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Tacrolimus Levels in LN — SCE Rheumatology MCQ

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HardRheumatology PharmacologyTacrolimus Levels in LNSCE Rheumatology

A 50-year-old woman with biopsy-proven class IV+V lupus nephritis has persistent nephrotic-range proteinuria despite mycophenolate and glucocorticoids. Her eGFR is preserved, and tacrolimus is added to reduced-dose mycophenolate as an initial combination regimen. Which therapeutic drug-monitoring strategy most closely reflects the target used for this lupus nephritis regimen?

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Correct answer: A — Pre-dose whole-blood trough concentration of approximately 4–6 ng/mL

Explanation lettering: B = shown as A · D = shown as B · E = shown as C · A = shown as D · C = shown as E

The best answer is B. In initial lupus nephritis regimens combining tacrolimus with reduced-dose mycophenolate, an approximate whole-blood trough target of 4–6 ng/mL is commonly used. For twice-daily tacrolimus, the trough is sampled immediately before the next dose, approximately 12 hours after the previous dose. Random or post-dose measurements cannot be interpreted against a trough target, so A and D are incorrect; routine peak monitoring is not used, excluding E. A target of 8–12 ng/mL is more consistent with higher-exposure protocols, including some transplant or induction settings, and is not the approximate target specified for this lupus nephritis combination. Renal function, blood pressure, potassium, glucose and interacting CYP3A medicines must also be monitored.

Reference: Nordmann-Gomes A et al. Lupus nephritis randomised controlled trials: evidence gaps and under-represented groups. Figure 1: guideline-recommended initial treatment regimens. Lupus Science & Medicine. 2024;11:e001331. https://lupus.bmj.com/content/lupusscimed/11/2/e001331.full.pdf