• Kevin Bax, Janice Tijssen, Michael J Rieder, and Guido Filler.
• University of Western Ontario, Department of Paediatrics, London, ON, Canada Children's Hospital, London Health Sciences Centre, London, ON, Canada.
• Ann Pharmacother. 2014 Nov 1;48(11):1525-8.

ObjectiveTo report a novel approach to the management of tacrolimus intoxication that leads to rapid normalization of serum tacrolimus concentrations.Case SummaryA 9-year-old female renal transplant recipient developed a severe tacrolimus intoxication as a result of prolonged diarrhea, which resulted in acute kidney injury, severe dehydration, and neurological symptoms. We used a combination of intravenous steroids and intravenous phenytoin to normalize the tacrolimus level from 32 to 5 ng/mL in less than 24 hours, with complete resolution of symptoms and signs.DiscussionTacrolimus intoxication is a rare event but may result in life-threatening complications. Treatment recommendations beyond holding the drug and enzyme induction with phenytoin or phenobarbital are elusive. This approach leads to a relatively slow normalization of the tacrolimus level over 72 hours. The authors hypothesized that additional induction of the p-glycoprotein through steroids was synergistic.ConclusionsThe combination of phenytoin and a corticosteroid may be an effective approach that leads to rapid normalization of severely elevated tacrolimus levels.© The Author(s) 2014.

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