Name: Mycophenolate mofetil indication, dosage and more | Dermatology Games
Published: 2020-09-22T15:47:04+00:00

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Indications

Dermatitis
- Psoriasis.
- Atopic dermatitis : 1 gm, given orally twice daily for 4 weeks. At week 5, the dosage was reduced to 500 mg twice daily and stopped at 8 weeks.
- Dyshidrotic eczema.
- Chronic actinic dermatitis.
Bullous dermatoses
- Pemphigus vulgaris : 2 g daily.
- Pemphigus foliaceus.
- Bullous pemphigoid.
- Cicatricial pemphigoid.
- Paraneoplastic pemphigus.
- Epidermolysis bullosa acquisita.
- Linear IgA bullous disease.
Autoimmune connective tissue diseases
- Systemic lupus erythematosus.
- Subacute cutaneous lupus erythematosus.
- Chronic cutaneous lupus erythematosus.
- Chilblain lupus erythematosus.
- Diffuse systemic sclerosis.
- Dermatomyositis : 20 mg/kg twice daily.
Vasculitis
- Wegener’s granulomatosis.
- Microscopic polyangiitis.
- Churg–Strauss syndrome.
- Hypocomplementemic urticarial vasculitis.
- Nodular vasculitis.
- Behçet’s syndrome (conﬂicting results).
Miscellaneous
- Cutaneous Crohn’s disease.
- Sarcoidosis.
- Recurrent erythema multiforme.
- Necrobiosis lipoidica.
- Chronic urticaria.
- Lichen planus.
- Lichen planopilaris.
- Graft-versus-host disease: acute and chronic variants.

Dosage

1.0-1.5 gm orally two times per day.
Start therapy with 500 mg each day ,at night, for 1 week. to minimizes GI adverse effects and improves patient compliance.
After the first week >> increase to 500 mg twice daily >> increase in 500 mg increments every 2–4 weeks until a dose of 1.5 g twice daily (range 2–3 g daily).

Mycophenolate mofetil is a lymphocyte selective Immunosuppressive drug.
Mycophenolic acid ( active drug ) non-competitively binds to and inhibits inosine monophosphate dehydrogenase (IMPDH), the key enzyme in the denovo pathway within activated lymphocytes, DNA synthesis in T and B lymphocytes is preferentially inhibited.
MMF prevents proliferation of T cells.
MMF inhibits antibody production by activated B-cell lymphocytes.
MMF has been shown to inhibit several fbroblast functions implicated in tissue fibrosis.

Examination
- Complete physical examination\n
Lab
- CBC.
- Liver function tests.
- Serum creatinine.
- Pregnancy test for women of childbearing potential.
- Hepatitis B and C panel.
- Purifed Protein Derivative.

Examination (at least every 3–6 months)
- Complete physical examination\n
Lab (every 2–4 weeks following dose escalation and every 2–3 months once dose is stable)
- CBC with differential.
- Serum chemistry panel and/or serum creatinine.
- Serum liver function tests.

Carcinogenicity
- Lymphoproliferative disorders, non-melanoma skin cancer – controversial.
Gastrointestinal(common)
- Dose-dependent, most common Nausea, diarrhea, soft stools, anorexia, abdominal cramps, frequent stools, vomiting, anal tenderness.

In patients who are unable to tolerate the gastrointestinal side-effects of MMF, mycophenolic acid delayed release tablets may be an alternative.

Genitourinary
- Urgency, frequency, dysuria, burning, sterile pyuria (occasionally).
- Decrease in frequency after first year.
Infectious
- Viral, bacterial, atypical mycobacteria, fungal (more common in transplant patients).
- Progressive multifocal leukoencephalopathy –controversial.
Hematologic
- Dose-dependent, reversible Neutropenia, anemia, thrombocytopenia, agranulocytosis.
- Neutrophil dysplasia.
Neurologic
- Weakness, fatigue, headache, tinnitus, insomnia\n
Teratogenicity
- First trimester loss, external ear/facial abnormalities.
- Anomalies of distal limbs, heart, esophagus, and kidneys.

Abosulte
- Pregnancy.
- Drug hypersensitivity.
Relative
- Lactation.
- Peptic ulcer disease.
- Hepatic/renal disease (may need to reduce dose).
- Drugs that interfere with enterohepatic circulation (cholestyramine).
- Azathioprine (concomitant administration increases risk of bone marrow suppression.

It is recommended to stop MMF in the following situations:
• Total white cell count <4 × 109/L.
• Neutrophil count <2 × 109/L.
• Platelet count <150 × 109/L.
• Aspartate or alanine aminotransferase >2 × the upper normal limit.
• Hypogammaglobulinaemia

Antacids and proton-pump inhibitors both reduce the serum levels of active MPA.
Agents that inhibit enterohepatic recirculation, such as bile acid sequestrants and various classes of antibiotics, also lead to decreased serum MMF levels.
Rifampicin: may decrease MMF efficacy.
Azathioprine: also inhibits purine metabolism with potential enhanced toxicity.
Antibiotics including cephalosporins, ﬂuoroquinolones, macrolides, penems, penicillins, sulfonamides inhibit enterohepatic recirculation and decrease mycophenolate mofetil levels.
Antiviral drugs: may increase mycophenolic acid plasma concentration.
Medications such as salicylic acid, phenytoin and xanthine bronchodilators that compete with MPA for albuminbinding sites can increase the free, active fraction of MPA.

Pregnancy category D.
Contraception is mandatory before, during and for 6 wks after therapy.
Pregnancy and breast-feeding should be avoided during treatment and patients (including males) must use adequate contraceptive precautions.

The dosage should be reduced or therapy discontinued for a WBC <3500– 4000cells/mm.
MMF should be used with caution in patients with active gastrointestinal disease, and live attenuated vaccines should be avoided.
Patients taking mycophenolate mofetil should not be given live attenuated virus vaccines.

Mycophenolate mofetil (MMF) is prodrug of the antimetabolite mycophenolic acid (MPA).
Onset of response typically requires at least 6–8 weeks.
Mycophenolate mofetil is generally used in conjunction with other immunosuppressive drugs, most commonly as a “steroid-sparing” agent.

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