8 Tacrolimus (Prograf) Side Effects and How to Manage Them

More than 46,000 organ transplants are performed in the U.S. every year. Transplants are life-preserving procedures. But they do come with some risks. One risk is transplant rejection, which is when a person’s immune system mistakenly attacks a transplanted organ.

Tacrolimus (Prograf) is an important tool for preventing organ rejection. This prescription-only medication suppresses your immune system by design. It’s thought to work by blocking immune cells called T cells. And it’s effective at what it does, helping to prevent many different types of transplant rejections, including those of the liver, heart, and kidney. 

But tacrolimus also has several potential side effects. Some of these side effects are relatively mild, while others warrant swift intervention from your transplant team.

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Tacrolimus side effects at a glance

Tacrolimus is associated with several side effects. The most common side effects include:

• Tremors (shakiness or trembling movements, commonly in the hands)

• Headache

• Insomnia (trouble sleeping)

• Paresthesia (pins-and-needles sensation, often in the hands and feet)

• High blood pressure

• Higher cholesterol

• Diarrhea

• Nausea

• Constipation

• Vomiting

• Infection

• Edema (swelling from fluid buildup)

• Abdominal pain

Tacrolimus is also associated with certain rare but serious side effects, including:

• New-onset diabetes

• Kidney problems

• Seizures

• Confusion

• Heart problems

Other side effects are also possible, but they are less common. Here, we’ll review eight notable oral tacrolimus side effects and how to manage them.

1. Nerve-related side effects, such as shakiness

Shakiness and tingling sensations in the hands and feet are common tacrolimus side effects. Most people taking tacrolimus experience them at some point.

If you experience these side effects, it’s a good idea to let your transplant specialist know. They may be able to help by adjusting your medication dosage. They may also recommend other management tips, such as wrapping ice packs around your forearms or hands to help with hand tremors. However, there isn’t extensive evidence about the benefits of this approach.

2. High blood pressure

Another common side effect that you may experience while taking tacrolimus is high blood pressure. 

Your transplant specialist will regularly assess your blood pressure at your scheduled appointments. But doing your part to manage your blood pressure between appointments is helpful, too. Sticking to the DASH diet, getting at least 30 minutes of physical activity per day, and not smoking are all helpful ways to maintain your target blood pressure.

If lifestyle changes aren’t enough to help you manage your blood pressure, speak to your transplant specialist. They may make modifications to your medication regimen, which could include prescribing you blood pressure medication.

3. Blood glucose changes

Tacrolimus can raise blood glucose (sugar) levels. And this doesn’t just pose a potential issue for people who already have diabetes. Tacrolimus was occasionally linked to new cases of diabetes in clinical studies. Though, new cases of diabetes related to tacrolimus may be reversible.

Because of this risk, it’s important to monitor your blood glucose while taking tacrolimus. A healthcare professional may do this for you, or they may ask you to do it at home.

Following a diabetes-friendly diet — which includes prioritizing whole grain foods, fiber, and lean proteins — is another cornerstone of maintaining healthy blood glucose levels. Starting treatment with or adjusting existing diabetes medications can help control blood glucose levels, too, if needed.

4. Headache

Having headaches, especially when you’re dealing with a health condition, can be burdensome. But it may help to know in advance that tacrolimus can cause headaches as a side effect, so you can be prepared. 

If possible, it’s ideal to manage your headaches with simple lifestyle changes. This includes maintaining optimal hydration, meditating, and ensuring you have good sleep hygiene habits.

But lifestyle changes aren’t always enough to manage headaches. If needed, ask your transplant specialist if it’s OK for you to take over-the-counter (OTC) headache medications with tacrolimus. You may be able to safely take an OTC medication like acetaminophen (Tylenol) for pain relief.

5. Stomach upset

Tacrolimus may upset your stomach, causing symptoms such as diarrhea or nausea. You may also experience constipation or stomach discomfort.

These gut-related symptoms are fairly common and usually short-lived. Taking tacrolimus with food may help address some of these side effects while your body is adjusting to the medication. However, if you do so, make sure to consistently take the medication with a meal or snack. Don’t alternate between taking it with and without food. This can cause fluctuations in tacrolimus levels, which can reduce the medication’s effectiveness or increase the chances of side effects.

Another strategy is to avoid foods that irritate your stomach. This includes foods that are spicy, acidic, or greasy. Caffeinated and carbonated drinks can also be hard on your stomach.

Stomach-calming medications are another management option, but it’s important to loop in your transplant specialist about a safe one to try. Some of them, such as bismuth subsalicylate (Pepto-Bismol), should be avoided with tacrolimus.

Keep in mind: It’s important to avoid foods that aren't safe to take with tacrolimus. Don’t consume grapefruit juice or whole grapefruit while taking the medication. Grapefruit and grapefruit juice can alter the level of tacrolimus in your blood and increase the risk of side effects.

6. Kidney problems, ranging from mild to serious

Tacrolimus can be hard on your kidneys. In rare cases, tacrolimus has been linked to acute (sudden) or chronic (long-term) kidney harm.

It’s hard to manage this potential side effect on your own. But you can look out for possible warning signs of kidney damage. Inform your transplant specialist without delay if you notice that you’re urinating less frequently or are having a difficult time producing urine. Watch out for swelling in your legs, ankles, or feet, too. These are all possible symptoms of kidney damage.

Your transplant specialist can monitor your labs for any kind of kidney injury. This is why it’s important to keep them in the loop about any symptoms you experience and regularly attend scheduled appointments.

7. High potassium levels

Your kidneys play an important role in making sure your body maintains healthy levels of electrolytes such as sodium, potassium, and magnesium. However, tacrolimus may make your potassium levels jump too high. And having high potassium levels, also called hyperkalemia, is a possible sign of kidney damage.

Preventing problems from hyperkalemia often comes down to monitoring lab work. In many cases, it’s hard to notice symptoms of high potassium on your own. Your transplant team will monitor your blood levels of potassium to ensure they stay at target levels.

If your potassium levels get too high, your transplant specialist may adjust your medication dosages accordingly — especially if you’re taking other medications that also cause hyperkalemia.

8. Serious infection and cancer

Because of how it works, tacrolimus increases your risk of infection. This includes bacterial, viral, and fungal infections. These infections can be life threatening and lead to hospitalization in some cases.

It’s important to take all potential infection symptoms seriously — even if they feel minor. Notify your transplant specialist right away if you experience any symptoms of infection, including:

• Fever

• Chills

• Muscle aches

• Cough

• Sore throat

• Fatigue

Tacrolimus may also somewhat increase your risk of cancer, particularly skin cancer and lymphoma. Your transplant team will help you monitor for any signs or symptoms of cancer through routine examinations and scans.

When to contact your transplant specialist about tacrolimus side effects

Protecting your health — and your new organ — is a long-term situation. As such, you should always feel empowered to talk to your transplant team if you’re experiencing an issue. This is especially true if you’re experiencing new or worsening side effects, side effects that feel severe, or symptoms of an infection.

It can be tricky to manage potential tacrolimus-related side effects on your own. So it’s important to attend your regularly-scheduled medical appointments to make sure your treatment is going according to plan. Your transplant specialist can monitor your lab work and help you proactively manage any issues that arise.

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Written by:

Mandeep Sohal, PharmD

Mandeep Sohal, PharmD, has more than 7 years of experience in the pharmaceutical industry and is licensed in California. In his career, he’s had experience with specialty pharmacy, community pharmacy, pharmacy benefit management, and pharmaceutical manufacturers.

Edited by:

Joshua Murdock, PharmD, BCBBS

Joshua Murdock, PharmD, BCBBS, is a licensed pharmacist in Arizona, Colorado, and Rhode Island. He has worked in the pharmacy industry for more than 10 years and currently serves as a pharmacy editor for GoodRx.

Reviewed by:

Austin Ulrich, PharmD, BCACP

Austin Ulrich, PharmD, BCACP, is a board-certified ambulatory care clinical pharmacist. In his early career, he provided direct patient care in a variety of settings, including hospital and community pharmacies, and in a primary care clinic as a clinical pharmacist.

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