Brand names: CellCept, Myfortic
Drug class: Immunosuppressive Agents
Chemical name: 6-(1,3-Dihydro-4-hydroxy-6-methoxy-7-methyl-3-oxo-5-isobenzofuranyl)-4-methyl-2-(4-morpholinyl)ethyl ester hexenoic acid
Molecular formula: C₂₃H₃₁NO₇C₂₃H₃₁NO₇•HClC₁₇H₁₉NaO₆C₁₇H₂₀O₆
CAS number: 116680-01-4

Medically reviewed by Drugs.com on Dec 25, 2023. Written by ASHP.

Introduction

Immunosuppressive agent.^{1 2 3 4 5 6 7} Mycophenolate mofetil is a prodrug that is hydrolyzed in vivo to mycophenolic acid, the pharmacologically active metabolite.^{1 2 7 12} Mycophenolate sodium delayed-release tablets release the active moiety, mycophenolic acid, in the small intestine.^{27 28}

Uses for Mycophenolate

Renal Allotransplantation

Prevention of rejection of renal allografts.^{1 3 4 5 6 12 27}

Cardiac Allotransplantation

Prevention of rejection of cardiac allografts.^{1 7}

Hepatic Allotransplantation

Prevention of rejection of liver allografts.^{1 9}

Lung Allotransplantation

Has been used for the prevention of rejection of lung allografts^{† [off-label]}.^{500 501 502 503 504 505 506 507 508 509}

Crohn’s Disease

Has been used in the management of Crohn’s Disease^{† [off-label]}.^{13 14 15 16 18 20 21 22 23 24 25} Not a first-line agent; reserved for patients who are refractory to or intolerant of other agents (e.g., azathioprine, mercaptopurine, methotrexate, infliximab).^{14 23}

Systemic Sclerosis

Has been used in the management of systemic sclerosis (often called scleroderma)^{† [off-label]}.^{300 301 302 303 304 305 306 307 308 310 311 312 313 314 315 316 317 318 319 320}

Based on encouraging results in a number of uncontrolled clinical studies and case series as well as a randomized, controlled clinical trial,^{300 301 302 303 305 306 308 310 311 312 313 314 320} mycophenolate (i.e., mycophenolate mofetil and mycophenolate sodium) is considered a first-line agent for the initial management (i.e., induction therapy) of systemic sclerosis, particularly for patients with early and active systemic sclerosis who have active skin involvement and/or interstitial lung disease (ILD).^{304 307 315 316 319 321} Longer-term mycophenolate therapy also is used and recommended by some experts to maintain improvement and prevent progression of skin involvement or ILD.^{307 315 316 319 321}

Mycophenolate mofetil and mycophenolate sodium are considered therapeutically equivalent;^{300 301 321} some clinicians consider mycophenolate sodium to be better tolerated than mycophenolate mofetil, particularly in terms of adverse GI effects.^{300 301 321} Some clinicians have greater experience prescribing mycophenolate mofetil for systemic sclerosis but would consider switching to mycophenolate sodium in patients unable to tolerate mycophenolate mofetil at the recommended target dosage while other clinicians prefer to initiate and maintain therapy with mycophenolate sodium.^{300 301 321}

Mycophenolate Dosage and Administration

General

Distribute medication guide each time mycophenolate is dispensed.^{41 42 43 44}

Administration

Administer mycophenolate mofetil and mycophenolate sodium orally;^{1 27} administer mycophenolate mofetil hydrochloride by IV infusion.¹

In patients undergoing allotransplantation, the drug usually is used with cyclosporine and corticosteroids; other immunosuppressive agents (e.g., antithymocyte globulin, antilymphocyte globulin, muromonab-CD3, basiliximab) also have been used.^{1 3 4 5 6 27 28 29 30 31} Safety and efficacy of concomitant use with immunosuppressive drugs other than these agents not determined.^{1 32} (See Specific Drugs under Interactions.)

Handle with care.¹

Mycophenolate mofetil: Do not crush tablets; do not open or crush capsules.^{1 43}

Mycophenolate sodium: Do not crush, chew, or cut tablets.^{27 44} Tablets should be swallowed whole to maintain integrity of enteric coating.²⁷

Avoid inhalation of powder in capsules or oral suspension (before and after reconstitution) and contact with skin or mucous membranes.¹

Avoid contact with IV solution.¹ In case of skin or mucous membrane contact, wash affected area with soap and water.¹

If contact with eyes occurs, wash with water.¹

Wipe up any spilled drug with a wet paper towel.¹

Oral Administration

Mycophenolate mofetil: Administer orally as soon as possible following renal, cardiac, or hepatic transplantation.¹

Mycophenolate mofetil: Administer preferably on an empty stomach, 1 hour before or 2 hours after food.^{1 43} May be given with food, if necessary, in stable renal transplant recipients.^{1 43} (See Food under Pharmacokinetics.) If a dose is missed, take the missed dose as soon as it is remembered unless it is almost time for the next dose.⁴³ Do not take a double dose.⁴³

Mycophenolate sodium: Administer as soon as possible following renal transplantation in adults.²⁷ If a dose is missed, take the missed dose as soon as it is remembered unless it is almost time for the next dose.⁴⁴ Do not take a double dose.⁴⁴

Mycophenolate sodium: Administer in stable pediatric renal transplant recipients; safety and efficacy in de novo pediatric renal transplant recipients not established.²⁷

Mycophenolate sodium: Administer on an empty stomach, 1 hour before or 2 hours after food.^{27 44} (See Food under Pharmacokinetics.)

Reconstitution

Mycophenolate mofetil for oral suspension: Reconstitute at time of dispensing by adding 94 mL of water (about 47 mL initially followed by another 47 mL after vigorous shaking for 1 minute) to provide a suspension containing 200 mg/mL.^{1 12} Shake bottle well again for 1 minute.¹

Mycophenolate mofetil for oral suspension: Do not admix with other drugs.¹

NG Tube

Mycophenolate mofetil for oral suspension: Can administer by nasogastric tube (minimum 1.7 mm in interior diameter; minimum French size number 8).¹

IV Administration

Mycophenolate mofetil hydrochloride injection: Initiate within 24 hours following transplantation.¹

Reserve IV administration for patients who cannot tolerate or are unable to take an oral dosage form.¹

Administer IV for up to 14 days.¹

Switch from parenteral to oral therapy as soon as possible.¹

Do not mix or administer concurrently via the same infusion catheter with any other IV drugs or infusion admixtures.¹

Reconstitution

Mycophenolate mofetil hydrochloride injection: Add 14 mL of 5% dextrose injection to a vial containing 500 mg of mycophenolate mofetil; shake vial gently.¹

Use strict aseptic technique; drug contains no preservative.¹

Dilution

For a 1-g infusion dose, add contents of 2 reconstituted vials to 140 mL of 5% dextrose injection to provide a solution containing 6 mg/mL.¹

For a 1.5-g infusion dose, add the contents of 3 reconstituted vials to 210 mL of 5% dextrose injection to provide a solution containing 6 mg/mL.¹

Start IV administration within 4 hours of reconstitution and dilution.¹

Rate of Administration

Infuse over ≥ 2 hours by either a peripheral or central vein; do not administer by rapid IV (“bolus”) injection or rapid IV infusion.¹

Dosage

Available as mycophenolate mofetil (oral capsules, tablets, for oral suspension) and mycophenolate mofetil hydrochloride (injection); dosage expressed in terms of mycophenolate mofetil.¹

Available as mycophenolate sodium (delayed-release tablets); dosage expressed in terms of mycophenolic acid.²⁷

Mycophenolate sodium delayed-release tablets should not be used interchangeably with mycophenolate mofetil tablets, capsules, or oral suspension without clinician supervision.²⁷

If neutropenia (ANC <1300/mm³) develops, temporarily discontinue or reduce dosage.^{1 27} (See Hematologic Effects under Cautions.)

Pediatric Patients

Renal Allotransplantation

Mycophenolate mofetil capsules, tablets, and oral suspension

Oral

Children 3 months to 18 years of age: 600 mg/m² as the oral suspension twice daily (maximum 1 g twice daily).¹

Children with a body surface area of 1.25–1.5 m²: 750 mg as capsules twice daily.¹

Children with a body surface area >1.5 m²: 1 g as capsules or tablets twice daily.¹

Mycophenolate sodium delayed-release tablets

Oral

Children 5–16 years of age: 400 mg/m² twice daily (maximum 720 mg twice daily).²⁷

Children 5–16 years of age with a body surface area <1.19 m²: accurate dosage cannot be administered using commercially available tablets.²⁷

Children 5–16 years of age with a body surface area of 1.19–1.58 m²: 1080 mg daily (given as three 180-mg tablets twice daily or as one 180-mg tablet and one 360-mg tablet twice daily).²⁷

Children 5–16 years of age with a body surface >1.58 m²: 1440 mg daily (given as four 180-mg tablets twice daily or two 360-mg tablets twice daily).²⁷

Adults

Renal Allotransplantation

Mycophenolate mofetil capsules, tablets, and oral suspension

Oral

1 g twice daily.¹ No efficacy advantage with dosage of 1.5 g twice daily;¹ 2-g daily dosage associated with a superior safety profile compared with the 3-g daily dosage.¹

Mycophenolate sodium delayed-release tablets

Oral

720 mg twice daily.²⁷

Mycophenolate mofetil hydrochloride for injection

IV

1 g twice daily.¹ No efficacy advantage with dosage of 1.5 g twice daily;¹ 2-g daily dosage associated with a superior safety profile compared with the 3-g daily dosage.¹

Cardiac Allotransplantation

Mycophenolate mofetil capsules, tablets, and oral suspension

Oral

1.5 g twice daily.¹

Mycophenolate mofetil hydrochloride for injection

IV

1.5 g twice daily.¹

Hepatic Allotransplantation

Mycophenolate mofetil capsules, tablets, and oral suspension

Oral

1.5 g twice daily.¹

Mycophenolate mofetil hydrochloride for injection

IV

1 g twice daily.¹

Lung Allotransplantation† [off-label]

Mycophenolate mofetil capsules, tablets, and oral suspension

Oral

Dosages of 1–1.5 g twice daily have been used.^{500 502 506 507 508}

Mycophenolate mofetil hydrochloride for injection

IV

Dosages of 1–1.5 g twice daily have been used.⁵⁰⁰

Mycophenolate sodium delayed-release tablets

Oral

Dosages of 1.08 g twice daily have been used.⁵⁰⁹

Crohn’s Disease† [off-label]

Mycophenolate mofetil capsules, tablets, and oral suspension

Oral

Dosages of 1–2 g daily have been used.^{14 15 19 21 23 24}

Systemic Sclerosis†

Mycophenolate mofetil capsules, tablets, and oral suspension

Oral

Initial dosage of 500 mg twice daily has been used for 1–4 weeks.^{303 305 308 311 313 314 320} The dosage has then been gradually increased up to a target maintenance dosage of 1–1.5 g twice daily based on clinical response and tolerability.^{303 305 306 308 311 312 313 314 320 321} Some patients may require somewhat lower maintenance dosages because of adverse effects, particularly adverse GI effects (see Cautions).^{303 311 313 321}

Optimal duration of therapy not fully known; mycophenolate has been used for up to 5 years in some patients.³¹⁰ Long-term immunosuppressant therapy appears necessary to stabilize and prevent progression of the disease.^{310 314 321}

Mycophenolate sodium delayed-release tablets

Oral

Initial dosages of 360 mg once or twice daily have been used.^{300 301 321} The dosage has then been increased to 720 or 1080 mg twice daily as tolerated.^{300 301 321}

Optimal duration of therapy not fully known; mycophenolate has been used for up to 5 years in some patients.³¹⁰ Long-term immunosuppressant therapy appears necessary to stabilize and prevent progression of the disease.^{310 314 321}

Prescribing Limits

Pediatric Patients

Renal Allotransplantation

Mycophenolate mofetil capsules, tablets, and oral suspension

Oral

Children 3 months to 18 years of age: Maximum 1 g twice daily.¹

Mycophenolate sodium delayed-release tablets

Oral

Children 5–16 years of age: Maximum 720 mg twice daily.²⁷

Special Populations

Hepatic Impairment

Renal Allotransplantation

No dosage adjustment necessary in renal transplant recipients with severe hepatic parenchymal disease; not known whether dosage adjustment is needed for other hepatic diseases.^{1 27}

Cardiac Allotransplantation

No data available for cardiac transplant recipients with severe hepatic parenchymal disease.¹

Renal Impairment

Renal Allotransplantation

Dosage adjustment not necessary in renal transplant recipients experiencing postoperative delayed graft function.^{1 27}

Mycophenolate mofetil capsules, tablets, or oral suspension or mycophenolate mofetil hydrochloride for injection: Avoid dosages >1 g twice daily in renal transplant recipients with severe chronic renal impairment (GFR <25 mL/minute per 1.73 m²) beyond the immediate posttransplant period.¹

Cardiac Allotransplantation

No data available for cardiac transplant recipients with severe chronic renal impairment.¹

Hepatic Allotransplantation

No data available for hepatic transplant recipients with severe chronic renal impairment.¹

Geriatric Patients

Mycophenolate mofetil capsules, tablets, or oral suspension or mycophenolate mofetil hydrochloride for injection: Select dosage carefully.¹ Dosage adjustment based solely on age is not necessary in geriatric patients ≥65 years of age.¹

Mycophenolate sodium delayed-release tablets: Maximum 720 mg twice daily.²⁷

Cautions for Mycophenolate

Contraindications

• Known hypersensitivity to mycophenolate mofetil, mycophenolate sodium, mycophenolic acid, or any ingredient in the formulation.^{1 27}

• IV formulation contraindicated in patients with known severe hypersensitivity to IV polysorbate (Tween) 80.¹

Warnings/Precautions

Warnings

Carcinogenicity

Increased risk of lymphoma and other malignancies, particularly of the skin, in patients receiving immunosuppressive regimens.^{1 27} Risk appears to be related to the intensity and duration of immunosuppression rather than to any specific immunosuppressive agent.^{1 27}

Fetal/Neonatal Morbidity and Mortality

May cause fetal harm when administered to pregnant women.^{1 27 33 35 36 40} Congenital malformations and increased incidence of spontaneous abortions reported during postmarketing surveillance and from the National Transplantation Pregnancy Registry (NTPR); teratogenicity and embryolethality demonstrated in animals.^{1 27 33 35 40}

Use not recommended during pregnancy unless potential benefits justify risks to the fetus.^{1 27 33} Women of childbearing potential should have a negative blood or urine pregnancy test (i.e., sensitivity of at least 25 mIU/mL for human chorionic gonadotropin [HCG]) within 1 week prior to beginning therapy.^{1 27 40} Do not initiate therapy until a report of the pregnancy test is available indicating that results are negative.^{1 27 40}

Women of childbearing potential should use 2 reliable forms of contraception 4 weeks prior to, during, and for 6 weeks following discontinuance of mycophenolate mofetil.^{1 27 40} If used during pregnancy or patient becomes pregnant while receiving the drug, apprise of potential fetal hazard and risk for loss of pregnancy; encourage patient to enroll in the NTPR.^{1 27}

Infectious Complications

Increased susceptibility to infection (i.e., opportunistic infections, sepsis, life-threatening/fatal infections).^{1 27}

Incidence of opportunistic infections in cardiac allograft recipients receiving mycophenolate was about 10% higher than in those receiving azathioprine; the difference was not associated with excess mortality due to infection or sepsis in patients receiving mycophenolate.¹ Viral infections (e.g., cytomegalovirus [CMV] infections, herpes simplex, herpes zoster) reported more frequently in cardiac transplant recipients receiving mycophenolate than in those receiving azathioprine.¹

Latent Viral Infections

Increased risk of reactivation of latent viral infections, including BK virus-associated nephropathy (BKVN).^{1 27 484 485 486 487 488 489 490 492} Principally observed in renal transplant patients (usually within the first year posttransplantation); may result in severe allograft dysfunction and/or graft loss.^{1 27 484 485 486 487 488 489 490 491 492} Reported in patients receiving immunosuppressive regimens containing mycophenolate mofetil.^{1 486 488 489 490 491 492} Risk appears to correlate with degree of overall immunosuppression rather than use of specific immunosuppressant.^{485 486 487 488 489 490 491 492} Monitor closely for signs of BKVN (e.g., deterioration in renal function);^{1 27 484 485 486 488} if BKVN develops, institute early treatment, and consider reducing immunosuppressive therapy.^{1 27 484 485 486 487 488 490 491 492}

Progressive multifocal leukoencephalopathy (PML), an opportunistic viral infection of the brain caused by the JC virus, reported in at least 17 patients receiving mycophenolate mofetil (CellCept); death occurred in at least 7 patients.^{37 38 39} These patients had concomitant exposure to other immunosuppressive agents (i.e., azathioprine, corticosteroids, cyclophosphamide, cyclosporine, tacrolimus) or had compromised immune function.^{1 27 37 38} Not reported to date with mycophenolate sodium (Myfortic).³⁷ However, risk of PML with mycophenolate sodium expected to be the same as with mycophenolate mofetil; both drugs are metabolized to the same active metabolite (mycophenolic acid).³⁷

Consider possible diagnosis of PML in any immunocompromised patient who develops neurologic manifestations.^{1 27 37 38} Refer patient to a neurologist as clinically indicated.^{1 27 37 38} If PML develops, consider decreasing total immunosuppression; weigh benefits of reduced immunosuppression against risk of potential graft rejection in organ transplant recipients.^{1 27 37 38}

Hematologic Effects

Severe neutropenia (ANC <500/mm³) reported; observed most frequently between 31–180 days posttransplant.^{1 27} Neutropenia may be related to mycophenolate, concomitant therapies, viral infection, or a combination of these causes.^{1 27}

Perform CBC weekly during the first month of therapy, twice monthly during the second and third months, and then monthly thereafter during the first year.^{1 27}

Discontinue or adjust dosage if neutropenia develops, perform suitable diagnostic tests, and initiate appropriate patient management.^{1 27}

Pure red cell aplasia (PRCA), a condition in which RBC precursors in the bone marrow are absent or nearly absent, reported in at least 41 patients receiving mycophenolate mofetil.^{1 27 495 496 497 498} Some of these patients also were receiving other immunosuppressive agents (e.g., alemtuzumab, azathioprine, tacrolimus); relative contribution of mycophenolate mofetil to development of PRCA not known.^{1 27 495 498} Consider risk of PRCA also in patients receiving mycophenolate sodium; both drugs converted to the same active metabolite (mycophenolic acid).^{27 495}

PRCA may be reversible in some cases with dosage reduction or discontinuance.^{1 27 495 496 497 498} Consider possibility of graft rejection if immunosuppression reduced in transplant patients; implement any changes to immunosuppressive therapy under appropriate medical supervision.^{1 27 495 496}

Major Toxicities

GI Effects

Severe GI bleeding (requiring hospitalization) has occurred; increased incidence of adverse GI effects (e.g., ulceration, hemorrhage, perforation) reported.^{1 3 4 27} Caution in patients with serious active GI disease.^{1 3 4 27}

General Precautions

Hypoxanthine Phosphoribosyltransferase Deficiency

Avoid (on theoretical grounds) in patients with rare hereditary deficiency of hypoxanthine-guanine phosphoribosyltransferase (HGPRT), including Kelley-Seegmiller or Lesch-Nyhan syndrome.^{1 27} Mycophenolic acid inhibits inosine monophosphate dehydrogenase.¹

Phenylketonuria

Oral suspension contains aspartame (Nutrasweet), which is metabolized in the GI tract to provide about 0.56 mg of phenylalanine per 5 mL of the suspension.¹

Specific Populations

Pregnancy

Category D.^{1 27 33 34} (See Fetal/Neonatal Morbidity and Mortality under Cautions.)

Lactation

Distributed into milk in rats; not known whether distributed into human milk.^{1 27} Discontinue nursing or the drug.^{1 27} Avoid breast-feeding for at least 6 weeks after discontinuing mycophenolate sodium.²⁷

Pediatric Use

Mycophenolate mofetil: Safety for the prevention of rejection of renal allografts in children 3 months to 18 years of age based on data from a pediatric pharmacokinetic and safety study.¹

Mycophenolate mofetil: Safety and efficacy not established in pediatric patients <3 months of age receiving renal allografts.¹

Mycophenolate mofetil: Safety and efficacy not established in pediatric patients <18 years of age receiving allogenic cardiac or hepatic transplants.^{1 12}

Mycophenolate sodium: Safety and efficacy in stable renal transplant recipients 5–16 years of age based on data from a pediatric pharmacokinetic study and clinical studies in adults.²⁷ Safety and efficacy not established in children <5 years of age; a mycophenolate sodium dosage form appropriate for pediatric patients with body surface area <1.19 m² currently not available.²⁷

Mycophenolate sodium: Safety and efficacy not established in de novo renal transplant patients.²⁷

Mycophenolate mofetil: Safety profile in children generally is similar to that in adults; ^{10 11} however, the incidence of abdominal pain,¹ fever,¹ infection,¹ pain,¹ sepsis,¹ diarrhea,¹ vomiting,¹ pharyngitis,¹ respiratory tract infection,¹ hypertension,¹ and anemia¹ higher in pediatric patients than in adults.^{1 10} Lymphoproliferative malignancies reported rarely; other types of malignancies not reported.¹ Severe GI bleeding (requiring hospitalization) reported.¹

Geriatric Use

Insufficient experience in patients ≥65 years of age to determine whether geriatric patients respond differently than younger adults.^{1 27} Select dosage with caution because of age-related decreases in hepatic, renal, and/or cardiac function and potential for concomitant diseases and drug therapy.^{1 27}

Possible increased risk of developing GI hemorrhage, pulmonary edema, or certain infections (e.g., invasive CMV infection).^{1 27}

Renal Impairment

Mycophenolate mofetil: No data available in cardiac or hepatic transplant recipients with severe chronic renal impairment; may use if potential benefits outweigh potential risks.¹

Mycophenolate sodium: Follow patients with severe chronic renal impairment (GFR <25 mL/minute per 1.73 m²) for adverse effects due to increased concentrations of free (unbound) mycophenolic acid and total mycophenolic acid glucuronide concentrations.²⁷

Common Adverse Effects

Mycophenolate mofetil: Diarrhea,^{1 3 4} leukopenia,^{1 3} sepsis,¹ vomiting,^{1 3} higher frequency of infections, including opportunistic infections^{1 3 4} (e.g., CMV infections,^{1 3 4} herpes zoster,³ herpes simplex,^{1 3} candidal infections,^{1 3} aspergillosis,^{3 4} Pneumocystis carinii pneumonia).^{1 3}

Mycophenolate sodium: Constipation, diarrhea, nausea, urinary tract infection, nasopharyngitis.²⁷

Drug Interactions

Drugs That Alter Intestinal Flora

Possible disruption of enterohepatic recirculation; less mycophenolic acid available for absorption.^{1 27}

Drugs That Interfere with Enterohepatic Recirculation

Possible decreased plasma concentrations of mycophenolic acid.^{1 27} Concomitant use not recommended.^{1 27}

Drugs That Undergo Renal Tubular Secretion

Possible increased plasma concentrations of phenolic glucuronide of mycophenolic acid or other drugs that undergo renal tubular secretion.¹

Vaccines

Vaccines may be less effective; avoid use of live virus vaccines.^{1 27 43} Influenza virus vaccine inactivated may be of value.^{1 27}

Specific Drugs

Mycophenolate Pharmacokinetics

Absorption

Bioavailability

Mycophenolate mofetil: Rapidly absorbed following oral administration; bioavailability is 94%.¹

Following oral and IV administration, mycophenolate mofetil undergoes rapid and complete metabolism to mycophenolic acid, the active metabolite.¹

Mycophenolate sodium: Following oral administration of the delayed-release tablets, mycophenolic acid is released in the small intestine; bioavailability is 72%.²⁷

Mycophenolate mofetil tablets, capsules, and oral suspension are bioequivalent.^{1 12}

Mycophenolate sodium delayed-release tablets cannot be used interchangeably with mycophenolate mofetil tablets, capsules, or oral suspension without clinician supervision.²⁷ Single oral doses of mycophenolate sodium delayed-release tablets (mycophenolic acid 720 mg) and mycophenolate mofetil 1 g result in bioequivalent mycophenolic acid exposure.²⁸

Food

Food decreases peak plasma concentrations of mycophenolic acid (by 33–40%); no effect on the mycophenolic acid AUC.^{1 27}

Special Populations

Plasma concentrations of free (unbound) mycophenolic acid and total mycophenolic acid glucuronide have increased in nontransplant individuals with severe chronic renal impairment (GFR <25 mL/minute per 1.73 m²).¹ Plasma mycophenolic acid concentrations in patients with delayed graft function similar to values in patients not experiencing delayed graft function.¹

Pharmacokinetic parameters, including AUC, in children 1–18 years of age receiving mycophenolate mofetil 600 mg/m² (oral suspension) twice daily following renal transplantation similar to values in adult renal transplant recipients receiving 1 g twice daily.¹

Peak plasma concentrations and AUC of mycophenolic acid in stable pediatric renal transplant patients 5–16 years of age receiving a single dose of mycophenolate sodium (mycophenolic acid 450 mg/m²) increased (33 and 18%, respectively) relative to adults receiving the same dose based on body surface area.²⁷ Clinical importance not determined.²⁷

Distribution

Plasma Protein Binding

Mycophenolic acid: ≥97–98% (mainly albumin).^{1 27}

Elimination

Metabolism

Mycophenolate mofetil undergoes complete metabolism to mycophenolic acid; metabolism occurs presystemically following oral administration.¹ Mycophenolic acid is metabolized by glucuronyl transferase to the phenolic glucuronide of mycophenolic acid.^{1 27} The phenolic glucuronide is converted to mycophenolic acid via enterohepatic recirculation.^{1 27}

Elimination Route

Mycophenolate mofetil: Excreted in urine (93%) as the phenolic glucuronide of mycophenolic acid (87%) and in feces (6%).¹

Mycophenolate sodium: Excreted principally in urine as phenolic glucuronide of mycophenolic acid (>60%) and as unchanged mycophenolic acid (3%).²⁷

Half-life

Mycophenolic acid: 8–17.9 hours.^{1 27}

Special Populations

Plasma concentrations of mycophenolic acid glucuronide higher in nontransplant subjects with severe renal impairment than in those with mild impairment or normal renal function.^{1 27}

Plasma concentrations of mycophenolic acid glucuronide higher in transplant patients with delayed renal graft function than in patients not experiencing delayed graft function.¹

Dialysis does not remove mycophenolic acid.^{1 27}

Pharmacokinetic studies in patients with alcoholic cirrhosis indicate that hepatic mycophenolic acid glucuronidation is not affected by hepatic parenchymal disease; hepatic disease with other etiologies (e.g., biliary cirrhosis) may show a different effect.¹

Stability

Storage

Oral

Capsules and Tablets

25°C (may be exposed to 15–30°C).^{1 27}

Mycophenolate mofetil: Dispense in light-resistant containers (e.g., original container).¹

Mycophenolate sodium: Dispense in tight containers.²⁷

Suspension

25°C (may be exposed to 15–30°C).¹ Store reconstituted suspension at 25°C (may be exposed to 15–30°C) for up to 60 days.¹ Reconstituted suspension may be refrigerated; do not freeze.¹

Parenteral

Powder for Injection

25°C (may be exposed to 15–30°C).¹ Store reconstituted solution and solution for infusion at 25°C (may be exposed to 15–30°C).¹

Compatibility

Parenteral

Solution CompatibilityHID

Actions

• Differs structurally and pharmacologically from other immunosuppressive agents.^{1 27}

• Prolongs survival of allogenic transplants in animal models.^{1 27} Has reversed ongoing acute rejection in animal allograph models.^{1 27}

• A potent, selective, noncompetitive, reversible inhibitor of inosine monophosphate dehydrogenase (IMPDH), an essential enzyme in de novo guanosine synthesis.^{1 2 7 27} Because T- and B-cells are dependent on de novo synthesis of purines (e.g., guanosine), mycophenolic acid has potent cytostatic effects on lymphocytes.^{1 2 4 5 27}

• Inhibits proliferative responses of T- and B-cells to both mitogenic and allospecific stimulation^{1 2 27} and suppresses antibody formation by B-cells.^{1 2 4 27} By preventing glycosylation of lymphocyte and monocyte glycoproteins involved in intercellular adhesion to endothelial cells, mycophenolic acid may inhibit recruitment of leukocytes to sites of inflammation and graft rejection.^{1 2 27}

Advice to Patients

• Importance of reading the manufacturer’s patient information (medication guide) prior to initiating therapy and each time prescription is refilled.^{1 43 44}

• Importance of taking mycophenolate as directed.^{1 27 43 44} Importance of following instructions for administration, handling, and storage of the oral suspension.^{1 43 44}

• Risk of lymphoproliferative disease and other malignancies (e.g., skin cancer).^{1 27 43 44} Limit sunlight or other UV light exposure by wearing protective clothing and using sunscreens with a high protection factor.^{1 27 43 44} Avoid use of tanning beds or sunlamps.^{43 44}

• Importance of informing clinician of any unexplained fever, prolonged tiredness, weight loss, swelling of lymph nodes, or unusual skin changes (e.g., new lesions or bumps, discoloration, brown or black lesions with uneven borders).^{43 44}

• Necessity of routine laboratory testing (e.g., CBC).^{1 27 43 44}

• Importance of informing a clinician immediately of any evidence of infection (e.g., temperature ≥100.5°F, cold or flu symptoms, earache, headache, pain on urination, white patches in mouth or throat), unexpected bruising, bleeding, or other manifestations of bone marrow depression.^{1 27 43 44} Importance of informing clinicians of any unusual tiredness, lack of energy, dizziness, or fainting.^{43 44}

• Importance of informing women of childbearing potential of possible risks to fetus prior to initiating therapy.^{40 43 44} Importance of women informing clinicians if they are or plan to become pregnant or to breast-feed; importance of advising women to avoid pregnancy and to use 2 reliable methods of contraception 4 weeks before, during, and for 6 weeks after discontinuance of the drug.^{1 27 33 43 44} Advise patients that mycophenolate may decrease effectiveness of certain oral contraceptives.^{1 27 40 43 44} Warn of potential hazard to the fetus and potential risk for loss of pregnancy in cases of inadvertent exposure to mycophenolate during pregnancy.^{1 27 43 44}

• Importance of patients informing clinician if they plan on receiving any vaccines; instruct patients to avoid live vaccines while taking mycophenolate.^{43 44}

• Women receiving mycophenolate sodium should avoid breast-feeding for at least 6 weeks after discontinuance of the drug.²⁷

• Importance of informing clinicians of concomitant conditions (e.g., ulcers, Lesch-Nyhan or Kelley-Seegmiller syndrome, phenylketonuria) and existing or contemplated therapy, including prescription or OTC drugs.^{1 27 43 44}

• Importance of informing patients of other important precautionary information.^{1 27 43 44} (See Cautions.)

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.

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