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Tacrolimus (topical): Drug information

Tacrolimus (topical): Drug information
(For additional information see "Tacrolimus (topical): Patient drug information" and see "Tacrolimus (topical): Pediatric drug information")

For abbreviations, symbols, and age group definitions used in Lexicomp (show table)
ALERT: US Boxed Warning
Malignancy:

Although a causal relationship has not been established, rare cases of malignancy (ie, skin cancer and lymphoma) have been reported in patients treated with topical calcineurin inhibitors, including tacrolimus ointment. Avoid continuous long-term use of topical calcineurin inhibitors, including tacrolimus ointment, in any age group, and limit application to areas of involvement with atopic dermatitis.

Pediatrics:

Tacrolimus ointment is not indicated for use in children younger than 2 years of age. Only tacrolimus 0.03% ointment is indicated for use in children 2 to 15 years of age.

Brand Names: US
  • Protopic [DSC]
Brand Names: Canada
  • Protopic
Pharmacologic Category
  • Calcineurin Inhibitor;
  • Immunosuppressant Agent;
  • Topical Skin Product
Dosing: Adult
Allergic contact dermatitis

Allergic contact dermatitis (alternative agent) (off-label use): Topical: Apply a thin layer of 0.1% ointment to the affected area(s) twice daily (Ref).

Atopic dermatitis

Atopic dermatitis (moderate to severe): Topical:

Treatment: Apply thin layer of 0.03% or 0.1% ointment to affected area twice daily; rub in gently and completely. Discontinue use when symptoms have cleared. If no improvement within 6 weeks, patients should be re-examined to confirm diagnosis.

Maintenance therapy (off-label use): Apply one application (thin layer of 0.03% or 0.1% ointment) to areas usually affected twice daily twice a week (Ref).

Oral lichen planus

Oral lichen planus (off-label use): Topical: Apply thin layer of 0.1% ointment to affected area(s) up to 4 times daily; the treatment period in clinical trials ranged from 4 to 6 weeks (Ref).

Psoriasis

Psoriasis (intertriginous and facial) (off-label use): Topical: Apply thin layer of 0.1% ointment to affected area twice daily; the treatment period in clinical trials was 6 to 8 weeks (Ref).

Pyoderma gangrenosum

Pyoderma gangrenosum (refractory) (off-label use): Topical: Apply thin layer of 0.1% ointment to affected area once daily. May taper to 0.03% ointment once daily after improvement is evident following several weeks of initial therapy (Ref).

Vitiligo

Vitiligo (primarily the head and neck region ) (off-label use): Topical: Apply thin layer of 0.1% ointment to affected area twice daily; reassess every 3 to 6 months for adequate response (Ref).

Dosing: Kidney Impairment: Adult

There are no dosage adjustments provided in the manufacturer's labeling.

Dosing: Hepatic Impairment: Adult

There are no dosage adjustments provided in the manufacturer's labeling.

Dosing: Older Adult

Refer to adult dosing.

Dosing: Pediatric

(For additional information see "Tacrolimus (topical): Pediatric drug information")

Atopic dermatitis, moderate to severe

Atopic dermatitis, moderate to severe: Note: Discontinue use when symptoms have cleared. If no improvement occurs within 6 weeks, patients should be reexamined to confirm diagnosis. Topical:

Ointment 0.03%: Children ≥2 years and Adolescents: Apply a thin layer to affected area twice daily; rub in gently and completely

Ointment 0.1%: Adolescents ≥16 years: Apply a thin layer of 0.1% ointment to affected area twice daily; rub in gently and completely

Dosing: Kidney Impairment: Pediatric

There are no dosage adjustments provided in the manufacturer's labeling.

Dosing: Hepatic Impairment: Pediatric

There are no dosage adjustments provided in the manufacturer's labeling.

Adverse Reactions

The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified. As reported in children and adults, unless otherwise noted. Frequency not always defined.

Cardiovascular: Peripheral edema (adults 3% to 4%), hypertension (adults 1%)

Central nervous system: Headache (adults 19% to 20%), tingling of skin (2% to 8%), hyperesthesia (adults 3% to 7%), insomnia (adults 4%), paresthesia (adults 3%), depression (adults 2%), pain (1% to 2%)

Dermatologic: Burning sensation of skin (43% to 58%), pruritus (41% to 46%), erythema (25% to 28%), skin infection (adults 12%), acne vulgaris (adults 4% to 7%), urticaria (adults 3% to 6%), folliculitis (2% to 6%), skin rash (adults 2% to 5%), dermatological disease (children 4%), vesiculobullous dermatitis (children 4%), contact dermatitis (3% to 4%), pustular rash (adults 2% to 4%), contact eczema herpeticum (children 2%), fungal dermatitis (adults 1% to 2%), sunburn (adults 1% to 2%), alopecia (adults 1%), xeroderma (children 1%)

Gastrointestinal: Diarrhea (3% to 5%), dyspepsia (adults 1% to 4%), abdominal pain (children 3%), gastroenteritis (adults 2%), vomiting (adults 1%), nausea (children 1%)

Genitourinary: Dysmenorrhea (adults 4%), urinary tract infection (adults 1%)

Hematologic & oncologic: Lymphadenopathy (children 3%), malignant lymphoma, malignant neoplasm of skin

Hypersensitivity: Hypersensitivity reaction (adults 6% to 12%)

Infection: Herpes zoster (1% to 5%), varicella zoster infection (1% to 5%), infection (adults 1% to 2%)

Neuromuscular & skeletal: Myalgia (adults 2% to 3%), weakness (adults 2% to 3%), arthralgia (adults 1% to 3%), back pain (adults 2%)

Ocular: Conjunctivitis (adults 2%)

Otic: Otitis media (children 12%), otalgia (children 1%)

Respiratory: Flu-like symptoms (23% to 31%), increased cough (children 18%), asthma (adults 6%), rhinitis (children 6%), pharyngitis (adults 4%), sinusitis (adults 2% to 4%), bronchitis (adults 2%), pneumonia (adults 1%)

Miscellaneous: Fever (children 21%), allergic reaction (4% to 12%), alcohol intolerance (adults 3% to 7%), accidental injury (6%), cyst (adults 1% to 3%)

<1%, postmarketing, and/or case reports (Limited to important or life-threatening): Abnormality in thinking, abscess, acne rosacea, acute renal failure, aggravated tooth caries, anaphylactoid reaction, anemia, anorexia, anxiety, application site edema, arthritis, arthropathy, basal cell carcinoma, benign neoplasm (breast), blepharitis, bone disease, bursitis, candidiasis, cataract, chest pain, chills, colitis, conjunctival edema, constipation, cutaneous candidiasis, cystitis, dehydration, dermal ulcer, diaphoresis, dizziness, dry nose, dysgeusia, dyspnea, ear disease, ecchymoses, edema, epistaxis, eye pain, furunculosis, gastritis, gastrointestinal disease, heart valve disease, hernia, hyperbilirubinemia, hypercholesterolemia, hypertonia, hypothyroidism, impetigo (bullous), laryngitis, leukoderma, malaise, malignant lymphoma, malignant melanoma, migraine, muscle cramps, nail disease, neck pain, neoplasm (benign), oral candidiasis, oral mucosa ulcer, osteoarthritis, osteomyelitis, otitis externa, pulmonary disease, rectal disease, renal insufficiency, seborrhea, seizure, septicemia, skin carcinoma, skin discoloration, skin hypertrophy, skin photosensitivity, squamous cell carcinoma, stomatitis, syncope, tachycardia, tendinopathy, unintended pregnancy, vaginitis, vasodilation, vertigo, visual disturbance, vulvovaginal candidiasis, xerophthalmia, xerostomia

Contraindications

Hypersensitivity to tacrolimus or any component of the formulation

Warnings/Precautions

Concerns related to adverse events:

• Infection: Do not apply to areas of active bacterial or viral infection; infections at the treatment site should be cleared prior to therapy. Patients with atopic dermatitis are predisposed to skin infections, and tacrolimus therapy has been associated with risk of developing eczema herpeticum, varicella zoster, and herpes simplex.

• Lymphadenopathy: May be associated with development of lymphadenopathy; possible infectious causes should be investigated. Discontinue use in patients with unknown cause of lymphadenopathy or acute infectious mononucleosis.

• Malignancy: Avoid use on malignant or premalignant skin conditions (eg, cutaneous T-cell lymphoma). Limit sun and ultraviolet light exposure; use appropriate sun protection.

• Renal failure: Acute renal failure has been observed (rarely) with topical use.

Disease related concerns:

• Immunosuppression: Should not be used in immunocompromised patients. Safety and efficacy have not been evaluated.

• Skin diseases with altered absorption: Not recommended for use in patients with skin disease which may increase systemic absorption (eg, Netherton's syndrome).

Special populations:

• Pediatric: [US Boxed Warning] Use in children <2 years of age is not recommended, only the 0.03% ointment should be used in children ages 2 to 15 years.

Other warnings/precautions:

• Appropriate use: Topical calcineurin agents are considered second-line therapies in the treatment of atopic dermatitis/eczema, and should be limited to use in patients who have failed treatment with other therapies. Safety not established in patients with generalized erythroderma. If atopic dermatitis is not improved in <6 weeks, re-evaluate to confirm diagnosis. Safety of intermittent use for >1 year has not been established, particularly since the effect on immune system development is unknown.

Dosage Forms: US

Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product

Ointment, External:

Protopic: 0.03% (30 g [DSC], 60 g [DSC], 100 g [DSC]); 0.1% (30 g [DSC], 60 g [DSC], 100 g [DSC])

Generic: 0.03% (30 g, 60 g, 100 g); 0.1% (30 g, 60 g, 100 g)

Generic Equivalent Available: US

Yes

Pricing: US

Ointment (Tacrolimus External)

0.03% (per gram): $2.80 - $11.01

0.1% (per gram): $4.00 - $11.01

Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.

Dosage Forms: Canada

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Ointment, External:

Protopic: 0.03% (30 g, 60 g, 100 g); 0.1% (30 g, 60 g, 100 g)

Administration: Adult

Topical: Wash hands before and after application. Use the smallest amount of ointment needed to control symptoms. Use with occlusive dressings is not recommended; however, occlusion may be considered on photo-exposed areas in the treatment of nonfacial vitiligo (Ref). Do not bathe, shower, or swim right after application. Limit sun exposure during the treatment period. Limit application to involved areas.

Oral lichen planus (off-label use): Apply a thin layer of tacrolimus using finger or cotton tip or a latex glove. Lesion should be dried before applying medication. Do not eat or drink for at least 30 minutes after application (Ref).

Administration: Pediatric

For external use only; avoid exposure to eyes or mouth. Wash hands before and after application. Use the smallest amount of ointment needed to control the signs and symptoms of atopic dermatitis. Do not cover with occlusive dressings. Do not bathe, shower, or swim right after application. Moisturizers can be applied after application. Limit sun exposure during the treatment period. Burning at the application site is most common in first few days; improves as atopic dermatitis improves.

Hazardous Drugs Handling Considerations

Hazardous agent (NIOSH 2016 [group 2]).

Use appropriate precautions for receiving, handling, administration, and disposal. Gloves (single) should be worn during receiving, unpacking, and placing in storage.

NIOSH recommends double gloving, a protective gown, and (if liquid that could splash) eye/face protection for administration of a topical product; if there is potential for inhalation, respiratory protection is recommended (NIOSH 2016). Assess risk to determine appropriate containment strategy (USP-NF 2017).

Medication Guide and/or Vaccine Information Statement (VIS)

An FDA-approved patient medication guide, which is available with the product information and at http://www.fda.gov/downloads/Drugs/DrugSafety/ucm088996.pdf, must be dispensed with this medication.

Use: Labeled Indications

Atopic dermatitis (moderate to severe): Treatment of moderate to severe atopic dermatitis in immunocompetent patients not responsive to conventional therapy or when conventional therapy is not appropriate.

Use: Off-Label: Adult

Allergic contact dermatitis; Atopic dermatitis (maintenance therapy); Oral lichen planus; Psoriasis (intertriginous and facial); Pyoderma gangrenosum (refractory); Vitiligo

Medication Safety Issues
Sound-alike/look-alike issues:

Tacrolimus may be confused with everolimus, pimecrolimus, sirolimus, tamsulosin, temsirolimus

High alert medication:

This medication is in a class the Institute for Safe Medication Practices (ISMP) includes among its list of drug classes that have a heightened risk of causing significant patient harm when used in error.

Metabolism/Transport Effects

Substrate of CYP3A4 (minor); Note: Assignment of Major/Minor substrate status based on clinically relevant drug interaction potential

Drug Interactions

Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the Lexicomp drug interactions program by clicking on the “Launch drug interactions program” link above.

Alcohol (Ethyl): May enhance the dermatologic adverse effect of Tacrolimus (Topical). Risk C: Monitor therapy

Corticosteroids (Systemic): May enhance the immunosuppressive effect of Tacrolimus (Topical). Risk X: Avoid combination

CYP3A4 Inhibitors (Moderate): May increase the serum concentration of Tacrolimus (Topical). Risk C: Monitor therapy

CYP3A4 Inhibitors (Strong): May increase the serum concentration of Tacrolimus (Topical). Risk C: Monitor therapy

Immunosuppressants (Cytotoxic Chemotherapy): May enhance the immunosuppressive effect of Tacrolimus (Topical). Risk X: Avoid combination

Immunosuppressants (Miscellaneous Oncologic Agents): May enhance the immunosuppressive effect of Tacrolimus (Topical). Risk X: Avoid combination

Immunosuppressants (Therapeutic Immunosuppressant Agents): May enhance the immunosuppressive effect of Tacrolimus (Topical). Risk X: Avoid combination

Methotrexate: May enhance the immunosuppressive effect of Tacrolimus (Topical). Risk X: Avoid combination

Reproductive Considerations

Topical tacrolimus may be used for the treatment of atopic dermatitis and psoriasis in patients planning a pregnancy (AAD-NPF [Elmets 2021]; Vestergaard 2019).

Pregnancy Considerations

Tacrolimus crosses the human placenta following systemic use.

When preferred treatments are insufficient, topical tacrolimus may be used for the treatment of atopic dermatitis and psoriasis in pregnant patients (AAD-NPF [Elmets 2021]; Vestergaard 2019).

Also refer to the Tacrolimus (Systemic) monograph for additional information

Breastfeeding Considerations

Tacrolimus is present in breast milk following systemic administration.

Due to the potential for adverse reactions in the breastfed infant, the manufacturer recommends a decision be made to discontinue breastfeeding or to discontinue the drug, considering the importance of treatment to the mother. Apply tacrolimus immediately after breastfeeding; avoid use on nipples and clean nipples prior to the next feeding (AAD-NPF [Elmets 2021]; Vestergaard 2019).

Refer to the Tacrolimus (Systemic) monograph for additional information.

Mechanism of Action

Suppresses cellular immunity (inhibits T-lymphocyte activation), by binding to an intracellular protein, FKBP-12 and complexes with calcineurin dependent proteins to inhibit calcineurin phosphatase activity

Pharmacokinetics (Adult Data Unless Noted)

Absorption: Minimally absorbed; serum concentrations range from undetectable to 20 ng/mL (~2 ng/mL in majority of adult patients studied)

Bioavailability: ~0.5%

Brand Names: International
International Brand Names by Country
For country code abbreviations (show table)

  • (AE) United Arab Emirates: Protopic | Tacroz | Tacroz forte;
  • (AR) Argentina: Protopic | Tacro Tic | Tacroderm;
  • (AT) Austria: Protopic | Tacrolimus accord;
  • (BD) Bangladesh: Atolimus | Dermus | Remus | Tacroderm | Tacrol | Tacrolim | Vitilimus;
  • (BE) Belgium: Protopic | Takrozem;
  • (BG) Bulgaria: Protopic;
  • (BR) Brazil: Atobach | Cropoc | Protopic | Tacrolimo | Tacroz | Tarfic;
  • (CH) Switzerland: Protopic;
  • (CL) Chile: Cromidin | Proalid | Protopic | T inmun;
  • (CN) China: Protopic;
  • (CO) Colombia: Cromus | Sineczem | T inmun;
  • (CZ) Czech Republic: Protopic;
  • (DE) Germany: Protopic | Tacrolimus dermapharm | Takrozem;
  • (DO) Dominican Republic: Cromus | Protopic | Tacroz | Talgraf;
  • (EC) Ecuador: Cromus | T inmun | Tacroz;
  • (EE) Estonia: Lebsanan;
  • (EG) Egypt: Protopic | Tarolimus | Treczimus;
  • (ES) Spain: Cellmune | Takrozem;
  • (FI) Finland: Protopic | Tacrolimus accord | Takrozem;
  • (FR) France: Protopic | Takrozem;
  • (GB) United Kingdom: Dermitopic | Protopic | Tacrolimus | Tacrolimus accord;
  • (GR) Greece: Protopic;
  • (HK) Hong Kong: Protopic | Remus;
  • (HR) Croatia: Protopic;
  • (HU) Hungary: Protopic;
  • (ID) Indonesia: Protopic;
  • (IE) Ireland: Protopic;
  • (IL) Israel: Protopic;
  • (IN) India: Acroli | Atomus | Crolim | Crolimate | Crolin power | Eczrid | Eczrid forte | Hhmus | Imederm | Imograf | Laxoderm | Loprolif | Mustopic | Mylimus | Olix | Olmis | Pangraf | T Top | Tacel | Taclus | Tacmod | Tacoba forte | Tacoryza | Tacrimus | Tacro | Tacrofit | Tacrojon | Tacrokid | Tacromiz | Tacropure | Tacrotopic | Tacrotor | Tacroz | Tacsite | Tacvido | Tacvido forte | Takfa | Talimus | Tames forte | Tbis | Tecrosis | Tecrosis f | Topgraf;
  • (IT) Italy: Carelimus | Protopic | Takrozem;
  • (JO) Jordan: Atopic | Protopic | Tacrus;
  • (JP) Japan: Protopic;
  • (KE) Kenya: Eczemus | Remus | Rocimus | Tacrovate | Tacrovate forte | Tacroz forte | Tacrus | Talimus;
  • (KR) Korea, Republic of: Protopic | Tacro | Topicro;
  • (KW) Kuwait: Protopic;
  • (LB) Lebanon: Protopic | Tacro Tic | Tacrus;
  • (LT) Lithuania: Lebsanan | Protopic;
  • (LU) Luxembourg: Protopic | Takrozem;
  • (LV) Latvia: Protopic;
  • (MX) Mexico: Arnaltem | Icralomidina | Limustin | Proalid | Protopic | Tenacrine | Traderma;
  • (MY) Malaysia: Protopic;
  • (NL) Netherlands: Protopic | Tacrolimus accord | Takrozem;
  • (NO) Norway: Protopic | Takrolimus accord | Takrozem;
  • (NZ) New Zealand: Protopic | Zematop;
  • (PE) Peru: Prodermic | Protopic | T inmun | Tacro Tic | Tacroz | Tacroz forte;
  • (PH) Philippines: Protopic | Rocimus | Tacroz;
  • (PK) Pakistan: Arilio | Crolimus | Eczemus | Eramus | Imunol | Prolimus | Romlus | Tacrocal | Tacrol | Tacrolim | Tacrozemus | Taczem | Topmus;
  • (PL) Poland: Dermitopic | Protopic;
  • (PR) Puerto Rico: Protopic;
  • (PT) Portugal: Protopic | Tacrolimus cantabria | Takrozem;
  • (PY) Paraguay: T inmun;
  • (QA) Qatar: Protopic | Tacroz | Tacroz Forte;
  • (RO) Romania: Protopic;
  • (RU) Russian Federation: Protopic | Tacropic;
  • (SA) Saudi Arabia: Protopic | Tacroz | Tacroz forte | Viotopic;
  • (SE) Sweden: Protopic | Takrolimus 2care4 | Takrolimus abacus medicine | Takrolimus accord | Takrolimus ebb | Takrozem;
  • (SG) Singapore: Protopic;
  • (SI) Slovenia: Protopic;
  • (SK) Slovakia: Protopic;
  • (TH) Thailand: Protopic;
  • (TN) Tunisia: Protopic;
  • (TR) Turkey: Tacrolin | Topiclin;
  • (TW) Taiwan: Protopic | Tacroli;
  • (UA) Ukraine: Protopic;
  • (UG) Uganda: Eczemus | Tacroz | Tacroz forte;
  • (UY) Uruguay: Protopic | Tacroderm;
  • (VE) Venezuela, Bolivarian Republic of: Cromus | Tacroz | Teinmun;
  • (VN) Viet Nam: Imutac | Quantopic;
  • (ZA) South Africa: Protopic;
  • (ZM) Zambia: Talimus;
  • (ZW) Zimbabwe: Tacroz forte
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