If I miss a dose of Envarsus (extended‑release tacrolimus), what should I do?

What to Do If You Miss a Dose of Envarsus

Take the missed dose of Envarsus (extended-release tacrolimus) as soon as you remember, then continue with your regular daily schedule without doubling up or shifting future doses. 1, 2

Immediate Action Steps

• Take the forgotten dose immediately upon remembering, regardless of how much time has passed since your scheduled dose time 1, 2
• Continue your next dose at the originally scheduled time the following day—do not shift your dosing schedule forward or backward 3, 1
• Never double your dose to make up for the missed one, as this significantly increases the risk of toxicity including nephrotoxicity, neurotoxicity, and hyperglycemia 4

Why This Approach Is Safe for Envarsus

• Envarsus XR has unique pharmacokinetic properties that allow for flexible monitoring windows of 3 hours before or after the target time, suggesting the formulation maintains more stable drug levels than immediate-release tacrolimus 5
• The extended-release formulation provides sustained drug exposure over 24 hours, making short delays less likely to cause dangerous drops in immunosuppression 6, 7
• Research demonstrates that once-daily tacrolimus maintains therapeutic trough levels even with timing variations, unlike twice-daily formulations that require strict 12-hour intervals 5, 6

Critical Monitoring After a Missed Dose

Contact your transplant team if:

• You miss more than one consecutive dose 4
• You experience any signs of rejection (fever, decreased urine output, swelling, pain over the transplant site) 4
• You develop new symptoms such as tremors, headache, confusion, or significant changes in blood sugar 4

Your next scheduled blood work should proceed as planned—no additional laboratory monitoring is typically needed for a single missed dose 1

Understanding the Risks

• Subtherapeutic tacrolimus levels increase the risk of organ rejection, which is why maintaining consistent dosing is critical 4, 1
• Even brief periods of low drug levels can trigger immune responses against your transplanted organ 4
• Tacrolimus has a narrow therapeutic index (target trough 5-15 ng/mL), meaning small variations in drug exposure can significantly impact outcomes 4, 6

Prevention Strategies for Future Adherence

• Set daily phone alarms at the exact time you take Envarsus to minimize future missed doses 3, 1
• Use a pill organizer to visually confirm whether you've taken your daily dose 3, 1
• Link medication timing to a daily routine (such as breakfast or bedtime) to create a consistent habit 4
• Keep a backup supply in a second location (work, car) in case you forget your dose at home 4

Important Drug Interaction Considerations

Be aware that many medications and foods can alter tacrolimus levels through the CYP3A4 enzyme system 4:

• High-fat meals decrease absorption by 37%—take Envarsus consistently with regard to meals 4
• Avoid grapefruit juice and St. John's wort, which significantly affect tacrolimus metabolism 4
• Notify your transplant team before starting any new medications, including over-the-counter drugs and supplements, as they may require dose adjustments 4

Common Pitfall to Avoid

Do not attempt to "catch up" by taking two doses close together—this is the most dangerous error patients make with immunosuppressants 2. The risk of acute toxicity (kidney damage, tremors, seizures) from excessive tacrolimus levels outweighs the risk from a single missed dose 4.