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Tacrolimus (FK506) and the pharmaceutical/academic/regulatory gauntlet

Starzl, TE and Todo, S and Demetris, AJ and Fung, JJ (1998) Tacrolimus (FK506) and the pharmaceutical/academic/regulatory gauntlet. American Journal of Kidney Diseases, 31 (6 SUPP). ISSN 0272-6386

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Abstract

The pivotal issue of transplant rejection diagnosis and management is design, conduct, and analysis of clinical trials. The historical experience with clinical trials of major immunosuppressive drugs (cyclosporine and especially tacrolimus) is examined in this article. Cyclosporine was a turning point in transplantation, providing an extraordinary improvement over previous therapies. Additionally, early investigational experience with tacrolimus was shown to be important in rescue from cyclosporine failure. Experience with tacrolimus in liver recipients for primary therapy led to understanding that the side effect profile was similar to cyclosporine and that the important side effects of tacrolimus (toxicity and diabetes) could be lessened by altering the drug dose. Early dosing regimens were determined by attempts to balance the toxicities (representing a dose ceiling) against rejection (for minimum dosing). Drug levels became understandable and trough levels could be used to guide therapy. However, when the multicenter liver trial was implemented, high starting doses were included in the protocol design, ignoring information obtained with drug level monitoring. Disregard for this information led to a distortion of the potential value of tacrolimus. Historical controls from the Pittsburgh experience suggested that tacrolimus was a critical immunosuppressant, and the randomized trial against cyclosporine confirmed the drug's ability to compete. The multicenter liver trial, however, was not balanced across treatment arms for other immunosuppressive agents (ie, higher doses of prednisone from center to center, additional induction protocols at various centers). Additionally, analysis of study results differed across continents, and the role of tacrolimus in cyclosporine rescue was not examined thoroughly. When tacrolimus was proposed for use in extrahepatic organ transplantation, again the Pittsburgh experience, as well as experience from other single centers, was determined inadequate evidence of efficacy, and randomized trials were required by the FDA. The fact that multicenter trials in transplantation have historically been poorly designed or analyzed weighed against the dramatic improvements shown from historically controlled studies or single-center trials should lead to question of the regulatory requirement for multicenter randomized trials for all organ types.


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Details

Item Type: Article
Status: Published
Creators/Authors:
CreatorsEmailPitt UsernameORCID
Starzl, TEtes11@pitt.eduTES11
Todo, S
Demetris, AJ
Fung, JJ
Centers: Other Centers, Institutes, or Units > Thomas E. Starzl Transplantation Institute
Date: 1 January 1998
Date Type: Publication
Journal or Publication Title: American Journal of Kidney Diseases
Volume: 31
Number: 6 SUPP
Event Type: Conference
DOI or Unique Handle: 10.1053/ajkd.1998.v31.pm9631858
Institution: University of Pittsburgh
Refereed: Yes
ISSN: 0272-6386
Other ID: uls-drl:31735062133149, Starzl CV No. 1850
Date Deposited: 08 Apr 2010 17:31
Last Modified: 07 Apr 2019 01:55
URI: http://d-scholarship.pitt.edu/id/eprint/5236

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