The manufacturer of Tacrolimus (Prograf® and Advagraf®) has written to healthcare professionals to highlight the potential for medication errors with these two products.
Prograf is an immediate release formulation of tacrolimus that must be taken twice daily. Advagraf is a prolonged release formulation of tacrolimus that must be taken once daily.
These products are not interchangeable without careful supervision and monitoring. Changes have been agreed with regulatory agencies that will improve the product packaging and leaflets to highlight the differences.
Medication errors have caused serious adverse reactions including acute rejection of transplanted organs and toxicity due to elevated therapeutic levels.
Action: Clinicians should be aware of the potential for medication errors and take particular care when prescribing or dispensing this medication.