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Anti-Rejection Drug Interactions: The Complete List of Foods, Medicines and Supplements to Watch — Grapefruit, Pomelo, Paxlovid, NSAIDs, Herbs and Vaccines (v1.1, updated 2026-10-13)

Beyond CKD 24 min de lecture

What "fights" with tacrolimus, cyclosporine, sirolimus, mycophenolate and azathioprine after a kidney transplant? A red/amber/orange-graded list of 60+ foods, herbs, supplements, prescription drugs and vaccines, with practical habits, a version history and 21 references.

Version v1.1 | Updated 13 October 2026 (v1.0 first edition same day; v1.1 adds "2b. Deep dive"). Compiled from prescribing information, the KDIGO transplant care guideline, the American Society of Transplantation (AST) vaccination guideline and peer-reviewed literature (listed at the end) by a non-physician site owner. Not medical advice. Your regimen, doses and target levels are individual — ask your transplant team or pharmacist before adding or stopping any medicine or supplement.

Why anti-rejection drugs are so easily "disturbed"

Most anti-rejection drugs used after kidney transplant share two traits: a narrow therapeutic window (slightly too high damages the kidney, slightly too low invites rejection) and metabolism through the liver enzyme CYP3A4 and the intestinal transporter P-glycoprotein (P-gp). Any food, drug or herb that inhibits or induces these pathways swings blood levels widely. First know which class you take:

Class Common names Main pathway Biggest risk
Calcineurin inhibitors (CNI) Tacrolimus (Prograf, Advagraf, Envarsus XR), Cyclosporine (Neoral) CYP3A4, P-gp High level → kidney toxicity, high potassium, tremor; low level → rejection
mTOR inhibitors Sirolimus (Rapamune), Everolimus (Certican/Zortress) CYP3A4, P-gp As above; plus poor wound healing, mouth ulcers, high lipids
Antimetabolites Mycophenolate (CellCept, Myfortic), Azathioprine (Imuran) Glucuronidation, renal excretion; AZA via xanthine oxidase Absorption blocked by antacids/iron; AZA + urate-lowering drugs → bone-marrow suppression
Corticosteroids Prednisolone, Methylprednisolone CYP3A4 (less sensitive) Blood sugar, blood pressure, bone, infection
Biologics Belatacept (Nulojix, IV) Protein catabolism, almost no CYP interactions Infection; contraindicated if EBV-seronegative

1. Food and drink

1-1 🔴 Avoid completely

Food Effect Notes
Grapefruit, grapefruit juice Tacrolimus/cyclosporine/sirolimus levels rise (up to 2–5×) Furanocoumarins irreversibly inhibit gut CYP3A4; one glass lasts 24–72 h — "taking the dose the next day" does not help
Pomelo Same The classic Mid-Autumn Festival cause of tacrolimus spikes in Asia; Japanese case report of pomelo-induced toxicity
Seville (bitter) orange, marmalade Same Sweet oranges and mandarins are not a problem
Star fruit (carambola), incl. juice and candied Neurotoxicity in impaired kidneys (intractable hiccups, confusion, seizures); may inhibit CYP3A4 Contraindicated for all CKD, dialysis and transplant patients
St John's wort Tacrolimus/cyclosporine/sirolimus levels fall 30–60% → rejection Common in "natural antidepressant" supplements and herbal teas; takes ~2 weeks to wash out
Alcohol + extended-release tacrolimus (Advagraf/Envarsus/Astagraf XL) Alcohol accelerates release — a full day's dose dumps at once Label warning: avoid alcohol around dosing; less critical with immediate-release Prograf but still not advised

1-2 🟡 Use caution

Food Effect Advice
Pomegranate, pomegranate juice Case reports of raised tacrolimus Occasional small amounts OK; no daily juice
High-fat meals Tacrolimus absorption falls (AUC −~30%); sirolimus absorption rises What matters is consistency — same relation to food every day, or trough levels are meaningless
High-potassium foods (banana, orange juice, tomato, potato, salt substitutes/low-sodium soy sauce) Tacrolimus/cyclosporine themselves raise potassium; salt substitutes use potassium chloride Potassium limits are looser than on dialysis, but avoid salt substitutes and potassium supplements; check labs
Raw/undercooked food, unpasteurised dairy, raw salads, oysters, runny eggs Not an interaction — infection risk (Listeria, Salmonella, Toxoplasma) Especially the first 6 months and during high-dose periods
Large amounts of green tea / coffee Limited evidence; high-dose EGCG extract capsules may affect CYP3A4 and liver Brewed tea is fine; avoid concentrated extracts
Liquorice (herbal formulas, sweets, tea) Potentiates steroids → low potassium, high blood pressure, oedema Avoid large amounts on long-term steroids

1-3 🟠 Herbs and supplements

The thing patients most often "forget to mention." Rule of thumb: anything marketed to "boost immunity" is working against your anti-rejection drugs.

Item Risk Evidence
Schisandra (Wuzhi capsule) Tacrolimus level ~2× higher (CYP3A4/P-gp inhibition) Healthy-volunteer PK study; used deliberately in China to "spare" drug — dangerous without monitoring
Berberine (Coptis, Phellodendron) Cyclosporine level rises Trial in kidney transplant recipients
High-dose curcumin/turmeric capsules Case report: acute tacrolimus nephrotoxicity (level ~8 → >29 ng/mL) Case report; culinary turmeric is fine
Cannabidiol (CBD) oil Tacrolimus ~3× higher Case report (Am J Transplant 2019)
Red yeast rice Contains natural lovastatin; with cyclosporine → rhabdomyolysis Same as statin interaction
Echinacea, astragalus, reishi, agaricus, cat's claw, cordyceps Immunostimulant — theoretically antagonises immunosuppression; some CYP effects Low-grade evidence, but transplant centres uniformly advise avoid
Ginseng CYP3A4 and glucose effects; case reports of lower tacrolimus Avoid
Chamomile (large amounts) Case report of raised cyclosporine Occasional cup OK
Probiotics (esp. Saccharomyces boulardii) No level change, but fungaemia cases in heavily immunosuppressed patients Avoid live products in year 1, in hospital or with a central line
Fish oil, vitamin D, calcium, iron, magnesium No effect on CNI levels; but calcium, iron, magnesium and aluminium antacids block mycophenolate absorption Separate from CellCept/Myfortic by ≥2 hours
High-dose vitamin C / E No clear interaction; megadose vitamin C raises oxalate stone risk Stay within recommended intake

One line: herbal remedies, "kidney tonics", wellness teas — ask your doctor or pharmacist first. If you see a traditional-medicine practitioner, show them your anti-rejection prescription.

2. Medicines

2-1 🔴 Raise tacrolimus/cyclosporine/sirolimus levels (CYP3A4/P-gp inhibitors)

Class Drugs Severity What to do
COVID-19 oral antivirals Paxlovid (nirmatrelvir/ritonavir) ★★★ Extreme: ritonavir raises tacrolimus tens of times; multiple acute kidney failure reports Tell the prescriber you are a transplant recipient. Most centres hold tacrolimus during Paxlovid and resume 2–3 days after by level, or use molnupiravir/remdesivir instead
Azole antifungals Ketoconazole, itraconazole, voriconazole, posaconazole, fluconazole (dose-dependent) ★★★ Pre-emptive tacrolimus reduction by 1/3–2/3 with frequent levels
Macrolide antibiotics Clarithromycin, erythromycin ★★★ Common in H. pylori regimens and bronchitis; azithromycin has minimal effect — ask to switch
Calcium-channel blockers Diltiazem, verapamil, nicardipine (amlodipine minor) ★★ Some centres co-prescribe diltiazem deliberately; the key is never stop or start it on your own
HIV / hepatitis C drugs Ritonavir, cobicistat, some DAAs (e.g. glecaprevir/pibrentasvir with cyclosporine) ★★★ Joint ID–transplant management
CMV prophylaxis Letermovir (Prevymis) ★★ Raises cyclosporine and tacrolimus
Antiarrhythmics Amiodarone, dronedarone ★★ Long half-life — effect persists for weeks
Others Metoclopramide (↑absorption), nefazodone, fluvoxamine, imatinib, ticagrelor ★–★★ Check a level when starting or stopping

2-2 🔴 Lower levels (CYP3A4 inducers) → rejection risk

Drug Notes
Rifampin, rifabutin The classic tuberculosis problem — tacrolimus may fall >50%; dose must rise 2–5× with close monitoring
Phenytoin, carbamazepine, phenobarbital, oxcarbazepine Older antiepileptics; levetiracetam and lamotrigine do not interact — ask neurology about alternatives
Efavirenz, nevirapine HIV drugs
Modafinil, bosentan, enzalutamide, apalutamide Less common but monitor
St John's wort See food section

2-3 🔴 Additive kidney toxicity (levels unchanged, but both hurt the kidney)

Drug Notes
NSAIDs: ibuprofen, diclofenac, naproxen, mefenamic acid, celecoxib, etoricoxib Use acetaminophen/paracetamol for pain. Dental, orthopaedic and over-the-counter products often contain NSAIDs — always say "I have a kidney transplant." Avoid large-area long-term topical NSAID patches too
Aminoglycosides (gentamicin, amikacin), vancomycin, colistin, amphotericin B Hospital antibiotics; dose adjustment and monitoring
Iodinated contrast (CT, angiography) Tell the transplant team before the scan; hydration and review of other nephrotoxins
High-dose IV acyclovir/valacyclovir Crystal nephropathy; usual oral doses are relatively safe

2-4 🟡 Additive hyperkalaemia

Tacrolimus and cyclosporine already raise potassium. Check potassium regularly when combined with ACE inhibitors/ARBs, spironolactone, eplerenone, trimethoprim (co-trimoxazole/Bactrim — routine Pneumocystis prophylaxis after transplant), potassium supplements, salt substitutes, long-term heparin.

2-5 🔴 Specific combinations to remember

Combination Consequence Action
Azathioprine + allopurinol or febuxostat Xanthine oxidase blocked → AZA metabolites accumulate → severe bone-marrow suppression Tell your doctor if you have gout; if unavoidable, AZA reduced to 1/4–1/3 with frequent blood counts — most centres switch to mycophenolate
Cyclosporine + simvastatin/lovastatin/high-dose atorvastatin Statin levels rise several-fold → rhabdomyolysis Use pravastatin, fluvastatin or low-dose rosuvastatin; tacrolimus interacts less but still monitor
Cyclosporine + colchicine Myoneuropathy Tell your doctor during gout flares
Cyclosporine + digoxin Digoxin toxicity Monitor
Mycophenolate + Al/Mg antacids, iron, calcium, sevelamer, cholestyramine MPA absorption falls 20–40% Separate by ≥2 hours
Mycophenolate (CellCept) + proton-pump inhibitors (omeprazole, pantoprazole…) CellCept needs acid to dissolve — exposure −~25%; Myfortic unaffected Tell your doctor if on long-term PPI
Mycophenolate + acyclovir/valacyclovir/ganciclovir/valganciclovir Compete for tubular secretion — both rise More marked with reduced kidney function; common during CMV prophylaxis — monitor blood counts
Mycophenolate + oral contraceptives Contraceptive efficacy may fall; mycophenolate is highly teratogenic Two methods of contraception; switch drugs ≥6 weeks before planned pregnancy
Sirolimus + cyclosporine Sirolimus level rises Separate doses by 4 hours
Sirolimus/everolimus + ACE inhibitors Higher angioedema risk Watch for face, lip, tongue swelling
Tacrolimus + other QT-prolonging drugs (some antipsychotics, high-dose ondansetron, fluoroquinolones) Arrhythmia Tell your doctor if you have heart disease

2-6 🔴 Vaccines: live attenuated vaccines are contraindicated

Contraindicated (live) Allowed (inactivated/subunit)
MMR, varicella, live zoster (Zostavax), yellow fever, oral typhoid, BCG, nasal-spray influenza, oral polio, live smallpox/mpox Influenza (injection), COVID-19, pneumococcal (PCV20/PPSV23), hepatitis B, recombinant zoster (Shingrix), HPV, tetanus, RSV, hepatitis A, meningococcal
  • If a travel destination requires yellow fever vaccination, obtain a medical exemption letter from your transplant clinic.
  • Household members may receive live vaccines; wear gloves and wash hands when changing nappies for 4 weeks after an infant's rotavirus vaccine.

2b. Deep dive: how much do levels actually change? (public databases and literature)

New in v1.1. Figures below come from prescribing information (FDA labels / EMA SmPCs), the clinical pharmacokinetic studies cited in FDA drug-interaction guidance, and peer-reviewed literature. AUC = area under the concentration–time curve (total exposure); Cmax = peak concentration; "×" = ratio with vs without the interacting agent. Numbers vary with study design and population — they illustrate magnitude and must never be used to self-adjust doses.

Free, verifiable public databases

Database Provider What to look up Short link
DailyMed US National Library of Medicine Full US labels (Section 7 Drug Interactions; Section 12.3 Pharmacokinetics gives actual fold-changes) /go/dailymed
Drugs@FDA US FDA Approval packages incl. Clinical Pharmacology Reviews with raw PK data /go/fda
FDA Table of Substrates, Inhibitors and Inducers US FDA Official strong/moderate/weak CYP3A4 and P-gp classification /go/fda-ddi
EMA EPAR / SmPC European Medicines Agency European labels, Section 4.5 /go/ema
Flockhart Cytochrome P450 Drug Interaction Table Indiana University School of Medicine Quick substrate/inhibitor/inducer lookup per CYP /go/flockhart
Liverpool Drug Interactions (HIV/HEP/COVID) University of Liverpool Traffic-light checker for antivirals (incl. Paxlovid) vs immunosuppressants /go/liverpool
PharmGKB Stanford University CYP3A5 genotype–tacrolimus dosing evidence /go/pharmgkb
CPIC guidelines Clinical Pharmacogenetics Implementation Consortium CYP3A5–tacrolimus dosing recommendation (2015) /go/cpic
DrugBank University of Alberta Interaction summaries and mechanisms (free tier) /go/drugbank
Taiwan TFDA licence search Taiwan FDA Approved products and Chinese labels /go/tfda

Tacrolimus: quantified interactions

Co-administered agent Change in tacrolimus exposure Source
Ritonavir (in Paxlovid) Healthy volunteers: tacrolimus AUC ↑ ~57-fold, half-life 32 h → 232 h after a single 100 mg ritonavir dose; clinical cases >100 ng/mL Badri et al. 2015; Paxlovid FDA label §7; Lange et al. 2022
Ketoconazole 200 mg/day Oral bioavailability 14% → 30% (~2×); most centres cut dose 50–75% Floren et al. 1997; Prograf FDA label §12.3
Voriconazole Healthy volunteers: AUC ↑ 3.2×, Cmax ↑ 2.2×; label advises reducing tacrolimus to one-third Vfend FDA label §7
Posaconazole AUC ↑ 4.6×, Cmax ↑ 2.2×; label advises ~two-thirds reduction Noxafil FDA label §7
Itraconazole Case series: 2–3× rise, ~50% dose reduction Prograf label §7; Capone et al. 1996
Fluconazole 200 mg/day Kidney recipients: ~1.4–2× rise (dose-dependent; 100 mg less) Mañez et al. 1994
Clarithromycin Case series: 2–3× rise within 24–48 h Wolter et al. 1994; Prograf label §7
Erythromycin Cases: 2–4× rise Shaeffer et al. 1994
Azithromycin No significant change (not CYP3A4-dependent) Page et al. 2011
Diltiazem 180 mg/day Kidney recipients: tacrolimus dose requirement ↓ 25–50% (C/D ratio ↑ 1.5–2×) Hebert et al. 1999; Jones et al. 1997
Verapamil ~2× rise Prograf label §7
Amlodipine Mostly no significant effect; minor rises in a few reports Prograf label §7 (listed as weak)
Letermovir 480 mg/day Healthy volunteers: AUC ↑ 2.4×, Cmax ↑ 1.6× Prevymis FDA label §7
Amiodarone Cases: 2–3× rise, persisting weeks after stopping Nalli et al. 2011
Nirmatrelvir alone Weak CYP3A4 inhibitor in vitro; clinical interaction driven by ritonavir Paxlovid label §12.3
Rifampin 600 mg/day Healthy volunteers: oral tacrolimus AUC ↓ 68%, clearance ↑ 47%; clinically 2–5× dose increases Hebert et al. 1999; Prograf label §7
Phenytoin Cases: >50% fall; phenytoin levels may also rise Thompson et al. 1996
Carbamazepine Falls requiring dose increase; paediatric reports of 2–3× doses Prograf label §7
St John's wort 600 mg/day (0.3% hypericin) Kidney recipients: tacrolimus AUC ↓ 58%, Cmax ↓ 65%; doses had to be raised back after stopping Hebert et al. 2004; Mai et al. 2003
Grapefruit juice (250 mL/day for days) Liver recipients: ~2–5× rise (high inter-individual variability) Liu et al. 2009; Peynaud et al. 2007
Pomelo Case: level 10 → >25 ng/mL Egashira et al. 2003
Schisandra extract (Wuzhi capsule) Healthy volunteers: AUC ↑ 2.6×, Cmax ↑ 2.2×; in kidney recipients AUC ↑ 1.5–2× Xin et al. 2007; Qin et al. 2013
High-dose curcumin Case: level 8.4 → 29.9 ng/mL, acute kidney injury Nayeri et al. 2017
CBD oil (2000–2900 mg/day) Case: ~3× rise in dose-normalised level Leino et al. 2019
High-fat meal Healthy volunteers: tacrolimus AUC ↓ 27–37%, Cmax ↓ 50–77% vs fasting Prograf FDA label §12.3
Alcohol + Envarsus XR In-vitro dissolution: markedly faster release in 40% ethanol within 2 h; labelled warning Envarsus XR FDA label §2, §7

Cyclosporine: quantified interactions

Agent Change in cyclosporine exposure Source
Ketoconazole 200 mg/day Dose requirement ↓ 70–85% (historically used deliberately to spare drug) First et al. 1993; Neoral label §7
Diltiazem Dose requirement ↓ ~30–50% Neoral label §7
Clarithromycin ~1.5–2× rise Neoral label §7
Rifampin 70–80% fall; 2–5× dose increases Neoral label §7
St John's wort Kidney/heart recipients: 30–60% fall; multiple acute rejection reports (incl. 2 heart-transplant rejections) Ruschitzka et al. 2000; Breidenbach et al. 2000
Grapefruit juice 200 mL Kidney recipients: AUC ↑ ~40–60% Ducharme et al. 1995
Berberine 300 mg tid Kidney recipients: AUC ↑ ~35%, C/D ratio ↑ 88% Wu et al. 2005
Simvastatin 80 mg + cyclosporine Simvastatin AUC ↑ ~2.5–8×, rhabdomyolysis; label limits simvastatin to ≤10 mg or contraindicates Zocor FDA label §7; Neuvonen et al. 2006
Atorvastatin + cyclosporine Atorvastatin AUC ↑ 8.7×; avoid or ≤10 mg Lipitor FDA label §7
Rosuvastatin + cyclosporine Rosuvastatin AUC ↑ 7×; limit 5 mg Crestor FDA label §7
Pravastatin + cyclosporine AUC ↑ 5–10× yet few myopathy reports; still a preferred choice (start ≤20 mg) Pravachol label §7
Colchicine + cyclosporine Colchicine AUC ↑ 3.2×; multiple myoneuropathy cases Colcrys FDA label §7

Sirolimus / Everolimus

Agent Change Source
Ketoconazole Sirolimus AUC ↑ 10.9×, Cmax ↑ 4.4× — labelled contraindicated Rapamune FDA label §7
Voriconazole Sirolimus AUC ↑ 11× — contraindicated Vfend label §7
Diltiazem Sirolimus AUC ↑ 60%, Cmax ↑ 43% Rapamune label §7
Verapamil Sirolimus AUC ↑ 2.2×; verapamil AUC itself ↑ 1.5× Rapamune label §7
Erythromycin Sirolimus AUC ↑ 4.2× Rapamune label §7
Rifampin Sirolimus AUC ↓ 82% Rapamune label §7
Cyclosporine simultaneous vs 4 h apart Simultaneous: sirolimus AUC ↑ 230%; 4 h apart: ↑ 80% Rapamune label §7
High-fat meal Oral solution AUC ↑ 35%; tablets ↑ 23–35% Rapamune label §12.3
Everolimus + ketoconazole Everolimus AUC ↑ 15× Zortress FDA label §7

Mycophenolate

Agent Change in MPA (active metabolite) Source
Mg/Al antacids MMF: MPA AUC ↓ 17%, Cmax ↓ 33% CellCept FDA label §7
Sevelamer 2400 mg MPA AUC ↓ 25%, Cmax ↓ 30% CellCept label §7; Pieper et al. 2004
Cholestyramine 4 g tid MPA AUC ↓ 40% CellCept label §7
Pantoprazole 40 mg bid MMF: MPA AUC ↓ 27%, Cmax ↓ 57%; Myfortic (enteric-coated) unaffected Kofler et al. 2009; Rupprecht et al. 2009
Rifampin Heart–lung recipient: MPA AUC ↓ 70% (UGT induction and intestinal efflux) Kuypers et al. 2005
Acyclovir / Ganciclovir Both AUCs rise slightly (tubular competition); more marked with reduced kidney function CellCept label §7
Cyclosporine (vs tacrolimus) MPA AUC is ~30–40% lower with cyclosporine than with tacrolimus (CsA blocks enterohepatic recirculation) — the main reason MPA levels shift when switching CNIs van Gelder et al. 2001
Oral contraceptives Levonorgestrel AUC ↓ 15%; pregnancy risk is mainly teratogenicity rather than contraceptive failure CellCept label §7, §8.1

Azathioprine

Agent Change Source
Allopurinol 6-MP/6-TGN levels ↑ 3–5×; AZA must be cut to 25–33%, severe leukopenia still reported Imuran FDA label §7; Kennedy et al. 1996
Febuxostat Also a xanthine-oxidase inhibitor; labelled contraindicated with AZA Uloric FDA label §4
Warfarin AZA reduces warfarin effect (INR falls); INR rebounds when AZA is stopped Imuran label §7
ACE inhibitors Case reports of worsened leukopenia/anaemia Imuran label §7

Pharmacogenomics: why the same dose gives such different levels

  • CYP3A5 genotype: carriers of at least one CYP3A5*1 (expresser) allele (~30–40% of East Asians, ~70% of people of African ancestry, ~10–20% of Europeans) metabolise tacrolimus faster and need roughly 1.5–2× the dose to reach the same level. CPIC 2015 recommends a 1.5–2× starting dose for expressers (not exceeding 0.3 mg/kg/day) with continued monitoring.
  • CYP3A4*22: reduced activity; carriers need lower doses (~5–7% of Europeans, rare in Asians).
  • ABCB1 (P-gp) polymorphisms: small and inconsistent effect on tacrolimus levels — not recommended as a dosing basis.
  • In practice: some centres offer CYP3A5 testing; useful for reaching target quickly early after transplant, but it does not replace level monitoring.

Three reminders when reading these numbers

  1. Fold-changes are averages: the same drug may be 1.5× in one person and 5× in another — which is why "re-check the level 3–7 days after starting or stopping any interacting drug" matters more than memorising figures.
  2. Rebound after stopping is just as dangerous: when an inhibitor stops (end of Paxlovid, stopping diltiazem), tacrolimus levels fall back within days — if the dose was lowered, rejection risk follows; when an inducer stops (rifampin, St John's wort), levels climb back toward toxicity.
  3. Labels are the most reliable and conservative source: most figures above can be found directly in Sections 7 and 12.3 of the corresponding DailyMed label; where a label and an online article disagree, trust the label.

3. Practical habits

  1. Carry an "anti-rejection drug card": drug names, doses, latest trough level, transplant centre phone. Show it at the dentist, ER, pharmacy and any practitioner.
  2. Three questions: "Will this affect my tacrolimus/cyclosporine level?" "Is it harmful to the kidney or does it raise potassium?" "Should I get an extra level checked?"
  3. Re-check the level 5–7 days after any new drug — CYP3A4 effects usually stabilise in 3–5 days.
  4. Be consistent: same time daily, same relationship to food, no brand switching without a level (Prograf ↔ generics included).
  5. Lab day: draw the trough before the morning dose, then take it. A post-dose level is meaningless.
  6. Keep an up-to-date medication list (app or national health record) and show it at every clinic visit.
  7. In Taiwan, at every clinic, dental office or pharmacy, ask the front desk / nurse / pharmacist to read your NHI IC-card orders and the NHI cloud medication record (雲端藥歷). It lists every prescription you have received across institutions — the most direct way to catch duplicate or interacting drugs — but only if someone actually opens it. Abroad, carry a printed medication list instead.

Version history

Version Date Content
v1.0 2026-10-13 First edition: 5 drug classes, food/herb/drug interactions, vaccines, practical habits, references
v1.1 2026-10-13 Added "2b. Deep dive": 10 public databases, 60+ quantified interactions for tacrolimus/cyclosporine/sirolimus/mycophenolate/azathioprine (AUC/Cmax fold-changes with label sections), CYP3A5 pharmacogenomics, rebound-after-stopping reminders; references expanded to 39

(Planned next update: interactions with newer oral antivirals and emerging agents such as belatacept/tegoprubart.)

References

  1. Astellas Pharma. Prograf / Advagraf / Envarsus XR Prescribing Information (alcohol and extended-release warnings).
  2. Novartis. Sandimmun Neoral (cyclosporine) Prescribing Information.
  3. Roche. CellCept Prescribing Information; Novartis. Myfortic Prescribing Information.
  4. Pfizer. Rapamune (sirolimus) Prescribing Information.
  5. KDIGO Transplant Work Group. KDIGO Clinical Practice Guideline for the Care of Kidney Transplant Recipients. Am J Transplant. 2009;9(Suppl 3):S1-S155.
  6. Bailey DG, Dresser G, Arnold JM. Grapefruit–medication interactions. CMAJ. 2013;185(4):309-316.
  7. Egashira K, et al. Pomelo-induced increase in the blood level of tacrolimus in a renal transplant patient. Transplantation. 2003;75(7):1057.
  8. Neto MM, et al. Intoxication by star fruit in 32 uraemic patients. Nephrol Dial Transplant. 2003;18(1):120-125.
  9. Nowack R. CYP450- and transporter-mediated herb–drug interactions in renal transplant patients. Nephrology (Carlton). 2008;13(4):337-347.
  10. Xin HW, et al. Effects of Schisandra sphenanthera extract on the pharmacokinetics of tacrolimus. Br J Clin Pharmacol. 2007;64(4):469-475.
  11. Wu X, et al. Effects of berberine on the blood concentration of cyclosporin A in renal transplanted recipients. Eur J Clin Pharmacol. 2005;61(8):567-572.
  12. Nayeri A, et al. Acute calcineurin inhibitor nephrotoxicity secondary to turmeric intake. Transplant Proc. 2017;49(1):198-200.
  13. Leino AD, et al. Clinically significant drug-drug interaction between cannabidiol and tacrolimus. Am J Transplant. 2019;19(10):2944-2948.
  14. Lange NW, et al. Nirmatrelvir/ritonavir use: managing drug-drug interactions with transplant immunosuppressants. Am J Transplant. 2022;22(7):1925-1926.
  15. Salerno DM, et al. Early clinical experience with nirmatrelvir/ritonavir in solid organ transplant recipients. Am J Transplant. 2022;22(8):2083-2088.
  16. Kennedy DT, et al. Azathioprine and allopurinol: the price of an avoidable interaction. Ann Pharmacother. 1996;30(9):951-954.
  17. Neuvonen PJ, Niemi M, Backman JT. Drug interactions with lipid-lowering drugs. Clin Pharmacol Ther. 2006;80(6):565-581.
  18. Bullingham R, et al. Effects of food and antacid on the pharmacokinetics of mycophenolate mofetil. Br J Clin Pharmacol. 1996;41(6):513-516.
  19. Kofler S, et al. Proton pump inhibitor co-medication reduces mycophenolate acid drug exposure. J Heart Lung Transplant. 2009;28(6):605-611.
  20. Perazella MA. Trimethoprim-induced hyperkalaemia. Drug Saf. 2000;22(3):227-236.
  21. Danziger-Isakov L, Kumar D; AST ID Community of Practice. Vaccination of solid organ transplant candidates and recipients. Clin Transplant. 2019;33(9):e13563.
  22. Badri P, et al. Pharmacokinetics and dose recommendations for cyclosporine and tacrolimus when coadministered with ABT-450, ombitasvir, and dasabuvir. Am J Transplant. 2015;15(5):1313-1322.
  23. Floren LC, et al. Tacrolimus oral bioavailability doubles with coadministration of ketoconazole. Clin Pharmacol Ther. 1997;62(1):41-49.
  24. Hebert MF, et al. Effects of rifampin on tacrolimus pharmacokinetics in healthy volunteers. J Clin Pharmacol. 1999;39(1):91-96.
  25. Hebert MF, et al. Effects of St. John's wort (Hypericum perforatum) on tacrolimus pharmacokinetics in healthy volunteers. J Clin Pharmacol. 2004;44(1):89-94.
  26. Mai I, et al. Impact of St John's wort treatment on the pharmacokinetics of tacrolimus and mycophenolic acid in renal transplant patients. Nephrol Dial Transplant. 2003;18(4):819-822.
  27. Ruschitzka F, et al. Acute heart transplant rejection due to Saint John's wort. Lancet. 2000;355(9203):548-549.
  28. Ducharme MP, et al. Disposition of intravenous and oral cyclosporine after administration with grapefruit juice. Clin Pharmacol Ther. 1995;57(5):485-491.
  29. Liu C, et al. Co-administration of grapefruit juice increases bioavailability of tacrolimus in liver transplant patients: a prospective study. Eur J Clin Pharmacol. 2009;65(9):881-885.
  30. Qin XL, et al. Effect of Wuzhi capsule on tacrolimus pharmacokinetics in renal transplant recipients. Eur J Clin Pharmacol. 2013;69(3):591-596.
  31. Pieper AK, et al. The effect of sevelamer on the pharmacokinetics of cyclosporin A and mycophenolate mofetil in pediatric renal transplant recipients. Nephrol Dial Transplant. 2004;19(10):2630-2633.
  32. Rupprecht K, et al. Bioavailability of mycophenolate mofetil and enteric-coated mycophenolate sodium is differentially affected by pantoprazole in healthy volunteers. J Clin Pharmacol. 2009;49(10):1196-1201.
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This article compiles publicly available medical information for educational purposes only and is not medical advice. For any health concern, please consult a qualified healthcare professional.

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