within 24 hours of transplantation, but may be delayed until renal function shows evidence of recovery.
2.4 Dosage Adjustments in Patients with Hepatic Impairment
Due to the reduced clearance and prolonged half-life, patients with severe hepatic impairment may require lower doses of Protopic. Close monitoring of blood concentrations is warranted.
The use of Protopic Capsules USP in liver transplant recipients experiencing post-transplant hepatic impairment may be associated with increased risk of developing renal insufficiency related to high whole-blood concentrations of Protopic. These patients should be monitored closely and dosage adjustments should be considered. Some evidence suggests that lower doses should be used in these patients .
2.5 Administration Instructions
It is recommended that patients initiate oral therapy with Protopic Capsules USP if possible. Initial dosage and observed Protopic whole blood trough concentrations for adults are shown in Table 1 and for pediatrics in Table 3 ; for blood concentration monitoring details in kidney transplant patients .
It is important to take Protopic Capsules USP consistently every day either with or without food because the presence and composition of food decreases the bioavailability of Protopic .
Patients should not eat grapefruit or drink grapefruit juice in combination with Protopic .
Protopic Capsules USP should not be used simultaneously with cyclosporine. Protopic Capsules USP or cyclosporine should be discontinued at least 24 hours before initiating the other. In the presence of elevated Protopic or cyclosporine concentrations, dosing with the other drug usually should be further delayed.
In patients unable to take oral Protopic Capsules USP, therapy may be initiated with Protopic injection as a continuous IV infusion. If IV therapy is necessary, conversion from IV to oral Protopic Capsules USP is recommended as soon as oral therapy can be tolerated. This usually occurs within 2-3 days. In patients receiving an IV infusion, the first dose of oral therapy should be given 8-12 hours after discontinuing the IV infusion.
2.6 Therapeutic Drug Monitoring
Monitoring of Protopic blood concentrations in conjunction with other laboratory and clinical parameters is considered an essential aid to patient management for the evaluation of rejection, toxicity, dose adjustments and compliance. Observed whole blood trough concentrations can be found in Table 1. Factors influencing frequency of monitoring include but are not limited to hepatic or renal dysfunction, the addition or discontinuation of potentially interacting drugs and the post-transplant time. Blood concentration monitoring is not a replacement for renal and liver function monitoring and tissue biopsies. Data from clinical trials show that Protopic whole blood concentrations were most variable during the first week post-transplantation.
The relative risks of toxicity and efficacy failure are related to Protopic whole blood trough concentrations. Therefore, monitoring of whole blood trough concentrations is recommended to assist in the clinical evaluation of toxicity and efficacy failure.
Methods commonly used for the assay of Protopic include high performance liquid chromatography with tandem mass spectrometric detection (HPLC/MS/MS) and immunoassays. Immunoassays may react with metabolites as well as parent compound. Therefore assay results obtained with immunoassays may have a positive bias relative to results of HPLC/MS. The bias may depend upon the specific assay and laboratory. Comparison of the concentrations in published literature to patient concentrations using the current assays must be made with detailed knowledge of the assay methods and biological matrices employed. Whole blood is the matrix of choice and specimens should be collected into tubes containing ethylene diamine tetraacetic acid (EDTA) anti-coagulant. Heparin anti-coagulation is not recommended because of the tendency to form clots on storage. Samples which are not analyzed immediately should be stored at room temperature or in a refrigerator and assayed within 7 days; see assay instructions for specifics. If samples are to be kept longer they should be deep frozen at -20° C. One study showed drug recovery >90% for samples stored at -20° C for 6 months, with reduced recovery observed after 6 months.
3 DOSAGE FORMS AND STRENGTHS
Oblong shape, hard gelatin capsules for oral administration contains Protopic USP as follows:
Capsules: 0.5 mg, 1 mg and 5 mg (3)
Protopic capsule USP is contraindicated in patients with a hypersensitivity to Protopic. Protopic injection is contraindicated in patients with a hypersensitivity to HCO-60 (polyoxyl 60 hydrogenated castor oil) or any components of the formulation. Hypersensitivity symptoms reported include dyspnea, rash, pruritus, and acute respiratory distress syndrome .
Hypersensitivity to Protopic or HCO-60 (polyoxyl 60 hydrogenated castor oil) or any components of the formulation (4)
5 WARNINGS AND PRECAUTIONS
5.1 Management of Immunosuppression
Only physicians experienced in immunosuppressive therapy and management of organ transplant patients should use Protopic Capsules USP. Patients receiving the drug should be managed in facilities equipped and staffed with adequate laboratory and supportive medical resources. The physicians responsible for maintenance therapy should have complete information requisite for the follow up of the patient .
5.2 Lymphoma and Other Malignancies
Patients receiving immunosuppressants, including Protopic Capsules USP, are at increased risk of developing lymphomas and other malignancies, particularly of the skin . The risk appears to be related to the intensity and duration of immunosuppression rather than to the use of any specific agent.
As usual for patients with increased risk for skin cancer, exposure to sunlight and UV light should be limited by wearing protective clothing and using a sunscreen with a high protection factor.
Post transplant lymphoproliferative disorder has been reported in immunosuppressed organ transplant recipients. The majority of PTLD events appear related to Epstein Barr Virus (EBV) infection. The risk of PTLD appears greatest in those individuals who are EBV seronegative, a population which includes many young children.
5.3 Serious Infections
Patients receiving immunosuppressants, including Protopic Capsules USP, are at increased risk of developing bacterial, viral, fungal, and protozoal infections, including opportunistic infections . These infections may lead to serious, including fatal, outcomes. Because of the danger of oversuppression of the immune system which can increase susceptibility to infection, combination immunosuppressant therapy should be used with caution.
5.4 Polyoma Virus Infections
Patients receiving immunosuppressants, including Protopic Capsules USP, are at increased risk for opportunistic infections, including polyoma virus infections. Polyoma virus infections in transplant patients may have serious, and sometimes fatal, outcomes. These include polyoma virus-associated nephropathy, mostly due to BK virus infection, and JC virus-associated progressive multifocal leukoencephalopathy (PML) which have been observed in patients receiving Protopic .
PVAN is associated with serious outcomes, including deteriorating renal function and kidney graft loss . Patient monitoring may help detect patients at risk for PVAN.
Cases of PML have been reported in patients treated with Protopic Capsules USP. PML, which is sometimes fatal, commonly presents with hemiparesis, apathy, confusion, cognitive deficiencies and ataxia. Risk factors for PML include treatment with immunosuppressant therapies and impairment of immune function. In immunosuppressed patients, physicians should consider PML in the differential diagnosis in patients reporting neurological symptoms and consultation with a neurologist should be considered as clinically indicated.
Reductions in immunosuppression should be considered for patients who develop evidence of PVAN or PML. Physicians should also consider the risk that reduced immunosuppression represents to the functioning allograft.
5.5 Cytomegalovirus (CMV) Infections
Patients receiving immunosuppressants, including Protopic Capsules USP, are at increased risk of developing CMV viremia and CMV disease. The risk of CMV disease is highest among transplant recipients seronegative for CMV at time of transplant who receive a graft from a CMV seropositive donor. Therapeutic approaches to limiting CMV disease exist and should be routinely provided. Patient monitoring may help detect patients at risk for CMV disease. Consideration should be given to reducing the amount of immunosuppression in patients who develop CMV viremia and/or CMV disease.
5.6 New Onset Diabetes After Transplant
Protopic Capsules USP was shown to cause new onset diabetes mellitus in clinical trials of kidney and liver transplantation. New onset diabetes after transplantation may be reversible in some patients. Black and Hispanic kidney transplant patients are at an increased risk. Blood glucose concentrations should be monitored closely in patients using Protopic .
Protopic Capsules USP, like other calcineurin-inhibitors, can cause acute or chronic nephrotoxicity, particularly when used in high doses. Acute nephrotoxicity is most often related to vasoconstriction of the afferent renal arteriole, is characterized by increasing serum creatinine, hyperkalemia, and/or a decrease in urine output, and is typically reversible. Chronic calcineurin-inhibitor nephrotoxicity is associated with increased serum creatinine, decreased kidney graft life, and characteristic histologic changes observed on renal biopsy; the changes associated with chronic calcineurin-inhibitor nephrotoxicity are typically progressive. Patients with impaired renal function should be monitored closely as the dosage of Protopic Capsules USP may need to be reduced. In patients with persistent elevations of serum creatinine who are unresponsive to dosage adjustments, consideration should be given to changing to another immunosuppressive therapy.
Based on reported adverse reactions terms related to decreased renal function, nephrotoxicity was reported in approximately 52% of kidney transplantation patients and in 40% and 36% of liver transplantation patients receiving Protopic Capsules USP in the U.S. and European randomized trials, respectively .
Due to the potential for additive or synergistic impairment of renal function, care should be taken when administering Protopic Capsules USP with drugs that may be associated with renal dysfunction. These include, but are not limited to, aminoglycosides, ganciclovir, amphotericin B, cisplatin, nucleotide reverse transcriptase inhibitors (e.g., tenofovir) and protease inhibitors (e.g., ritonavir, indinavir). Similarly, care should be exercised when administering with CYP3A4 inhibitors such as antifungal drugs (e.g., ketoconazole), calcium channel blockers (e.g., diltiazem, verapamil), and macrolide antibiotics (e.g., clarithromycin, erythromycin, troleandomycin) which will result in increased Protopic whole blood concentrations due to inhibition of Protopic metabolism .
Protopic Capsules USP may cause a spectrum of neurotoxicities, particularly when used in high doses. The most severe neurotoxicities include posterior reversible encephalopathy syndrome, delirium, and coma. Patients treated with Protopic have been reported to develop PRES. Symptoms indicating PRES include headache, altered mental status, seizures, visual disturbances and hypertension. Diagnosis may be confirmed by radiological procedure. If PRES is suspected or diagnosed, blood pressure control should be maintained and immediate reduction of immunosuppression is advised. This syndrome is characterized by reversal of symptoms upon reduction or discontinuation of immunosuppression.
Coma and delirium, in the absence of PRES, have also been associated with high plasma concentrations of Protopic. Seizures have occurred in adult and pediatric patients receiving Protopic .
Less severe neurotoxicities, include tremors, parathesias, headache, and other changes in motor function, mental status, and sensory function . Tremor and headache have been associated with high whole-blood concentrations of Protopic and may respond to dosage adjustment.
Hyperkalemia has been reported with Protopic Capsules USP use. Serum potassium levels should be monitored. Careful consideration should be given prior to use of other agents also associated with hyperkalemia (e.g., potassium-sparing diuretics, ACE inhibitors, angiotensin receptor blockers) during Protopic therapy .
Hypertension is a common adverse effect of Protopic therapy and may require antihypertensive therapy . The control of blood pressure can be accomplished with any of the common antihypertensive agents, though careful consideration should be given prior to use of antihypertensive agents associated with hyperkalemia (e.g., potassium-sparing diuretics, ACE inhibitors, angiotensin receptor blockers) . Calcium-channel blocking agents may increase Protopic blood concentrations and therefore require dosage reduction of Protopic .
5.11 Anaphylactic Reactions with Protopic Injection
Anaphylactic reactions have occurred with injectables containing castor oil derivatives, including Protopic Capsules USP, in a small percentage of patients (0.6%). The exact cause of these reactions is not known. Protopic injection should be reserved for patients who are unable to take Protopic Capsules USP .
Patients receiving Protopic 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, the infusion should be stopped. An aqueous solution of epinephrine should be available at the bedside as well as a source of oxygen.
5.12 Use with Sirolimus
The safety and efficacy of Protopic with sirolimus has not been established in kidney transplant patients. Use of sirolimus with Protopic in studies of de novo liver transplant patients was associated with an excess mortality, graft loss, and hepatic artery thrombosis and is not recommended .
5.13 Use with CYP3A4 Inhibitors and Inducers
When coadministration Protopic with strong CYP3A4-inhibitors (e.g., telaprevir, boceprevir, ritonavir, ketoconazole, itraconazole, voriconazole, clarithromycin) and strong inducers (e.g., rifampin, rifabutin) adjustments in the dosing regimen of Protopic and subsequent frequent monitoring of Protopic whole blood trough concentrations and tacrolimus-associated adverse reactions are recommended .
5.14 QT Prolongation
Protopic may prolong the QT/QTc interval and may cause Torsade de Pointes. Avoid Protopic in patients with congenital long QT syndrome. In patients with congestive heart failure, bradyarrhythmias, those taking certain antiarrhythmic medications or other medicinal products that lead to QT prolongation, and those with electrolyte disturbances such as hypokalemia, hypocalcemia, or hypomagnesemia, consider obtaining electrocardiograms and monitoring electrolytes periodically during treatment.
When coadministering Protopic with other substrates and/or inhibitors of CYP3A4 that also have the potential to prolong the QT interval, a reduction in Protopic dose, frequent monitoring of Protopic whole blood concentrations, and monitoring for QT prolongation is recommended. Use of Protopic with amiodarone has been reported to result in increased Protopic whole blood concentrations with or without concurrent QT prolongation .
5.15 Myocardial Hypertrophy
Myocardial hypertrophy has been reported in infants, children, and adults, particularly those with high Protopic trough concentrations, and is generally manifested by echocardiographically demonstrated concentric increases in left ventricular posterior wall and interventricular septum thickness. This condition appears reversible in most cases following dose reduction or discontinuance of therapy. In patients who develop renal failure or clinical manifestations of ventricular dysfunction while receiving Protopic therapy, echocardiographic evaluation should be considered. If myocardial hypertrophy is diagnosed, dosage reduction or discontinuation of Protopic Capsules USP should be considered .
The use of live vaccines should be avoided during treatment with Protopic; examples include the following: intranasal influenza, measles, mumps, rubella, oral polio, BCG, yellow fever, varicella, and TY21a typhoid vaccines.
5.17 Pure Red Cell Aplasia
Cases of pure red cell aplasia (PRCA) have been reported in patients treated with Protopic. A mechanism for tacrolimus-induced PRCA has not been elucidated. All patients reported risk factors for PRCA such as parvovirus B19 infection, underlying disease, or concomitant medications associated with PRCA. If PRCA is diagnosed, discontinuation of Protopic Capsules USP should be considered .
5.18 Gastrointestinal Perforation
Gastrointestinal perforation has been reported in patients treated with Protopic; all reported cases were considered to be a complication of transplant surgery or accompanied by infection, diverticulum, or malignant neoplasm. As gastrointestinal perforation may be serious or life-threatening, appropriate medical/surgical management should be instituted promptly .
6 ADVERSE REACTIONS
The following serious and otherwise important adverse drug reactions are discussed in greater detail in other sections of labeling:
To report SUSPECTED ADVERSE REACTIONS, contact Panacea Biotec Global Pharmacovigilance Function at 1-877-687-4130 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.
6.1 Clinical Studies Experience
Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. In addition, the clinical trials were not designed to establish comparative differences across study arms with regards to the adverse reactions discussed below.
The incidence of adverse reactions was determined in three randomized kidney transplant trials. One of the trials used azathioprine and corticosteroids and two of the trials used mycophenolate mofetil (MMF) and corticosteroids concomitantly for maintenance immunosuppression.
Tacrolimus-based immunosuppression in conjunction with azathioprine and corticosteroids following kidney transplantation was assessed in trial where 205 patients received Protopic based immunosuppression and 207 patients received cyclosporine based immunosuppression. The trial population had a mean age of 43 years (mean±sd was 43±13 years on Protopic and 44±12 years on cyclosporine arm), the distribution was 61% male, and the composition was White (58%), Black (25%), Hispanic (12%) and Other (5%). The 12 month post-transplant information from this trial is presented below.
The most common adverse reactions (≥ 30%) observed in tacrolimus-treated kidney transplant patients are: infection, tremor, hypertension, abnormal renal function, constipation, diarrhea, headache, abdominal pain, insomnia, nausea, hypomagnesemia, urinary tract infection, hypophosphatemia, peripheral edema, asthenia, pain, hyperlipidemia, hyperkalemia and anemia.
Adverse reactions that occurred in ≥ 15% of kidney transplant patients treated with Protopic in conjunction with azathioprine are presented below:
Two trials were conducted for tacrolimus-based immunosuppression in conjunction with MMF and corticosteroids. In the non-US trial (Study 1), the incidence of adverse reactions was based on 1195 kidney transplant patients that received Protopic (Group C, n=403), or one of two cyclosporine (CsA) regimens (Group A, n=384 and Group B, n=408) in combination with MMF and corticosteroids; all patients, except those in one of the two cyclosporine groups, also received induction with daclizumab. The trial population had a mean age of 46 years (range 17 to 76), the distribution was 65% male, and the composition was 93% Caucasian. The 12 month post-transplant information from this trial is presented below.
Adverse reactions that occurred in ≥ 10% of kidney transplant patients treated with Protopic in conjunction with MMF in Study 1 [Note: This trial was conducted entirely outside of the United States. Such trials often report a lower incidence of adverse reactions in comparison to U.S. trials] are presented below:
In the U.S. trial (Study 2) with tacrolimus-based immunosuppression in conjunction with MMF and corticosteroids, 424 kidney transplant patients received Protopic (n=212) or cyclosporine (n=212) in combination with MMF 1 gram twice daily, basiliximab induction, and corticosteroids. The trial population had a mean age of 48 years (range 17 to 77), the distribution was 63% male, and the composition was White (74%), Black (20%), Asian (3%) and other (3%). The 12 month post-transplant information from this trial is presented below.
Adverse reactions that occurred in ≥15% of kidney transplant patients treated with Protopic in conjunction with MMF in Study 2 are presented below:
Less frequently observed adverse reactions in both liver transplantation and kidney transplantation patients are described under the subsection Less Frequently Reported Adverse Reactions .
There were two randomized comparative liver transplant trials. In the U.S. trial, 263 adult and pediatric patients received Protopic and steroids and 266 patients received cyclosporine-based immunosuppressive regimen (CsA/AZA). The trial population had a mean age of 44 years (range 0.4 to70), the distribution was 52% male, and the composition was White (78%), Black (5%), Asian (2%), Hispanic (13%) and Other (2%). In the European trial, 270 patients received Protopic and steroids and 275 patients received CsA/AZA. The trial population had a mean age of 46 years (range 15 to 68), the distribution was 59% male, and the composition was White (95.4%), Black (1%), Asian (2%) and Other (2%).
The proportion of patients reporting more than one adverse event was > 99% in both the Protopic group and the CsA/AZA group. Precautions must be taken when comparing the incidence of adverse reactions in the U.S. trial to that in the European trial. The 12-month post-transplant information from the U.S. trial and from the European trial is presented below. The two trials also included different patient populations and patients were treated with immunosuppressive regimens of differing intensities. Adverse reactions reported in ≥15% in Protopic patients (combined trial results) are presented below for the two controlled trials in liver transplantation.
The most common adverse reactions (≥40%) observed in Tacrolimus-treated liver transplant patients are: tremor, headache, diarrhea, hypertension, nausea, abnormal renal function, abdominal pain, insomnia, paresthesia, anemia, pain, fever, asthenia, hyperkalemia, hypomagnesemia, and hyperglycemia. These all occur with oral and IV administration of Protopic and some may respond to a reduction in dosing (e.g., tremor, headache, paresthesia, hypertension). Diarrhea was sometimes associated with other gastrointestinal complaints such as nausea and vomiting.
Less frequently observed adverse reactions in both liver transplantation and kidney transplantation patients are described under the subsection Less Frequently Reported Adverse Reactions .
Other targeted treatment-emergent adverse reactions in tacrolimus-treated patients occurred at a rate of less than 15%, and include the following: Cushingoid features, impaired wound healing, hyperkalemia, Candida infection, and CMV infection/syndrome.
New Onset Diabetes After Transplant
New Onset Diabetes After Transplant is defined as a composite of fasting plasma glucose ≥126 mg/dL, HbA1C ≥ 6%, insulin use ≥ 30 days or oral hypoglycemic use. In a trial in kidney transplant patients (Study 2), NODAT was observed in 75% in the tacrolimus-treated and 61% in the Neoral-treated patients without pre-transplant history of diabetes mellitus (Table 8) .
In early trials of Protopic, Post-Transplant Diabetes Mellitus (PTDM) was evaluated with a more limited criteria of “use of insulin for 30 or more consecutive days with < 5 day gap” in patients without a prior history of insulin-dependent diabetes mellitus or non-insulin dependent diabetes mellitus. Data are presented in Tables 9 to 11. PTDM was reported in 20% of Tacrolimus/Azathioprine (AZA)-treated kidney transplant patients without pre-transplant history of diabetes mellitus in a Phase 3 trial (Table 9). The median time to onset of PTDM was 68 days. Insulin dependence was reversible in 15% of these PTDM patients at one year and in 50% at 2 years post-transplant. Black and Hispanic kidney transplant patients were at an increased risk of development of PTDM (Table 10).
Insulin-dependent PTDM was reported in 18% and 11% of tacrolimus-treated liver transplant patients and was reversible in 45% and 31% of these patients at 1 year post-transplant, in the U.S. and European randomized trials, respectively, (Table 11). Hyperglycemia was associated with the use of Protopic Capsules USP in 47% and 33% of liver transplant recipients in the U.S. and European randomized trials, respectively, and may require treatment .
Less Frequently Reported Adverse Reactions
The following adverse reactions were reported in either liver and/or kidney transplant recipients who were treated with Protopic in clinical trials.
Abnormal dreams, agitation, amnesia, anxiety, confusion, convulsion, crying, depression, elevated mood, emotional lability, encephalopathy, haemorrhagic stroke, hallucinations, hypertonia, incoordination, monoparesis, myoclonus, nerve compression, nervousness, neuralgia, neuropathy, paralysis flaccid, psychomotor skills impaired, psychosis, quadriparesis, somnolence, thinking abnormal, vertigo, writing impaired
Abnormal vision, amblyopia, ear pain, otitis media, tinnitus
Cholangitis, cholestatic jaundice, duodenitis, dysphagia, esophagitis, flatulence, gastritis, gastroesophagitis, gastrointestinal hemorrhage, GGT increase, GI disorder, GI perforation, hepatitis, hepatitis granulomatous, ileus, increased appetite, jaundice, liver damage, oesophagitis ulcerative, oral moniliasis, pancreatic pseudocyst, rectal disorder, stomatitis
Abnormal ECG, angina pectoris, arrhythmia, atrial fibrillation, atrial flutter, bradycardia, cardiac fibrillation, cardiopulmonary failure, cardiovascular disorder, congestive heart failure, deep thrombophlebitis, echocardiogram abnormal, electrocardiogram QRS complex abnormal, electrocardiogram ST segment abnormal, heart failure, heart rate decreased, hemorrhage, hypotension, peripheral vascular disorder, phlebitis, postural hypotension, syncope, tachycardia, thrombosis, vasodilatation
Acute kidney failure, albuminuria, BK nephropathy, bladder spasm, cystitis, dysuria, hematuria, hydronephrosis, kidney failure, kidney tubular necrosis, nocturia, pyuria, toxic nephropathy, urge incontinence, urinary frequency, urinary incontinence, urinary retention, vaginitis
Acidosis, alkaline phosphatase increased, alkalosis, ALT (SGPT) increased, AST (SGOT) increased, bicarbonate decreased, bilirubinemia, dehydration, GGT increased, gout, healing abnormal, hypercalcemia, hypercholesterolemia, hyperphosphatemia, hyperuricemia, hypervolemia, hypocalcemia, hypoglycemia, hyponatremia, hypoproteinemia, lactic dehydrogenase increase, weight gain
Coagulation disorder, ecchymosis, haematocrit increased, haemoglobin abnormal, hypochromic anemia, leukocytosis, polycythemia, prothrombin decreased, serum iron decreased
Abdomen enlarged, abscess, accidental injury, allergic reaction, cellulitis, chills, fall, feeling abnormal, flu syndrome, generalized edema, hernia, mobility decreased, peritonitis, photosensitivity reaction, sepsis, temperature intolerance, ulcer
Arthralgia, cramps, generalized spasm, joint disorder, leg cramps, myalgia, myasthenia, osteoporosis
Asthma, emphysema, hiccups, lung disorder, lung function decreased, pharyngitis, pneumonia, pneumothorax, pulmonary edema, respiratory disorder, rhinitis, sinusitis, voice alteration
Acne, alopecia, exfoliative dermatitis, fungal dermatitis, herpes simplex, herpes zoster, hirsutism, neoplasm skin benign, skin discoloration, skin disorder, skin ulcer, sweating
6.2 Postmarketing Adverse Reactions
The following adverse reactions have been reported from worldwide marketing experience with Protopic. Because these reactions are reported voluntarily from a population of uncertain size it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. Decisions to include these reactions in labeling are typically based on one or more of the following factors: seriousness of the reaction, (2) frequency of the reporting, or (3) strength of causal connection to the drug.
Other reactions include:
Atrial fibrillation, atrial flutter, cardiac arrhythmia, cardiac arrest, electrocardiogram T wave abnormal, flushing, myocardial infarction, myocardial ischaemia, pericardial effusion, QT prolongation, Torsade de Pointes, venous thrombosis deep limb, ventricular extrasystoles, ventricular fibrillation, myocardial hypertrophy .
Bile duct stenosis, colitis, enterocolitis, gastroenteritis, gastrooesophageal reflux disease, hepatic cytolysis, hepatic necrosis, hepatotoxicity, impaired gastric emptying, liver fatty, mouth ulceration, pancreatitis haemorrhagic, pancreatitis necrotizing, stomach ulcer, venoocclusive liver disease
Agranulocytosis, disseminated intravascular coagulation, hemolytic anemia, neutropenia, pancytopenia, thrombocytopenic purpura, thrombotic thrombocytopenic purpura, pure red cell aplasia
Cases of progressive multifocal leukoencephalopathy (PML), sometimes fatal; -polyoma virus-associated nephropathy, (PVAN) including graft loss
Glycosuria, increased amylase including pancreatitis, weight decreased
Feeling hot and cold, feeling jittery, hot flushes, multi-organ failure, primary graft dysfunction
Carpal tunnel syndrome, cerebral infarction, hemiparesis, leukoencephalopathy, mental disorder, mutism, posterior reversible encephalopathy syndrome , progressive multifocal leukoencephalopathy (PML) , quadriplegia, speech disorder, syncope
Acute respiratory distress syndrome, interstitial lung disease, lung infiltration, respiratory distress, respiratory failure
Stevens-Johnson syndrome, toxic epidermal necrolysis
Blindness, blindness cortical, hearing loss including deafness, photophobia
Acute renal failure, cystitis haemorrhagic, hemolytic-uremic syndrome, micturition disorder
7 DRUG INTERACTIONS
Since Protopic is metabolized mainly by CYP3A enzymes, drugs or substances known to inhibit these enzymes may increase Protopic whole blood concentrations. Drugs known to induce CYP3A enzymes may decrease Protopic whole blood concentrations . Dose adjustments may be needed along with frequent monitoring of Protopic whole blood trough concentrations when Protopic is administered with CYP3A inhibitors or inducers. In addition, patients should be monitored for adverse reactions including changes in renal function and QT prolongation .
7.1 Mycophenolic Acid Products
With a given dose of mycophenolic acid (MPA) products, exposure to MPA is higher with Protopic Capsules USP co-administration than with cyclosporine co-administration because cyclosporine interrupts the enterohepatic recirculation of MPA while Protopic does not. Clinicians should be aware that there is also a potential for increased MPA exposure after crossover from cyclosporine to Protopic in patients concomitantly receiving MPA-containing products.
7.2 Grapefruit Juice
Grapefruit juice inhibits CYP3A-enzymes resulting in increased Protopic whole blood trough concentrations, and patients should avoid eating grapefruit or drinking grapefruit juice with Protopic .
7.3 Protease Inhibitors
Most protease inhibitors inhibit CYP3A enzymes and may increase Protopic whole blood concentrations. It is recommended to avoid concomitant use of Protopic with nelfinavir unless the benefits outweigh the risks . Whole blood concentrations of Protopic are markedly increased when co-administered with telaprevir or with boceprevir . Monitoring of Protopic whole blood concentrations and tacrolimus-associated adverse reactions, and appropriate adjustments in the dosing regimen are recommended when Protopic and other protease inhibitors (e.g., ritonavir, telaprevir, boceprevir) are used concomitantly.
7.4 Antifungal Agents
Frequent monitoring of whole blood concentrations and appropriate dosage adjustments of Protopic are recommended when concomitant use of the following antifungal drugs with Protopic is initiated or discontinued .
Azoles: Voriconazole, posaconazole, itraconazole, ketoconazole, fluconazole and clotrimazole inhibit CYP3A metabolism of Protopic and increase Protopic whole blood concentrations. When initiating therapy with voriconazole or posaconazole in patients already receiving Protopic, it is recommended that the Protopic dose be initially reduced to one-third of the original dose and the subsequent Protopic doses be adjusted based on the Protopic whole blood concentrations.
Caspofungin is an inducer of CYP3A and decreases whole blood concentrations of Protopic.
7.5 Calcium Channel Blockers
Verapamil, diltiazem, nifedipine, and nicardipine inhibit CYP3A metabolism of Protopic and may increase Protopic whole blood concentrations. Monitoring of whole blood concentrations and appropriate dosage adjustments of Protopic are recommended when these calcium channel blocking drugs and Protopic are used concomitantly.
Erythromycin, clarithromycin, troleandomycin and chloramphenicol inhibit CYP3A metabolism of Protopic and may increase Protopic whole blood concentrations. Monitoring of blood concentrations and appropriate dosage adjustments of Protopic are recommended when these drugs and Protopic are used concomitantly.
Rifampin and rifabutin are inducers of CYP3A enzymes and may decrease Protopic whole blood concentrations. Monitoring of whole blood concentrations and appropriate dosage adjustments of Protopic are recommended when these antimycobacterial drugs and Protopic are used concomitantly.
Phenytoin, carbamazepine and phenobarbital induce CYP3A enzymes and may decrease Protopic whole blood concentrations. Monitoring of whole blood concentrations and appropriate dosage adjustments of Protopic are recommended when these drugs and Protopic are used concomitantly. Concomitant administration of phenytoin with Protopic may also increase phenytoin plasma concentrations. Thus, frequent monitoring phenytoin plasma concentrations and adjusting the phenytoin dose as needed are recommended when Protopic and phenytoin are administered concomitantly.
7.9 St. John’s Wort
St. John’s Wort induces CYP3A enzymes and may decrease Protopic whole blood concentrations. Monitoring of whole blood concentrations and appropriate dosage adjustments of Protopic are recommended when St. John’s Wort and Protopic are co-administered.
7.10 Gastric Acid Suppressors/Neutralizers
Lansoprazole and omeprazole, as CYP2C19 and CYP3A4 substrates, may potentially inhibit the CYP3A4 metabolism of Protopic and thereby substantially increase Protopic whole blood concentrations, especially in transplant patients who are intermediate or poor CYP2C19 metabolizers, as compared to those patients who are efficient CYP2C19 metabolizers. Cimetidine may also inhibit the CYP3A4 metabolism of Protopic and thereby substantially increase Protopic whole blood concentrations.
Coadministration with magnesium and aluminum hydroxide antacids increase Protopic whole blood concentrations . Monitoring of whole blood concentrations and appropriate dosage adjustments of Protopic are recommended when these drugs and Protopic are used concomitantly.
Bromocriptine, nefazodone, metoclopramide, danazol, ethinyl estradiol, amiodarone and methylprednisolone may inhibit CYP3A metabolism of Protopic and increase Protopic whole blood concentrations. Monitoring of blood concentrations and appropriate dosage adjustments of Protopic are recommended when these drugs and Protopic are co-administered.
8 USE IN SPECIFIC POPULATIONS
See 17 for PATIENT COUNSELING INFORMATION
Pregnancy Category C - There are no adequate and well-controlled studies in pregnant women. Protopic is transferred across the placenta. The use of Protopic during pregnancy in humans has been associated with neonatal hyperkalemia and renal dysfunction. Protopic given orally to pregnant rabbits at 0.5 to 4.3 times the clinical dose and pregnant rats at 0.8 to 6.9 times the clinical dose was associated with an increased incidence of fetal death in utero, fetal malformations (cardiovascular, skeletal, omphalocele, and gallbladder agenesis) and maternal toxicity. Protopic Capsules USP should be used during pregnancy only if the potential benefit to the mother justifies the potential risk to the fetus.
In pregnant rabbits, Protopic at oral doses of 0.32 and 1.0 mg/kg, 0.5 to 4.3 times the clinical dose range (0.075 – 0.2 mg/kg) based on body surface area, was associated with maternal toxicity as well as an increased incidence of abortions. At the 1 mg/kg dose, fetal rabbits showed an increased incidence of malformations (ventricular hypoplasia, interventricular septal defect, bulbous aortic arch, stenosis of ductus arteriosis, interrupted ossification of vertebral arch, vertebral and rib malformations, omphalocele, and gallbladder agenesis) and developmental variations. In pregnant rats, Protopic at oral doses of 3.2 mg/kg, 2.6 to 6.9 times the clinical dose range was associated with maternal toxicity, an increase in late resorptions, decreased numbers of live births, and decreased pup weight and viability. Protopic, given orally to pregnant rats after organogenesis and during lactation at 1.0 and 3.2 mg/kg, 0.8 to 6.9 times the recommended clinical dose range was associated with reduced pup weights and pup viability (3.2 mg/kg only); among the high dose pups that died early, an increased incidence of kidney hydronephrosis was observed.
8.3 Nursing Mothers
Protopic is excreted in human milk. As the effect of chronic exposure to Protopic in healthy infants is not established, patients maintained on Protopic should discontinue nursing taking into consideration importance of drug to the mother.
8.4 Pediatric Use
The safety and efficacy of Protopic Capsules USP in pediatric kidney transplant patients have not been established. Successful liver transplants have been performed in pediatric patients using Protopic Capsules USP. Two randomized active controlled trials of Protopic Capsules USP in primary liver transplantation included 56 pediatric patients. Thirty-one patients were randomized to tacrolimus-based and 25 to cyclosporine-based therapies. Additionally, a minimum of 122 pediatric patients were studied in an uncontrolled trial of Protopic in living related donor liver transplantation. Pediatric patients generally required higher doses of Protopic Capsules USP to maintain blood trough concentrations of Protopic similar to adult patients .
8.5 Geriatric Use
Clinical trials of Protopic Capsules USP did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. Other reported clinical experience has not identified differences in responses between the elderly and younger patients. In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic and renal function, and of concomitant disease or other drug therapy.
8.6 Use in Renal Impairment
The pharmacokinetics of Protopic in patients with renal impairment was similar to that in healthy volunteers with normal renal function. However, consideration should be given to dosing Protopic Capsules USP at the lower end of the therapeutic dosing range in patients who have received a liver transplant and have pre-existing renal impairment. Further reductions in dose below the targeted range may be required .
8.7 Use in Hepatic Impairment
The mean clearance of Protopic was substantially lower in patients with severe hepatic impairment (mean Child-Pugh score: >10) compared to healthy volunteers with normal hepatic function. Close monitoring of Protopic trough concentrations is warranted in patients with hepatic impairment .
The use of Protopic Capsules USP in liver transplant recipients experiencing post-transplant hepatic impairment may be associated with increased risk of developing renal insufficiency related to high whole-blood trough concentrations of Protopic. These patients should be monitored closely and dosage adjustments should be considered. Some evidence suggests that lower doses should be used in these patients .
Limited overdosage experience is available. Acute overdosages of up to 30 times the intended dose have been reported. Almost all cases have been asymptomatic and all patients recovered with no sequelae. Acute overdosage was sometimes followed by adverse reactions consistent with those listed in Adverse Reactions (6) (including tremors, abnormal renal function, hypertension, and peripheral edema); in one case of acute overdosage, transient urticaria and lethargy were observed. Based on the poor aqueous solubility and extensive erythrocyte and plasma protein binding, it is anticipated that Protopic is not dialyzable to any significant extent; there is no experience with charcoal hemoperfusion. The oral use of activated charcoal has been reported in treating acute overdoses, but experience has not been sufficient to warrant recommending its use. General supportive measures and treatment of specific symptoms should be followed in all cases of overdosage.
In acute oral studies, mortalities were seen at or above the following doses: in adult rats, 52 times the recommended human oral dose; in immature rats, 16 times the recommended oral dose; (all based on body surface area corrections).
Protopic is available for oral administration as capsules (Tacrolimus Capsules USP) containing the equivalent of 0.5 mg, 1 mg or 5 mg of Protopic USP. Inactive ingredients include anhydrous lactose, hypromellose 2910, croscarmellose sodium, and magnesium stearate. The 0.5 mg capsule shell contains gelatin, titanium dioxide and ferric oxide, the 1 mg capsule shell contains gelatin and titanium dioxide, and the 5 mg capsule shell contains gelatin, titanium dioxide and ferric oxide.
Protopic, previously known as FK506, is the active ingredient in Protopic Capsules USP. Protopic is a macrolide immunosuppressant produced by Streptomyces tsukubaensis. Chemically, Protopic is designated as [3S-[3R*[E(1S*,3S*,4S*)], 4S*,5R*,8S*,9E,12R*, 14R*,15S*,16R*,18S*,19S*,26aR*]]-5,6,8,11,12,13,14,15,16,17,18,19,24,25,26,26a-hexadecahydro-5,19-dihydroxy-3-[2-(4-hydroxy-3-methoxycyclohexyl)-1-methylethenyl]-14,16- dimethoxy-4,10,12,18-tetramethyl-8-(2-propenyl)-15,19-epoxy-3H-pyrido[2,1-c][1,4] oxaazacyclotricosine-1,7,20,21(4H,23H)-tetrone, monohydrate.
The chemical structure of Protopic USP is:
Protopic USP has a molecular formula of C44H69NO12-H2O and a formula weight of 822.03. Protopic appears as white to off white powder. It is soluble in acetone, chloroform, ethyl acetate and insoluble in water.
The Dissolution Test criteria of Protopic Capsules USP as outlined below:
Protopic Capsules USP comply with USP Organic Impurities test criteria as outlined below:
12 CLINICAL PHARMACOLOGY
12.1 Mechanism of Action
Protopic inhibits T-lymphocyte activation, although the exact mechanism of action is not known. Experimental evidence suggests that Protopic binds to an intracellular protein, FKBP-12.A complex of tacrolimus-FKBP-12, calcium, calmodulin, and calcineurin is then formed and the phosphatase activity of calcineurin inhibited. This effect may prevent the dephosphorylation and translocation of nuclear factor of activated T-cells, a nuclear component thought to initiate gene transcription for the formation of lymphokines (such as interleukin-2, gamma interferon). The net result is the inhibition of T-lymphocyte activation (i.e., immunosuppression).
Protopic prolongs the survival of the host and transplanted graft in animal transplant models of liver, kidney, bone marrow, small bowel and pancreas, lung and trachea, skin, cornea, and limb.
In animals, Protopic has been demonstrated to suppress some humoral immunity and, to a greater extent, cell-mediated reactions such as allograft rejection, delayed type hypersensitivity, collagen-induced arthritis, experimental allergic encephalomyelitis, and graft versus host disease.
Protopic activity is primarily due to the parent drug. The pharmacokinetic parameters (mean±S.D.) of Protopic have been determined following oral (PO) administration in healthy volunteers, and in kidney transplant and liver transplant patients (Table 12).
Due to intersubject variability in Protopic pharmacokinetics, individualization of dosing regimen is necessary for optimal therapy . Pharmacokinetic data indicate that whole blood concentrations rather than plasma concentrations serve as the more appropriate sampling compartment to describe Protopic pharmacokinetics.
Absorption of Protopic from the gastrointestinal tract after oral administration is incomplete and variable. The absolute bioavailability of Protopic was 17±10% in adult kidney transplant patients, 22±6% in adult liver transplant patients (N=17), and 18±5% in healthy volunteers (N=16).
A single dose trial conducted in 32 healthy volunteers established the bioequivalence of the 1 mg and 5 mg capsules. Another single dose trial in 32 healthy volunteers established the bioequivalence of the 0.5 mg and 1 mg capsules. Protopic maximum blood concentrations (Cmax) and area under the curve (AUC) appeared to increase in a doseproportional fashion in 18 fasted healthy volunteers receiving a single oral dose of 3, 7, and 10 mg.
In 18 kidney transplant patients, Protopic trough concentrations from 3 to 30 ng/mL measured at 10-12 hours post-dose (Cmin) correlated well with the AUC (correlation coefficient 0.93). In 24 liver transplant patients over a concentration range of 10 to 60 ng/mL, the correlation coefficient was 0.94.
The rate and extent of Protopic absorption were greatest under fasted conditions. The presence and composition of food decreased both the rate and extent of Protopic absorption when administered to 15 healthy volunteers.
The effect was most pronounced with a high-fat meal (848 kcal, 46% fat): mean AUC and Cmax were decreased 37% and 77%, respectively; Tmax was lengthened 5-fold. A high-carbohydrate meal (668 kcal, 85% carbohydrate) decreased mean AUC and mean Cmax by 28% and 65%, respectively.
In healthy volunteers (N=16), the time of the meal also affected Protopic bioavailability. When given immediately following the meal, mean Cmax was reduced 71%, and mean AUC was reduced 39%, relative to the fasted condition. When administered 1.5 hours following the meal, mean Cmax was reduced 63%, and mean AUC was reduced 39%, relative to the fasted condition.
In 11 liver transplant patients, Protopic Capsules USP administered 15 minutes after a high fat (400 kcal, 34% fat) breakfast, resulted in decreased AUC (27±18%) and Cmax (50±19%), as compared to a fasted state.
Protopic Capsules USP should be taken consistently every day either with or without food because the presence and composition of food decreases the bioavailability of Protopic .
The plasma protein binding of Protopic is approximately 99% and is independent of concentration over a range of 5-50 ng/mL. Protopic is bound mainly to albumin and alpha-1-acid glycoprotein, and has a high level of association with erythrocytes. The distribution of Protopic between whole blood and plasma depends on several factors, such as hematocrit, temperature at the time of plasma separation, drug concentration, and plasma protein concentration. In a U.S. trial, the ratio of whole blood concentration to plasma concentration averaged 35.
Protopic is extensively metabolized by the mixed-function oxidase system, primarily the cytochrome P-450 system (CYP3A). A metabolic pathway leading to the formation of 8 possible metabolites has been proposed. Demethylation and hydroxylation were identified as the primary mechanisms of biotransformation in vitro. The major metabolite identified in incubations with human liver microsomes is 13-demethyl Protopic. In in vitro studies, a 31-demethyl metabolite has been reported to have the same activity as Protopic.
The mean clearance following IV administration of Protopic is 0.040, 0.083, and 0.053, and 0.051 L/hr/kg in healthy volunteers, adult kidney transplant patients and adult liver transplant patients respectively. In man, less than 1% of the dose administered is excreted unchanged in urine.
In a mass balance study of IV administered radiolabeled Protopic to 6 healthy volunteers, the mean recovery of radiolabel was 77.8±12.7%. Fecal elimination accounted for 92.4±1.0% and the elimination half-life based on radioactivity was 48.1±15.9 hours whereas it was 43.5±11.6 hours based on Protopic concentrations. The mean clearance of radiolabel was 0.029±0.015 L/hr/kg and clearance of Protopic was 0.029±0.009 L/hr/kg. When administered PO, the mean recovery of the radiolabel was 94.9±30.7%. Fecal elimination accounted for 92.6±30.7%, urinary elimination accounted for 2.3±1.1% and the elimination half-life based on radioactivity was 31.9±10.5 hours whereas it was 48.4±12.3 hours based on Protopic concentrations. The mean clearance of radiolabel was 0.226±0.116 L/hr/kg and clearance of Protopic 0.172±0.088 L/hr/kg.
Pharmacokinetics of Protopic have been studied in liver transplantation patients, 0.7 to 13.2 years of age. Following IV administration of a 0.037 mg/kg/day dose to 12 pediatric patients, mean terminal half-life, volume of distribution and clearance were 11.5±3.8 hours, 2.6±2.1 L/kg and 0.138±0.071 L/hr/kg, respectively. Following oral administration to 9 patients, mean AUC and Cmax were 337±167 ng·hr/mL and 48.4±27.9 ng/mL, respectively. The absolute bioavailability was 31±24%.
Whole blood trough concentrations from 31 patients less than 12 years old showed that pediatric patients needed higher doses than adults to achieve similar Protopic trough concentrations .
Pharmacokinetics of Protopic have also been studied in kidney transplantation patients, 8.2±2.4 years of age. Following IV infusion of a 0.06 (range 0.06 – 0.09) mg/kg/day to 12 pediatric patients (8 male and 4 female), mean terminal half-life and clearance were 10.2±5.0 (range 3.4-25) hours and 0.12±0.04 (range 0.06-0.17) L/hr/kg, respectively. Following oral administration to the same patients, mean AUC and Cmax were 181±65 (range 81-300) ng·hr/mL and 30±11 (range 14-49) ng/mL, respectively. The absolute bioavailability was 19±14 (range 5.2-56) %.
Renal and Hepatic Impairment
The mean pharmacokinetic parameters for Protopic following single administrations to patients with renal and hepatic impairment are given in Table 13.
Protopic pharmacokinetics following a single IV administration were determined in 12 patients prior to their kidney transplant. The pharmacokinetic parameters obtained were similar for both groups. The mean clearance of Protopic in patients with renal dysfunction was similar to that in normal volunteers (Table 13) .
Protopic pharmacokinetics have been determined in six patients with mild hepatic dysfunction (mean Pugh score: 6.2) following single IV and oral administrations. The mean clearance of Protopic in patients with mild hepatic dysfunction was not substantially different from that in normal volunteers. Protopic pharmacokinetics were studied in 6 patients with severe hepatic dysfunction (mean Pugh score: >10). The mean clearance was substantially lower in patients with severe hepatic dysfunction, irrespective of the route of administration .
The pharmacokinetics of Protopic have been studied following single IV and oral administration of Protopic Capsules USP to 10 African-American, 12 Latino-American, and 12 Caucasian healthy volunteers. There were no significant pharmacokinetic differences among the three ethnic groups following a 4-hour IV infusion of 0.015 mg/kg. However, after single oral administration of 5 mg, mean Protopic Cmax in African-Americans (23.6±12.1 ng/mL) was significantly lower than in Caucasians (40.2±12.6 ng/mL) and the Latino-Americans (36.2±15.8 ng/mL) (p<0.01). Mean AUC0-inf tended to be lower in African-Americans (203±115 ng·hr/mL) than Caucasians (344±186 ng·hr/mL) and Latino- Americans (274±150 ng·hr/mL). The mean (±SD) absolute oral bioavailability (F) in African-Americans (12±4.5%) and Latino-Americans (14±7.4%) was significantly lower than in Caucasians (19±5.8%, p=0.011). There was no significant difference in mean terminal T1/2 among the three ethnic groups (range from approximately 25 to 30 hours). A retrospective comparison of African-American and Caucasian kidney transplant patients indicated that African-American patients required higher Protopic doses to attain similar trough concentrations
A formal trial to evaluate the effect of gender on Protopic pharmacokinetics has not been conducted, however, there was no difference in dosing by gender in the kidney transplant trial. A retrospective comparison of pharmacokinetics in healthy volunteers, and in kidney and liver transplant patients indicated no gender-based differences.
Frequent monitoring of whole blood concentrations and appropriate dosage adjustments of Protopic are recommended when concomitant use of the following drugs with Protopic is initiated or discontinued .
In a single dose study in 9 healthy volunteers, coadministration of Protopic (0.5 mg single dose) with telaprevir (750 mg three times daily for 13 days) increased the Protopic dose-normalized Cmax by 9.3-fold and AUC by 70-fold compared to Protopic alone .
In a single dose study in 12 subjects, coadministration of Protopic with boceprevir (800 mg three times daily for 11 days) increased Protopic Cmax by 9.9-fold and AUC by 17-fold compared to Protopic alone .
Based on a clinical study of 5 liver transplant recipients, co-administration of Protopic with nelfinavir increased blood concentrations of Protopic significantly and, as a result, a reduction in the Protopic dose by an average of 16-fold was needed to maintain mean trough Protopic blood concentrations of 9.7 ng/mL. It is recommended to avoid concomitant use of Protopic Capsules USP and nelfinavir unless the benefits outweigh the risks .
In a study of 6 normal volunteers, a significant decrease in Protopic oral bioavailability was observed with concomitant rifampin administration (600 mg). In addition, there was a significant increase in Protopic clearance (0.036±0.008 L/hr/kg vs. 0.053±0.010 L/hr/kg) with concomitant rifampin administration .
In a single-dose crossover study in healthy volunteers, co-administration of Protopic and magnesium-aluminum-hydroxide resulted in a 21% increase in the mean Protopic AUC and a 10% decrease in the mean Protopic Cmax relative to Protopic administration alone .
In a study of 6 normal volunteers, a significant increase in Protopic oral bioavailability was observed with concomitant ketoconazole administration (200 mg). The apparent oral clearance of Protopic during ketoconazole administration was significantly decreased compared to Protopic alone (0.430±0.129 L/hr/kg vs.0.148±0.043 L/hr/kg) .
Voriconazole (see complete prescribing information for VFEND®)
Repeat oral dose administration of voriconazole (400 mg every 12 hours for one day, then 200 mg every 12 hours for 6 days) increased Protopic (0.1 mg/kg single dose) Cmax and AUCτ in healthy subjects by an average of 2-fold (90% CI: 1.9, 2.5) and 3-fold (90% CI: 2.7, 3.8), respectively .
Repeat oral administration of posaconazole (400 mg twice daily for 7 days) increased Protopic (0.05 mg/kg single dose) Cmax and AUC in healthy subjects by an average of 2-fold (90% CI: 2.01, 2.42) and 4.5-fold (90% CI 4.03, 5.19), respectively .
Caspofungin reduced the blood AUC0-12 of Protopic by approximately 20%, peak blood concentration (Cmax) by 16%, and 12-hour blood concentration (C12hr) by 26% in healthy adult subjects when Protopic (2 doses of 0.1 mg/kg 12 hours apart) was administered on the 10th day of CANCIDAS® 70 mg daily, as compared to results from a control period in which Protopic was administered alone .
13 NONCLINICAL TOXICOLOGY
13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility
Carcinogenicity studies were conducted in male and female rats and mice. In the 80-week mouse oral study and in the 104-week rat oral study, no relationship of tumor incidence to Protopic dosage was found. The highest dose used in the mouse was 3.0 mg/kg/day (0.9 to 2.2 times the AUC at clinical doses of 0.075 to 0.2 mg/kg/day) and in the rat was 5.0 mg/kg/day (0.265 to 0.65 times the AUC at clinical doses of 0.075 to 0.2 mg/kg/day) .
A 104-week dermal carcinogenicity study was performed in mice with Protopic ointment (0.03% - 3%), equivalent to Protopic doses of 1.1-118 mg/kg/day or 3.3-354 mg/m2/day. In the study, the incidence of skin tumors was minimal and the topical application of Protopic was not associated with skin tumor formation under ambient room lighting. However, a statistically significant elevation in the incidence of pleomorphic lymphoma in high dose male (25/50) and female animals (27/50) and in the incidence of undifferentiated lymphoma in high dose female animals (13/50) was noted in the mouse dermal carcinogenicity study. Lymphomas were noted in the mouse dermal carcinogenicity study at a daily dose of 3.5 mg/kg (0.1% Protopic ointment). No drug-related tumors were noted in the mouse dermal carcinogenicity study at a daily dose of 1.1 mg/kg (0.03% Protopic ointment). The relevance of topical administration of Protopic in the setting of systemic Protopic use is unknown.
The implications of these carcinogenicity studies to the human condition are limited; doses of Protopic were administered that likely induced immunosuppression in these animals impairing their immune system’s ability to inhibit unrelated carcinogenesis.
No evidence of genotoxicity was seen in bacterial (Salmonella and E. coli) or mammalian (Chinese hamster lung-derived cells) in vitro assays of mutagenicity, the in vitro CHO/HGPRT assay of mutagenicity, or in vivo clastogenicity assays performed in mice; Protopic did not cause unscheduled DNA synthesis in rodent hepatocytes.
Protopic given orally at 1.0 mg/kg (0.8 to 2.2 times the clinical dose range of 0.075 to 0.2 mg/kg/day based on body surface area) to male and female rats, prior to and during mating, as well as to dams during gestation and lactation, was associated with embryolethality and adverse effects on female reproduction. Effects on female reproductive function (parturition) and embryolethal effects were indicated by a higher rate of pre-implantation loss and increased numbers of undelivered and nonviable pups. When given at 3.2 mg/kg (2.6 to 6.9 times the clinical dose range based on body surface area), Protopic was associated with maternal and paternal toxicity as well as reproductive toxicity including marked adverse effects on estrus cycles, parturition, pup viability, and pup malformations.
14 CLINICAL STUDIES
14.1 Kidney Transplantation
Tacrolimus-based immunosuppression in conjunction with azathioprine and corticosteroids following kidney transplantation was assessed in a randomized, multicenter, non-blinded, prospective trial. There were 412 kidney transplant patients enrolled at 19 clinical sites in the United States. Study therapy was initiated when renal function was stable as indicated by a serum creatinine ≤ 4 mg/dL (median of 4 days after transplantation, range 1 to 14 days). Patients less than 6 years of age were excluded.
There were 205 patients randomized to tacrolimus-based immunosuppression and 207 patients were randomized to cyclosporine-based immunosuppression. All patients received prophylactic induction therapy consisting of an antilymphocyte antibody preparation, corticosteroids and azathioprine. Overall 1 year patient and graft survival was 96.1% and 89.6%, respectively.
Data from this trial of Protopic in conjunction with azathioprine indicate that during the first three months of that trial, 80% of the patients maintained trough concentrations between 7-20 ng/mL, and then between 5-15 ng/mL, through 1 year.
fTacrolimus-based immunosuppression in conjunction with MMF, corticosteroids, and induction has been studied. In a randomized, open-label, multi-center trial (Study 1), 1589 kidney transplant patients received Protopic (Group C, n=401), sirolimus (Group D, n=399), or one of two cyclosporine (CsA) regimens (Group A, n=390 and Group B, n=399) in combination with MMF and corticosteroids; all patients, except those in one of the two cyclosporine groups, also received induction with daclizumab. The trial was conducted outside the United States; the trial population was 93% Caucasian. In this trial, mortality at 12 months in patients receiving Tacrolimus/MMF was similar (3%) compared to patients receiving cyclosporine/MMF (3% and 2%) or sirolimus/MMF (3%). Patients in the Protopic group exhibited higher estimated creatinine clearance rates (eCLcr) using the Cockcroft-Gault formula (Table 14) and experienced fewer efficacy failures, defined as biopsy proven acute rejection (BPAR), graft loss, death, and/or lost to follow-up (Table 15) in comparison to each of the other three groups. Patients randomized to Tacrolimus/MMF were more likely to develop diarrhea and diabetes after the transplantation and experienced similar rates of infections compared to patients randomized to either cyclosporine/MMF regimen .
The protocol-specified target Protopic trough concentrations (Ctrough, Tac) were 3-7 ng/mL; however, the observed median Ctroughs, Tac approximated 7 ng/mL throughout the 12 month trial (Table 16). Approximately 80% of patients maintained Protopic whole blood concentrations between 4-11 ng/mL through 1 year post-transplant.
The protocol-specified target cyclosporine trough concentrations (Ctrough,CsA) for Group B were 50-100 ng/mL; however, the observed median Ctroughs,CsA approximated 100 ng/mL throughout the 12 month trial. The protocol-specified target Ctroughs,CsA for Group A were 150-300 ng/mL for the first 3 months and 100-200 ng/mL from month 4 to month 12; the observed median Ctroughs, CsA approximated 225 ng/mL for the first 3 months and 140 ng/mL from month 4 to month 12.
While patients in all groups started MMF at 1gram twice daily, the MMF dose was reduced to less than 2 g per day in 63% of patients in the Protopic treatment arm by month 12 (Table 17); approximately 50% of these MMF dose reductions were due to adverse reactions. By comparison, the MMF dose was reduced to less than 2 g per day in 49% and 45% of patients in the two cyclosporine arms (Group A and Group B, respectively), by month 12 and approximately 40% of MMF dose reductions were due to adverse reactions.
In a second randomized, open-label, multi-center trial (Study 2), 424 kidney transplant patients received Protopic (N=212) or cyclosporine (N=212) in combination with MMF 1 gram twice daily, basiliximab induction, and corticosteroids. In this trial, the rate for the combined endpoint of BPAR, graft failure, death, and/or lost to follow-up at 12 months in the Tacrolimus/MMF group was similar to the rate in the cyclosporine/MMF group. There was, however, an imbalance in mortality at 12 months in those patients receiving Tacrolimus/MMF (4%) compared to those receiving cyclosporine/MMF (2%), including cases attributed to overimmunosuppression (Table 18).
The protocol-specified target Protopic whole blood trough concentrations (Ctrough,Tac) in Study 2 were 7-16 ng/mL for the first three months and 5-15 ng/mL thereafter. The observed median Ctroughs,Tac approximated 10 ng/mL during the first three months and 8 ng/mL from month 4 to month 12 (Table 19). Approximately 80% of patients maintained Protopic whole trough blood concentrations between 6 to 16 ng/mL during months 1 through 3 and, then, between 5 to 12 ng/mL from month 4 through 1 year.
The protocol-specified target cyclosporine whole blood concentrations (Ctrough,CsA) were 125 to 400 ng/mL for the first three months, and 100 to 300 ng/mL thereafter. The observed median Ctroughs, CsA approximated 280 ng/mL during the first three months and 190 ng/mL from month 4 to month 12.
Patients in both groups started MMF at 1gram twice daily. The MMF dose was reduced to less than 2 grams per day by month 12 in 62% of patients in the Tacrolimus/MMF group (Table 20) and in 47% of patients in the cyclosporine/MMF group. Approximately 63% and 55% of these MMF dose reductions were because of adverse reactions in the Tacrolimus/MMF group and the cyclosporine/MMF group, respectively .
14.2 Liver Transplantation
The safety and efficacy of tacrolimus-based immunosuppression following orthotopic liver transplantation were assessed in two prospective, randomized, non-blinded multicenter trials. The active control groups were treated with a cyclosporine-based immunosuppressive regimen (CsA/AZA). Both trials used concomitant adrenal corticosteroids as part of the immunosuppressive regimens. These trials compared patient and graft survival rates at 12 months following transplantation.
In one trial, 529 patients were enrolled at 12 clinical sites in the United States; prior to surgery, 263 were randomized to the tacrolimus-based immunosuppressive regimen and 266 to the CsA/AZA. In 10 of the 12 sites, the same CsA/AZA protocol was used, while 2 sites used different control protocols. This trial excluded patients with renal dysfunction, fulminant hepatic failure with Stage IV encephalopathy, and cancers; pediatric patients (≤ 12 years old) were allowed.
In the second trial, 545 patients were enrolled at 8 clinical sites in Europe; prior to surgery, 270 were randomized to the tacrolimus-based immunosuppressive regimen and 275 to CsA/AZA. In this trial, each center used its local standard CsA/AZA protocol in the active-control arm. This trial excluded pediatric patients, but did allow enrollment of subjects with renal dysfunction, fulminant hepatic failure in Stage IV encephalopathy, and cancers other than primary hepatic with metastases.
One-year patient survival and graft survival in the tacrolimus-based treatment groups were similar to those in the CsA/AZA treatment groups in both trials. The overall 1-year patient survival (CsA/AZA and tacrolimus-based treatment groups combined) was 88% in the U.S. trial and 78% in the European trial. The overall 1-year graft survival (CsA/AZA and tacrolimus-based treatment groups combined) was 81% in the U.S. trial and 73% in the European trial. In both trials, the median time to convert from IV to oral Protopic Capsules USP dosing was 2 days.
Although there is a lack of direct correlation between Protopic concentrations and drug efficacy, data from clinical trials of liver transplant patients have shown an increasing incidence of adverse reactions with increasing trough blood concentrations. Most patients are stable when trough whole blood concentrations are maintained between 5 to 20 ng/mL. Long-term post-transplant patients often are maintained at the low end of this target range. Data from the U.S. clinical trial show that the median trough blood concentrations, measured at intervals from the second week to one year post-transplantation ranged from 9.8 ng/mL to 19.4 ng/mL.
16 HOW SUPPLIED / STORAGE AND HANDLING
16.1 Protopic Capsules USP
Protopic Capsules USP, 0.5 mg: Light yellow color, oblong shape, size “5” hard gelatin capsules printed with “PBT” and “0.5” in red ink on cap and body respectively.
Capsules are supplied as follows:
NDC 62175-380-37 Bottle of 100
Protopic Capsules USP, 1 mg: White color, oblong shape, size “5” hard gelatin capsules printed with “PBT” and “1.0” in red ink on cap and body respectively.
Capsules are supplied as follows:
NDC 62175-381-37 Bottle of 100
Protopic Capsules USP, 5 mg: Pink color, oblong shape, size “4” hard gelatin capsules printed with “PBT” and “5.0” in red ink on cap and body respectively.
Capsules are supplied as follows:
NDC 62175-382-37 Bottle of 100
Store at 25°C (77°F); excursions permitted to 15°C-30°C (59°F-86°F)
17 PATIENT COUNSELING INFORMATION
Advise patients to:
17.2 Development of Lymphoma and Other Malignancies
Inform patients they are at increased risk of developing lymphomas and other malignancies, particularly of the skin, due to immunosuppression. Advise patients to limit exposure to sunlight and ultraviolet (UV) light by wearing protective clothing and use a sunscreen with a high protection factor .
17.3 Increased Risk of Infection
Inform patients they are at increased risk of developing a variety of infections, including opportunistic infections, due to immunosuppression and to contact their physician if they develop any symptoms of infection .
17.4 New Onset Diabetes After Transplant
Inform patients that Protopic Capsules USP can cause diabetes mellitus and should be advised to contact their physician if they develop frequent urination, increased thirst or hunger .
Inform patients that Protopic Capsules USP can have toxic effects on the kidney that should be monitored. Advise patients to attend all visits and complete all blood tests ordered by their medical team .
Inform patients that they are at risk of developing adverse neurologic effects including seizure, altered mental status, and tremor. Advise patients to contact their physician should they develop vision changes, deliriums, or tremors .
Inform patients that Protopic Capsules USP can cause hyperkalemia. Monitoring of potassium levels may be necessary, especially with concomitant use of other drugs known to cause hyperkalemia .
Inform patients that Protopic Capsules USP can cause high blood pressure which may require treatment with anti-hypertensive therapy .
17.9 Drug Interactions
Instruct patients to tell their health care providers when they start or stop taking all the medicines, including prescription medicines and non-prescription medicines, natural or herbal remedies, nutritional supplements and vitamins .
17.10 Pregnant Women and Nursing Mothers
Instruct patients to tell their healthcare provider if they plan to become pregnant or breast-feed their infant .
Inform patients that Protopic Capsules USP can interfere with the usual response to immunizations and that they should avoid live vaccines .
Panacea Biotec Ltd
Distt. Solan (H.P.) – 173205, India
Mfg. Lic. No: MB/05/203
Kremers Urban Pharmaceuticals Inc.
Princeton, NJ 08540, USA
Resource Number: L5678
Item Code: PPIT057H
Revised Date: September 2013
Protopic Capsules USP
(tacrolimus) capsule USP
Read this Patient Information before you start taking Protopic Capsules USP and each time you get a refill. There may be new information. This information does not take the place of talking with your doctor about your medical condition or your treatment.
What is the most important information I should know about Protopic Capsules USP?
Protopic Capsules USP can cause serious side effects, including:
What is Protopic Capsules USP?
Protopic Capsule USP is a prescription medicine used with other medicines to help prevent organ rejection in people who have had a kidney or liver transplant and Protopic Capsule USP is not for use with medicines called cyclosporines (Gengraf®, Neoral®, and Sandimune®).
Protopic Capsule USP is not for use with a medicine called sirolimus (Rapamune®) in people who have had a liver transplants.
It is not known if Protopic is safe and effective when used with sirolimus in people who have had kidney transplants.
It is not known if Protopic is safe and effective in children who have had a kidney transplants.
Who should not take Protopic Capsules USP?
Do not take Protopic Capsule USP if you are allergic to Protopic or any of the ingredients in Protopic Capsule USP. See the end of this leaflet for a complete list of ingredients in Protopic Capsule USP.
What should I tell my doctor before taking Protopic Capsules USP?
Before you take Protopic Capsules USP, tell your doctor if you:
Tell your doctor about all the medicines you take, including prescription and non-prescription medicines, vitamins, and heral supplements.
Especially tell your doctor if you take:
Ask your doctor or pharmacist if you are not sure if you take any of the medicines listed above. Tacrolimus Capsules USP may affect the way other medicines work, and other medicines may affect how Protopic Capsules USP works.
Know the medicines you take. Keep a list of your medicines and show it to your doctor and pharmacist when you get a new medicine.
How should I take Protopic Capsules USP?
What should I avoid while taking Protopic Capsules USP?
While you take Protopic Capsules USP you should not receive any live vaccines such as:
Avoid exposure to sunlight and UV light such as tanning machines. Wear protective clothing and use a sunscreen.
What are the possible side effects of Protopic Capsules USP?
Protopic Capsules USP may cause serious side effects, including:
The most common side effects of Protopic Capsules USP in people receiving kidney transplant are:
The most common side effects of Protopic Capsules USP in people receiving liver transplants are:
Tell your doctor if you have any side effect that bothers you or that does not go away.
These are not all the possible side effects of Protopic Capsules USP. For more information, ask your doctor or pharmacist.
Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.
How should I store Protopic Capsules USP?
Keep Protopic Capsules USP and all medicines out of reach of children.
General information about the safe and effective use of Protopic Capsules USP
Medicines are sometimes prescribed for purposes other than those listed in a Patient Information leaflet. Do not use Protopic Capsules USP for a condition for which it was not prescribed. Do not give Protopic Capsules USP to other people, even if they have the same symptoms that you have. It may harm them.
How Does Protopic Capsules USP Protect My New Organ?
The body’s immune system protects the body against anything that it does not recognize as part of the body. For example, when the immune system detects a virus or bacteria it tries to get rid of it to prevent infection. When a person has a liver or kidney transplant, the immune system does not recognize the new organ as a part of the body and tries to get rid of it, too. This is called “rejection”. Protopic Capsules USP protects your new organ by slowing down the body’s immune system.
This Patient Information leaflet summarizes the most important information about Protopic Capsules USP. If you would like more information, talk with your doctor. You can ask your pharmacist or doctor for information about Protopic Capsules USP that is written for health professionals.
For more information, go to call Panacea Biotec Global Pharmacovigilance Function at 1-877-687-4130.
What are the ingredients in Protopic Capsules USP?
Active ingredient: Protopic USP
Inactive ingredients: anhydrous lactose, hypromellose 2910, croscarmellose sodium, magnesium stearate, gelatin, titanium dioxide and ferric oxide.
Panacea Biotec Ltd
Distt. Solan (H.P.) – 173205, India
Mfg. Lic. No: MB/05/203
Kremers Urban Pharmaceuticals Inc.
Princeton, NJ 08540, USA
Resource Number: L5778
Item Code: PPIT064C
Revised Date: August 2012
Protopic 1mg Capsule
Protopic pharmaceutical active ingredients containing related brand and generic drugs:
Active ingredient is the part of the drug or medicine which is biologically active. This portion of the drug is responsible for the main action of the drug which is intended to cure or reduce the symptom or disease. The other portions of the drug which are inactive are called excipients; there role is to act as vehicle or binder. In contrast to active ingredient, the inactive ingredient's role is not significant in the cure or treatment of the disease. There can be one or more active ingredients in a drug.
Protopic available forms, composition, doses:
Form of the medicine is the form in which the medicine is marketed in the market, for example, a medicine X can be in the form of capsule or the form of chewable tablet or the form of tablet. Sometimes same medicine can be available as injection form. Each medicine cannot be in all forms but can be marketed in 1, 2, or 3 forms which the pharmaceutical company decided based on various background research results.
Composition is the list of ingredients which combinedly form a medicine. Both active ingredients and inactive ingredients form the composition. The active ingredient gives the desired therapeutic effect whereas the inactive ingredient helps in making the medicine stable.
Doses are various strengths of the medicine like 10mg, 20mg, 30mg and so on. Each medicine comes in various doses which is decided by the manufacturer, that is, pharmaceutical company. The dose is decided on the severity of the symptom or disease.
Protopic destination | category:
Destination is defined as the organism to which the drug or medicine is targeted. For most of the drugs what we discuss, human is the drug destination.
Drug category can be defined as major classification of the drug. For example, an antihistaminic or an antipyretic or anti anginal or pain killer, anti-inflammatory or so.
Protopic Anatomical Therapeutic Chemical codes:
A medicine is classified depending on the organ or system it acts [Anatomical], based on what result it gives on what disease, symptom [Therapeutical], based on chemical composition [Chemical]. It is called as ATC code. The code is based on Active ingredients of the medicine. A medicine can have different codes as sometimes it acts on different organs for different indications. Same way, different brands with same active ingredients and same indications can have same ATC code.
Protopic pharmaceutical companies:
Pharmaceutical companies are drug manufacturing companies that help in complete development of the drug from the background research to formation, clinical trials, release of the drug into the market and marketing of the drug.
Researchers are the persons who are responsible for the scientific research and is responsible for all the background clinical trials that resulted in the development of the drug.
Frequently asked QuestionsCan i drive or operate heavy machine after consuming Protopic?
Depending on the reaction of the Protopic after taken, if you are feeling dizziness, drowsiness or any weakness as a reaction on your body, Then consider Protopic not safe to drive or operate heavy machine after consumption. Meaning that, do not drive or operate heavy duty machines after taking the capsule if the capsule has a strange reaction on your body like dizziness, drowsiness. As prescribed by a pharmacist, it is dangerous to take alcohol while taking medicines as it exposed patients to drowsiness and health risk. Please take note of such effect most especially when taking Primosa capsule. It's advisable to consult your doctor on time for a proper recommendation and medical consultations.Is Protopic addictive or habit forming?
Medicines are not designed with the mind of creating an addiction or abuse on the health of the users. Addictive Medicine is categorically called Controlled substances by the government. For instance, Schedule H or X in India and schedule II-V in the US are controlled substances.
Please consult the medicine instruction manual on how to use and ensure it is not a controlled substance.In conclusion, self medication is a killer to your health. Consult your doctor for a proper prescription, recommendation, and guidiance.
Reviewsdrugs.com conducted a study on Protopic, and the result of the survey is set out below. It is noteworthy that the product of the survey is based on the perception and impressions of the visitors of the website as well as the views of Protopic consumers. We, as a result of this, advice that you do not base your therapeutic or medical decisions on this result, but rather consult your certified medical experts for their recommendations.
Visitor reported usefulNo survey data has been collected yet
Visitor reported side effectsNo survey data has been collected yet
Visitor reported price estimatesNo survey data has been collected yet
Visitor reported frequency of useNo survey data has been collected yet
One visitor reported dosesWhat is the dose of Protopic drug you are taking?
According to the survey conducted among sdrugs.com website users, the maximum number of people are using the following dose 1-5mg. Few medications come in only one or two doses. Few are specific for adult dose and child dose. The dose of the medicine given to the patient depends on the severity of the symptom/disease. There can be dose adjustments made by the doctor, based on the progression of the disease. Follow-up is important.
Visitor reported time for resultsNo survey data has been collected yet
Visitor reported administrationNo survey data has been collected yet
One visitor reported age
The information was verified by Dr. Arunabha Ray, MD Pharmacology