Missed Dose of Envarsus: Timing Guidance
If you miss a dose of Envarsus, take it as soon as you remember on the same day, but if it has been more than 14-15 hours since your scheduled dose time (meaning less than 9-10 hours until your next dose), skip the missed dose and resume your regular once-daily schedule. 1
Rationale for This Recommendation
The extended-release formulation of Envarsus (LCP-tacrolimus) has unique pharmacokinetic properties that distinguish it from immediate-release tacrolimus:
- Envarsus exhibits a prolonged absorption profile with time to maximum concentration occurring at approximately 5 hours post-dose, compared to 1 hour for immediate-release tacrolimus 2
- The drug maintains therapeutic levels over a 24-hour period through its extended-release mechanism 1, 3
- Taking two doses too close together risks supratherapeutic levels and toxicity, particularly nephrotoxicity and neurotoxicity 4
Practical Dosing Window
For a once-daily medication taken at 8 AM:
- If you remember at 10 PM (14 hours late): Take the missed dose
- If you remember at midnight (16 hours late): Skip it and take your next regular dose at 8 AM
The critical threshold is whether you have at least 9-10 hours remaining before your next scheduled dose 1.
Critical Safety Considerations
Never double your dose to make up for a missed dose 1. This is particularly dangerous with Envarsus because:
- Envarsus has improved bioavailability compared to immediate-release tacrolimus, requiring approximately 40% lower total daily doses to achieve equivalent exposure 3
- The concentration-to-dose ratio is 2.25 times higher with Envarsus compared to immediate-release formulations 2
- Tacrolimus has a narrow therapeutic index where small variations in exposure significantly impact outcomes 1
Monitoring After a Missed Dose
Contact your transplant team if you miss a dose, particularly if:
- You miss more than one dose in a week 5
- You experience any decline in kidney function 5
- Your next trough level is outside target range (typically 4-11 ng/mL depending on time post-transplant) 3
Trough levels should be checked whenever there is a change in medication pattern that may affect blood levels 5.
Common Pitfalls to Avoid
- Do not confuse Envarsus with immediate-release tacrolimus (Prograf) - they are not interchangeable and have different dosing requirements 1
- Do not assume the same missed-dose guidance applies to other immunosuppressants - each medication has unique pharmacokinetics 1
- Do not wait until your next clinic visit to report repeated missed doses - this requires immediate therapeutic drug monitoring 5