Revised: 17 June 2013
Website: March 2012
Prescriber Update 2012;33(1):1-2
This article draws prescribers' attention to the new prolonged-release formulation of tacrolimus that is now approved for use in New Zealand.
Tacrolimus is currently marketed as Prograf and the new formulation as Prograf XL. Importantly, tacrolimus has a narrow therapeutic index and medication errors have the potential to significantly harm patients.
he manufacturer of Prograf and Prograf XL has employed a number of methods to reduce the risk of confusion between the two brands, such as:
In addition, the manufacturer is attempting to introduce warning flags on prescribing and dispensing software.International experience
Cases of medication errors, due to confusion over tacrolimus formulations, have already been reported in other countries. In some cases, these errors resulted in serious adverse reactions, including rejection of transplanted organs1.
Errors have occurred at the prescribing, dispensing and administration of tacrolimus.