Drug Interaction Report

CONTRAINDICATED: Administration of intravesical BCG during immunosuppressant or intense antineoplastic therapy may be associated with a risk of disseminated infection due to enhanced replication of the BCG strain of Mycobacterium bovis in the presence of diminished immune competence. Deaths have been reported as a result of systemic BCG infection and sepsis. Patients may be immunosuppressed if they have recently received or are receiving alkylating agents, antimetabolites, radiation, some antirheumatic agents, high dosages of corticosteroids or adrenocorticotropic agents (e.g., greater than or equal to 2 mg/kg/day or 20 mg/day of prednisone or equivalent for 14 consecutive days or more), or long-term topical or inhaled corticosteroids. In addition, these patients may not develop an adequate immune response to BCG, which would reduce its anti-tumor efficacy.

MANAGEMENT: Use of intravesical BCG in immunosuppressed patients with congenital or acquired immune deficiencies, including those due to concurrent disease (e.g., AIDS, leukemia, lymphoma), cancer therapy (e.g., cytotoxic drugs, radiation) or immunosuppressive therapy (e.g., corticosteroids), is considered contraindicated. Clinicians should be aware that BCG may persist in the urinary tract for several months after BCG instillations, and delayed manifestations of disseminated BCG infection may develop months or years after BCG therapy. Patients who receive cancer or immunosuppressive therapy after BCG instillation may be at increased risk.

ADJUST DOSING INTERVAL: Consumption of food has led to a 27% decrease in the bioavailability of orally administered tacrolimus.

MANAGEMENT: Tacrolimus should be administered at least one hour before or two hours after meals.

GENERALLY AVOID: Grapefruit juice has been reported to increase tacrolimus trough concentrations. Data are limited, but inhibition of the CYP450 enzyme system appears to be involved.

MANAGEMENT: The clinician may want to recommend that the patient avoid ingesting large amounts of grapefruit juice while taking tacrolimus.