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Tacrolimus, a calcineurin inhibitor, has been widely used for the prophylaxis and treatment of graft-versus-host disease (GVHD) in hematopoietic stem cell transplantation or graft rejection in solid organ transplantation. 1 Tacrolimus is metabolized by cytochrome P450 (CYP) enzymes, mainly CYP3A, in the liver and small intestine. 1 Therefore, its drug interaction with a variety of agents which are substrates and/ or inhibitors and inducers of these enzymes has the potential to affect the pharmacokinetics of tacrolimus. 2,3 In addition to prescribed medicines, natural products such as food components and herbal products have also been reported to cause such interactions. 4 ― 6 These interactions can result in serious clinical events such as GVHD, graft rejection, and induction of the side effects of tacrolimus. We here report the first case of a clinically significant drug interaction between tacrolimus and rooibos tea. A 38-year-old woman with acute myeloid leukemia underwent bone marrow transplantation from an unrelated donor after being conditioned with total body irradiation and cytarabine. 7 Tacrolimus and methotrexate were given for the prophylaxis of acute GVHD. On day 29, she developed acute GVHD involving the gastrointestinal tract which was successfully treated with prednisolone (1 mg/kg). Tacrolimus was switched from oral to intravenous on day 36. The initial oral dose was 3 times greater than the intravenous dose, but was decreased after initiating oral voriconazole (400 mg per body) for the prophylaxis of fungal infection. After day 42, tacrolimus was given orally at a fixed dose (0.6 mg per body weight given in two divided doses every 12 hours) and the trough blood concentration of tacrolimus ranged between 9.2 and 10.3 ng/ml. The blood concentration of tacrolimus was measured every 2 to 3 days. On day 55, she began the regular consumption of a commercially purchased brand of rooibos tea at a rate of more than 2 liters per day. No other drugs or specific food components were initiated during this period. On day 59, the trough blood concentration of tacrolimus was found to be decreased to 3.0 ng/ml and skin GVHD recurred. The administration of tacrolimus was immediately switched

Drug-herbal interaction between tacrolimus and rooibos tea in a recipient of allogeneic hematopoietic stem cell transplantation