From the Guidelines
Yes, mycophenolate should typically be held in transplant patients with active infection. The standard approach is to temporarily discontinue or reduce the dose of mycophenolate mofetil (CellCept) or mycophenolate sodium (Myfortic) while treating the infection, as this medication significantly suppresses the immune system by inhibiting T and B lymphocyte proliferation.
Key Considerations
- The decision should be made in consultation with the transplant team, as the risk of infection must be balanced against the risk of rejection.
- For serious bacterial, fungal, or viral infections, mycophenolate is often completely held until the infection is controlled, as recommended by the 2016 infectious diseases society of America (IDSA) clinical practice guideline for the treatment of coccidioidomycosis 1.
- For less severe infections, a dose reduction (e.g., 50% of maintenance dose) may be sufficient.
Management Approach
- While mycophenolate is held, other immunosuppressants like calcineurin inhibitors (tacrolimus or cyclosporine) are usually continued, possibly at reduced doses.
- Once the infection resolves, mycophenolate can be gradually reintroduced, typically starting at a lower dose and titrating up while monitoring for infection recurrence or signs of rejection.
- This approach helps manage the delicate balance between preventing organ rejection and allowing sufficient immune function to clear the infection, and is supported by studies such as the easl clinical practice guidelines on hepatitis e virus infection 1.
From the FDA Drug Label
Increased susceptibility to infections, including opportunistic infections and severe infections with fatal outcomes [see Warnings and Precautions (5.3)]. Reduce or interrupt dosing in the event of neutropenia. (2.5)
Holding mycophenolate is recommended in transplant patients with infection. The drug label warns of an increased susceptibility to infections, including opportunistic infections and severe infections with fatal outcomes. Although it does not directly state to hold the medication in the event of an infection, it does recommend reducing or interrupting dosing in the event of neutropenia, which can be a consequence of infection. Therefore, as a conservative clinical decision, it is advisable to hold mycophenolate in transplant patients with infection 2.
From the Research
Holding Mycophenolate in Transplant Patients with Infection
- There is no direct evidence in the provided studies to suggest holding mycophenolate in transplant patients with infection 3, 4, 5, 6, 7.
- However, it is known that mycophenolate mofetil is an immunosuppressive drug that can increase the risk of infection in transplant patients 3, 7.
- The studies provided focus on the comparison of immunosuppressive agents, drug-drug interactions, and utilization patterns, but do not specifically address the management of mycophenolate in patients with infection 3, 4, 5, 6, 7.
- In general, the management of immunosuppressive drugs in transplant patients with infection requires careful consideration of the balance between preventing rejection and minimizing the risk of infection 6.
- Therapeutic drug monitoring is an important tool in managing immunosuppressive drugs, including mycophenolate, to ensure that blood and plasma levels are within the therapeutic range 6.