Once-Daily versus Twice-Daily Tacrolimus in Kidney Transplantation: A Systematic Review and Meta-analysis of Observational Studies

Abstract

Background Tacrolimus is the most commonly prescribed medication in initial immunosuppressive regimens to prevent acute rejection in kidney transplant recipients (KTRs). Tacrolimus was originally available as an immediate-release formulation (IR-Tac) given twice daily. Extended-release tacrolimus (ER-Tac) given once daily was later developed with the expectation of improved medication adherence. Data from observational studies, which compared outcomes between ER-Tac and IR-Tac in different populations of KTRs including those who are unlikely to be enrolled in randomized clinical trials, have been reported. Purpose To evaluate the incidence of biopsy-proven acute rejection (BPAR) at 12 months together with other outcomes reported in observational studies among adult KTRs who received ER-Tac compared to IR-Tac. Methods In accordance with the recommendations of the Cochrane Collaboration and the Meta-analysis of Observational Studies in Epidemiology, we systematically reviewed all observational studies that compared clinical outcomes between ER-Tac and IR-Tac in KTRs. The systematic searches were conducted on PubMed, EMBASE, Scopus, and Web of Science without language restriction. Reference lists were also searched and reviewed. Data were extracted for BPAR, graft survival, patient survival, estimated glomerular filtration rate (eGFR), serum creatinine (Scr), creatinine clearance (CrCl), at different times after kidney transplantation (KT). A meta-analysis was performed to integrate the results from the eligible studies. This study is registered with PROSPERO, number CRD42019135705. Results From the 1401 articles screened, 10 observational studies in KTRs who received tacrolimus were included. The pooled results showed significantly lower BPAR with ER-Tac than with IR-Tac at 12 months post-KT (5 studies, n = 659; RR, 0.69; 95% CI 0.51-0.95; p = 0.02; I 2 = 0%). No significant differences in BPAR at other time points after KT were found. Graft survival, patient survival, Scr, and eGFR were comparable between groups at different times over approximately 1 year after transplantation. Conclusions Based upon currently available evidence in observational studies, 30% lower risk of BPAR was observed in ER-Tac group compared with IR-Tac group at 12 months post-KT, while there was no significant difference in BPAR risk at any other studied time points. No differences in graft-and patient-survival rates and kidney function were found. Given the limitations of observational studies to make causal inference, as well as quality limitations among the included studies, caution should be exercised in interpreting these findings.

Efficacy and Safety of Tacrolimus-Based Maintenance Regimens in De Novo Kidney Transplant Recipients: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials

“…A previous systematic literature review compared 12-month post-kidney transplant outcomes between TAC QD and TAC BID in randomized controlled trials and observational studies, with the authors finding no significant differences between the regimens in relation to BPAR, graft survival, or patient survival [ 81 ]. By contrast, a more recent systematic literature and meta-analysis of observational studies revealed a 30% lower risk of BPAR at 12 months with TAC QD compared with TAC BID, with no difference in graft or patient survival or kidney function [ 82 ]. Herein, none of the treatments analyzed was associated with increased (or decreased) mortality risk compared with the reference regimen, Prograf+MPA+CS.…”

Medication adherence/persistence among patients with active multiple sclerosis in Finland

“…Also, patients on teriflunomide showed better adherence than patients using DMF, which may be due to difference in dosing scheme (teriflunomide once daily vs. DMF twice daily). In other therapeutic areas, higher dosing frequency has been associated with lower adherence in several, [17][18][19][20] but not in all, 21,22 studies. In addition, persistence to treatment was also higher with oral agents versus injectables.…”

Increased renal function decline in fast metabolizers using extended-release tacrolimus after kidney transplantation

“…On the one hand, non-adherence to Tac remains an underestimated problem; on the other hand, Tac metabolism and PK profiles are increasingly coming into focus 11 , 12 . Once-daily drugs such as ER-Tac can improve treatment adherence, but two recent meta-analyses showed comparable clinical outcomes of ER-Tac and IR-Tac 4 , 13 – 15 .…”