Drug (US brand name) | Oral bioavailability | Effect of food on absorption | Metabolism and clearance* | Enzyme/transporter inhibition* | Half-life in hours (range) |
Antimetabolites | |||||
Mycophenolate mofetil (MMF, CellCept) | 80.7% (renal transplant patients) 94% (healthy volunteers) |
| Rapidly hydrolyzed to its active metabolite mycophenolic acid (MPA), which is further metabolized by UGT to the inactive metabolite mycophenolic acid glucuronide (MPAG), which is excreted primarily via urine; MPA undergoes enterohepatic recirculation, and secondary increases in MPA levels are seen 6 to 12 hours after a dose of MMF | None known | 17.9 (11.4 to 24.4)¶ (MPA) MPAG can accumulate in renal failure |
Mycophenolate sodium, enteric coated (Myfortic)Δ | 72% (renal transplant patients) |
| Rapidly hydrolyzed to the active metabolite mycophenolic acid (MPA), which is further metabolized by UGT to the inactive metabolite mycophenolic acid glucuronide (MPAG), which is excreted primarily via urine; MPA undergoes enterohepatic recirculation, and secondary increases in MPA levels are seen 6 to 8 hours after a dose of mycophenolate sodium | None known | 12 (8 to 16) (MPA) MPAG can accumulate in renal failure |
Calcineurin inhibitors | |||||
Cyclosporine non-modified (Sandimmune) | Generally poor and unpredictable:
|
| Metabolized by CYP3A4 to reduced activity and inactive metabolites (eg, M1, M9, M4N) cleared fecally via bile Substrate of P-gp | Inhibitor of P-gp, BCRP, OATP1B1/1B3 | 19 (10 to 27) Prolonged in hepatic impairment |
Cyclosporine modified (microemulsion) (Neoral) | 23 to 50% better absorbed than non-modified formulation in renal and liver transplant patients, respectively |
| 8.4 (5 to 18) Prolonged in hepatic impairment | ||
Tacrolimus immediate-release capsule (Prograf) | 7 to 32% |
| Metabolized by CYP3A4/5 to active (eg, 13-O-demethyl) and inactive metabolites cleared fecally via bile Substrate of P-gp | May be an inhibitor of P-gp; supportive data are limited to in-vitro effects (ie, clinical effect is unknown) | 12 (2 to 36) Prolonged in severe hepatic impairment |
Tacrolimus extended-release capsule (Astagraf XL) | 12 to 19% |
| 38 (35 to 41) Prolonged in severe hepatic impairment | ||
Tacrolimus extended-release tablet (Envarsus XR) | 50% better absorbed than immediate-release capsule |
| 31 (23 to 39) Prolonged in severe hepatic impairment | ||
mTOR inhibitors | |||||
Everolimus (Zortress) | 30% |
| Metabolized by CYP3A4 to six weakly active metabolites that are excreted primarily via feces Substrate of P-gp | None known | 30 (19 to 41) Prolonged in hepatic impairment |
Sirolimus (Rapamune) | 18% (tablet) 14% (oral solution) |
| Metabolized by CYP3A4 to seven metabolites (some have weak activity) that are excreted primarily via feces Substrate of P-gp | None known | 62 (46 to 78) Prolonged in hepatic impairment |
AUC: area under the 24-hour serum concentration × time plot; Cmax: maximum concentration; CYP3A4: cytochrome P450 3A4; GI: gastrointestinal; MMF: mycophenolate mofetil; MPA: mycophenolic acid (active form of mycophenolate); MPAG: mycophenolic acid glucuronide (inactive metabolite of mycophenolic acid); mTOR inhibitors: mammalian (mechanistic) target of rapamycin inhibitors; P-gp: P-glycoprotein efflux membrane transporters (multi-drug efflux pump); UGT: uridine diphosphate (UDP) glucuronosyltransferase.
* The classification of immunosuppressive drug effects on drug metabolism are based upon US Food and Drug Administration (FDA) guidance.[1,2] Other sources may use a different classification system resulting in some agents being classified differently. Weak inhibitor effects are not listed. Clinically significant interactions can occasionally occur due to weak inhibitors, particularly if the target drug has a narrow therapeutic margin. Refer to the drug interactions program included within UpToDate for a full review of potential interactions.
¶ Standard deviation 6.5 hours per US manufacturer.
Δ To convert from mycophenolate mofetil (MMF, CellCept) 1000 mg every 12 hours, switch to mycophenolate sodium enteric coated (Myfortic) 720 mg every 12 hours.Prepared with data from: UpToDate Lexidrug. More information available at https://online.lexi.com/.
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