Tacrolimus chemical structure
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Tacrolimus

Tacrolimus (also FK-506 or Fujimycin) is a 23-membered macrolide lactone discovered in 1984 from the fermentation broth of a Japanese soil sample that contained the fungus Streptomyces tsukubaensis. It is an immunosuppressive drug whose main use is after allogenic organ transplant to reduce the activity of the patient's immune system and so the risk of organ rejection. more...

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It has similar immunosuppressive properties to cyclosporine, but is much more potent in equal volumes. Also like cyclosporine it has a wide range of adverse interactions, including that with grapefruit which increases plasma-tacrolimus concentration.

It has been used in a topical preparation in the treatment of severe atopic dermatitis, as have cyclosporine and azathioprine with much less success. It has also been used after bone marrow transplants and for severe refractory uveitis.

The drug is owned by Astellas Pharma Inc. (Merging of Fujisawa Pharmaceutical Co.,Ltd. and Yamanouchi Pharmaceutical Co., Ltd as of April 1, 2005) and is sold under the tradename Prograf®. It is sometimes referred to as FK-506, an early name relating to its action. It was first approved by the FDA in 1994 for use in liver transplantation, this has been extended to include kidney, heart, small bowel, pancreas, lung, trachea, skin, cornea, and limb transplants.

Tacrolimus is a macrolide antibiotic. It acts by reducing peptidyl-prolyl isomerase activity by binding to the immunophilin FKBP-12 (FK506 binding protein) creating a new complex. This inhibits both T-lymphocyte signal transduction and IL-2 transcription. Although this activity is similar to cyclosporine studies have shown that the incidence of acute rejection is reduced by tacrolimus use over cyclosporine.

Side effects can be severe and include blurred vision, liver and kidney problems (it is nephrotoxic), seizures, tremors, hypertension, hypomagnesemia, diabetes mellitus, hyperkalemia, itching, insomnia, confusion, loss of appetite, hyperglycemia, weakness, depression, cramps, and neuropathy, as well as potentially increasing the severity of existing fungal or infectious conditions such as herpes zoster or polyoma viral infections.

Dermatological use

Protopic® or tacrolimus is a recent topical treatment of eczema, particularly atopic eczema. It suppresses inflammation in a similar way to steroids, but is not as powerful. An important dermatological advantage of tacrolimus is that it can be used directly on the face; topical steroids cannot be used on the face, as they thin the skin dramatically there. On other parts of the body, topical steroid are generally a better treatment. A common side effect of tacrolimus ointment, if used over a wide area, is to cause a burning or itching sensation on the first one or two applications.

Cancer risks

Tacrolimus and a related drug for eczema (pimecrolimus) are being suspected of carrying a cancer risk, though the matter is still a subject of controversy. Dermatologists agree that the drug should be used as a second-line remedy only after conventional methods of treatment have failed. The FDA issued a health warning in March 2005 for the drug, based on animal models and a small number of patients. Until further human studies yield more conclusive results, the FDA recommends that users be advised of the potential risks.

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A multicentre, randomized, double-blind, controlled study of long-term treatment with 0.1% tacrolimus ointment in adults with moderate to severe atopic
From Journal of Drugs in Dermatology, 9/1/05

A Multicentre, Randomized, Double-Blind, Controlled Study of Long-Term Treatment with 0.1% Tacrolimus Ointment in Adults with Moderate to Severe Atopic Dermatitis

Reitamo S, et al. British Journal of Dermatology. 2005; 152:1282-1289.

Summary

The authors present a randomized, double-blind, controlled trial to evaluate the efficacy and safety of 0.1% tacrolimus ointment compared to topical corticosteroids in patients with moderate to severe atopic dermatitis. Nine hundred seventy-two patients were enrolled and randomly assigned to apply either tacrolimus ointment or topical corticosteroids twice daily for 6 months. The study design chose 1% hydrocortisone acetate ointment for application to the face and neck, and 0.1% hydrocortisone butyrate ointment, a mid-potency corticosteroid, for application to the rest of the body. At the start of the study, patients were given 5 white tubes for application to the body and 2 blue tubes for the face and neck to allow for blinding. Patients were required to use the study ointment twice daily to eczematous lesions and to continue application for 7 days after clearance, with re-application pending flares. Patients were evaluated using the modified Eczema Area and Severity Index (mEASI), a scoring rating both clinical signs of atopic dermatitis and the patient's subjective feeling of pruritus. The primary outcome measure was the percentage of patients achieving a 60% reduction in mEASI from baseline to 3 months. Secondary outcomes of response to treatment included the "patient's assessment of global response," the "physician's global evaluation of clinical response," and subjective measures of quality of sleep. Safety was assessed using laboratory evaluations and vital signs. Analysis was conducted using the intent-to-treat population. After 3 months, patients in the tacrolimus-treated arm achieved a statistically significant difference in response compared with the corticosteroid-treated arm. In addition, at all other time points measured, tacrolimus-treated patients had statistically significant response rates compared to corticosteroid-treated patients. Regarding adverse events, more people in the tacrolimus group experienced skin tingling, skin burning, flushing of the face after ingesting alcohol, and herpes simplex infections. The prevalence of herpes simplex infections decreased in the tacrolimus-treated group during the study, becoming comparable to the corticosteroid-treated group at 6 months of treatment. No malignancies were noted in the tacrolimus-treated group, nor were any changes in vital signs or laboratory values in either treatment group.

Comment

This is an important study in that it sought to directly compare the efficacy of 2 topical therapies for the treatment of atopic dermatitis. Given the complications of long-term corticosteroid use, including skin atrophy, telangiectasias, and striae, tacrolimus ointment is an important treatment modality in the management of patients with atopic dermatitis. This study was adequately powered and included patients with severe disease. Tacrolimus-treated patients achieved a statistically significant reduction in mEASI from baseline to 3 months compared with the corticosteroid-treated patients. Despite the success of this study demonstrating the efficacy of tacrolimus ointment, it may have been difficult to maintain blinding in patients complaining of symptoms such as skin burning, which is common after application of tacrolimus ointment. Indeed, 255 patients treated with tacrolimus ointment complained of skin burning compared with only 67 patients treated with corticosteroids. Also, 1% hydrocortisone acetate is an extremely weak corticosteroid and 0.1% hydrocortisone butyrate is a mid-potency corticosteroid. The authors explain that these medications were chosen to allay the concern of giving a more potent corticosteroid blindly to a patient for potentially 6 months. While this concern is justified, this corticosteroid regimen may not adequately reflect management of patients in the general population. Nonetheless, the study demonstrates the efficacy of tacrolimus ointment in the treatment of atopic dermatitis and supports its use as a steroid-sparing agent. More studies like this are needed to evaluate and compare commonly used therapies for specific skin disorders in order to help ascertain which are most effective.

COPYRIGHT 2005 Journal of Drugs in Dermatology, Inc.
COPYRIGHT 2005 Gale Group

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