Noted primarily for PO and IV use, but should be considered for topical use

Drug-drug:

• ↑risk of nephrotoxicity with aminoglycosides, amphotericin B, cisplatin, nucleotide reverse transcriptase inhibitors, protease inhibitors, or cyclosporine (allow 24 hr to pass after stopping cyclosporine before starting tacrolimus).
• Potassium-sparing diuretics, ACE inhibitors, or angiotensin II receptor antagonists↑ risk of hyperkalemia.
• Strong CYP3A4 inhibitors, including chloramphenicol, clarithromycin, cobicistat, itraconazole, ketoconazole, letermovir, nefazodone, posaconazole, protease inhibitors, and voriconazole, may significantly ↑ levels and risk of nephrotoxicity; ↓ tacrolimus dose by ../B/tu0.png when used with voriconazole or posaconazole; closely monitor tacrolimus whole blood trough concentrations
• Mild CYP3A4 inhibitorsand moderate CYP3A4 inhibitors, including amiodarone, calcium channel blockers, cimetidine, clotrimazole, danazol, erythromycin, ethinyl estradiol, fluconazole, imatinib, isavuconazonium, lansoprazole, nilotinib, and omeprazole, may ↑ levels and risk of toxicity; closely monitor tacrolimus whole blood trough concentrations and adjust tacrolimus dose if needed.
• Magnesium/aluminum hydroxide and metoclopramide may ↑ levels and risk of toxicity; closely monitor tacrolimus whole blood trough concentrations and adjust tacrolimus dose if needed.
• Strong CYP3A4 inducers, including carbamazepine, phenobarbital, phenytoin, rifabutin, and rifampin, may ↓ levels; ↑ tacrolimus dose and closely monitor tacrolimus whole blood trough concentrations.
• Mild CYP3A4 inducers and moderate CYP3A4 inducers, including methylprednisolone or prednisone, may ↓ levels; closely monitor tacrolimus whole blood trough concentrations and adjust tacrolimus dose if needed.
• Vaccinations may be less effective if given concurrently with tacrolimus (avoid use of live-virus vaccines).
• May ↑ levels of mycophenolate mofetil or mycophenolic acid.
• Caspofungin may ↓ levels; closely monitor tacrolimus whole blood trough concentrations and adjust tacrolimus dose if needed.

Drug-Natural Products:

• Concomitant use with astragalus, echinacea, and melatonin may interfere with immunosuppression.
• St. John's wort may ↓ levels; ↑ tacrolimus dose and closely monitor tacrolimus whole blood trough concentrations.
• Schisandra sphenanthera may significantly ↑ levels; closely monitor tacrolimus whole blood trough concentrations.