Mycophenolate mofetil (MMF)

Maximum 1gbd in CKD 4/5 (eGFR <25)

• Initiation: 500mg twice daily for first week, 500mg twice daily for second week, then increasing as advised by rheumatologist by 500mg per week until optimal or maximum dose is reached
• Maintenance: 2g daily (in 2 divided doses)
• Maximum dosage: 3g/day

• Pre-treatment - 2 x Negative Pregnancy tests if child bearing age female
• hepatitis and HIV serology, FBC, U+E, CRP, LFT inc albumin, CXR (If risk of TB or at Rheumatologist discretion)

then

• FBC, U+E, CRP, LFT inc albumin at 2 weeks, then monthly for 3 months, then 3 monthly

Pneumococcal and annual flu vaccine are recommended and passive VZIG if exposed to chicken pox

Patients who do not attend for monitoring should be warned of the risk that serious adverse effects may go unnoticed. In the event of persistent failure to attend for monitoring please inform the Rheumatology department.

Stop during infection, restart when well

• WBC <3.5 withhold and contact rheumatology
• Neutrophils <1.6
• Platelets <140
• AST or ALT >100
• Creatinine rise >30% in 12 months
• Unexplained eosinophilia >0.5
• Unexplained fall in albumin <30g/l
• MCV>105 with normal TSH and haematinics
• Bruising with or without sore throat – immediate FBC, discuss with rheumatology/haematology if abnormal

• Treatment is continued indefinitely providing it remains effective and there are no significant side effects. 
• Mycophenolate mofetil takes about 6 weeks to 3 months to become effective.
• During this period there are likely to be continued symptoms or signs of disease activity. 
• It is reasonable to use IM Depo steroids (Kenalog 40 mg or Depo Medrone 80mg) up to monthly, depending on the requirements of the individual patient. 
• The dose required is small (eg monthly Kenalog 40mg = 1.6mg prednisolone daily.
• SLE, vasculitis and myopathy patients are likely to be on oral steroids already and not require IM. Please contact the rheumatologist if advice is required for this.

• Disease modifying drugs will not prevent all flares.
• These can be managed with IM Depo steroid as outlined above.
• If flares become more frequent, or the disease fails to settle between flares, the dosage should be increased, or an alternative discussed with the rheumatologist.

• pregnancy and breast feeding
• localized or systemic infections

• suspected lymphproliferative disorder
• unexplained anaemia
• leucopenia
• thrombocytopenia
• very frail and elderly

• antacids – decrease absorption of MMF
• cholestyramine 
• probenecid – increases plasma concentration of MMF
• aciclovir – only significant in renal impairment – can increase concentration of MMF and aciclovir

Major organ toxicity unusual.

Malignancy

• lymphomas
• skin tumours

Haematological

• abnormal bruising with or without a sore throat may indicate bone marrow failure - stop drug and check FBC immediately

Gastrointestinal

• diarrhoea
• nausea
• vomiting
• abdominal cramps
• dyspepsia

Other

• sterile haematuria
• UTI
• renal tubular necrosis

Secretaries 01387 241776

Helpline 01387 241095 (answering machine) Rheumatology Nurse Specialists

Department of Rheumatology doctors via Switchboard 01387 246246/RMS Advice