From the Guidelines
For a patient with idiopathic NSIP who cannot take azathioprine due to CKD, mycophenolate mofetil is the recommended alternative immunosuppressive agent, as supported by the 2023 American College of Rheumatology (ACR)/American College of Chest Physicians (CHEST) guideline 1. The typical starting dose is 500 mg twice daily, gradually increasing to a target dose of 1,000-1,500 mg twice daily as tolerated. Some key points to consider when using mycophenolate in CKD patients include:
- Mycophenolate is preferred in CKD patients because it has less nephrotoxicity than azathioprine and undergoes hepatic metabolism rather than renal clearance 1.
- Dose adjustments are generally not required for mild to moderate CKD, though careful monitoring is still necessary.
- Regular blood tests (CBC, liver function, kidney function) should be performed every 1-2 weeks initially, then monthly once stable.
- Patients should be monitored for potential side effects including gastrointestinal disturbances, bone marrow suppression, and increased infection risk. In cases where mycophenolate is not tolerated, other options might include:
- Lower-dose corticosteroids
- Potentially rituximab, though these would require specialist consultation and careful consideration of the risk-benefit profile given the patient's CKD status 1. Key considerations for therapy selection include:
- The patient's specific clinical situation and disease severity
- The potential risks and benefits of each therapy option
- The need for careful monitoring and potential dose adjustments to minimize adverse effects.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Alternative Treatment Options for Ild NSIP in CKD Patients
In patients with interstitial lung disease (ILD) and chronic kidney disease (CKD), azathioprine may not be the best treatment option due to its potential nephrotoxicity.
- Mycophenolate mofetil (MMF) is a possible alternative, as it has been shown to be effective in preserving pulmonary function in patients with ILD 2.
- The combination of rituximab and MMF has also been found to be superior to MMF alone in patients with ILD and a nonspecific interstitial pneumonia (NSIP) pattern 3.
- Other immunomodulatory agents, such as cyclophosphamide, methotrexate, and tocilizumab, may also be considered as alternative treatment options for ILD in CKD patients 4, 5.
- However, it is essential to note that the evidence for these alternatives is limited, and more research is needed to determine their efficacy and safety in this patient population 2, 6.
Considerations for Treatment Selection
When selecting an alternative treatment for ILD in CKD patients, several factors should be considered, including: