What is the typical dose of mycophenolate (Cellcept) for treating lupus?

Mycophenolate Dosing for Lupus

For lupus nephritis (Class III/IV), the target dose of mycophenolate mofetil is 2-3 grams per day total, with 3 grams daily preferred for severe disease with crescents or rising creatinine, while Asian patients may require only 2 grams daily for equivalent efficacy. 1

Induction Therapy Dosing

Class III/IV Proliferative Lupus Nephritis

• Standard target dose: 2-3 grams/day of mycophenolate mofetil (MMF) for 6 months as induction therapy 1
• Equivalent mycophenolic acid (MPA) dose: 1.44-2.16 grams/day (or 720-1080 mg twice daily) 1

Disease Severity-Based Dosing

• Class III/IV without crescents: Both 2 and 3 grams daily are acceptable 1
• Class III/IV with crescents: 3 grams daily is favored 1
• Proteinuria with recent significant rise in creatinine: 3 grams daily is preferred 1

Race/Ethnicity Considerations

• Non-Asian patients: Aim for 3 grams/day as the target dose 1
• Asian patients: 2 grams/day may provide similar efficacy with potentially better tolerability 1
• African American and Hispanic patients: MMF may be particularly effective as these populations respond less well to cyclophosphamide 1

Maintenance Therapy Dosing

After Induction (Following 6 Months of Initial Treatment)

• Mycophenolate mofetil: 750-1000 mg twice daily (1.5-2 grams total daily) 1
• Mycophenolic acid: 540-720 mg twice daily (1.08-1.44 grams total daily) 1
• Duration: Minimum 36 months total (induction plus maintenance combined) 1

The most recent KDIGO 2024 guidelines specify these lower maintenance doses after the initial 6-month induction period 1, while the 2012 ACR guidelines used 2 grams daily for maintenance 1. The trend toward lower maintenance doses reflects evolving understanding of optimal long-term management.

Class V Pure Membranous Lupus Nephritis

• Target dose: 2-3 grams/day MMF combined with prednisone 0.5 mg/kg/day 1
• This applies specifically to patients with nephrotic-range proteinuria (>3 grams/24 hours) 1

Dose Adjustments and Monitoring

Tolerance-Based Modifications

• Adjust dose according to: tolerance, adverse effects (particularly gastrointestinal), efficacy, and trough MPA blood levels if available 1
• Therapeutic drug monitoring: Target MPA-AUC₀₋₁₂ of 60-90 mg*h/L may optimize outcomes, though routine monitoring is not yet standard practice 1

Common Pitfalls to Avoid

• Underdosing in non-Asian patients: Starting at 2 grams when 3 grams is indicated for severe disease reduces efficacy 1
• Premature dose reduction: Maintain full induction doses for the complete 6-month period before transitioning to maintenance 1
• Inadequate maintenance duration: Continue combination immunosuppression for at least 36 months total to prevent flares 1

Formulation Equivalency

• Mycophenolate mofetil (MMF) 2-3 grams/day is roughly equivalent to mycophenolic acid (MPA) 1.44-2.16 grams/day 1
• Enteric-coated mycophenolate sodium may cause less gastrointestinal toxicity, though this remains controversial 1

Combination Therapy Context

All mycophenolate dosing should be combined with glucocorticoids, typically starting with pulse IV methylprednisolone (500-2500 mg total) followed by oral prednisone 0.3-0.5 mg/kg/day, tapering to ≤7.5 mg/day by 3-6 months 1. For patients with nephrotic-range proteinuria or refractory disease, adding a calcineurin inhibitor (particularly tacrolimus) to MMF may be considered 1.