What is the typical regimen for mycophenolate (mycophenolate mofetil) with prednisone in clinical contexts?

Mycophenolate with Prednisone: Typical Regimens

For lupus nephritis, the standard regimen is mycophenolate mofetil 2-3 g/day (or mycophenolic acid at equivalent dose) combined with glucocorticoids: intravenous methylprednisolone pulses followed by oral prednisone 0.3-0.5 mg/kg/day during induction, then maintenance with mycophenolate and prednisone ≤7.5 mg/day (preferably as low as possible). 1

Induction Phase Dosing

Lupus Nephritis (Proliferative)

• Mycophenolate mofetil: 2-3 g/day orally (divided as 1-1.5 g twice daily) 1
• Mycophenolic acid: Equivalent dose to MMF (approximately 1440 mg/day divided as 720 mg twice daily) 1
• Prednisone: Start with intravenous methylprednisolone pulses, then oral prednisone 0.3-0.5 mg/kg/day 1
• Duration: Continue until complete response achieved, typically by 12 months 1

Autoimmune Hepatitis

• Mycophenolate mofetil: 1-2 g/day (starting dose 1 g daily, final dose 1.5-2 g daily) 1
• Prednisone: 0.5-1 mg/kg/day initially 1
• Note: This is considered second-line when azathioprine is not tolerated; standard first-line remains prednisone plus azathioprine 1

Transplantation Settings

• Kidney transplant: MMF 1 g twice daily (2 g/day total) with cyclosporine and corticosteroids 2
• Heart transplant: MMF 1.5 g twice daily (3 g/day total) with cyclosporine and corticosteroids 2
• Liver transplant: MMF 1.5 g twice daily orally after initial IV dosing, with cyclosporine and corticosteroids 2

Maintenance Phase Dosing

Lupus Nephritis

• Mycophenolate mofetil: 750-1000 mg twice daily during early maintenance 1
• Mycophenolic acid: 540-720 mg twice daily during early maintenance 1
• Prednisone: ≤7.5 mg/day, preferably as low as possible 1
• Duration: Total immunosuppression (induction plus maintenance) should be ≥36 months for proliferative lupus nephritis 1

Critical timing consideration: At the end of initial treatment, the goal is to reduce prednisone to ≤7.5 mg/day, as prolonged glucocorticoid exposure is associated with significant organ damage and morbidity 1

Glucocorticoid Tapering Strategy

Standard Taper for Lupus Nephritis

• Begin with IV methylprednisolone pulses 1
• Transition to oral prednisone 0.3-0.5 mg/kg/day 1
• Taper to ≤7.5 mg/day by end of induction phase 1
• Continue tapering to lowest possible dose during maintenance 1

Important caveat: A recent trial (CORTICOLUP) showed significantly increased flare rates when prednisone 5 mg daily was discontinued abruptly in patients with stable quiescent SLE (HR: 0.2 for continuation, P = 0.002), suggesting glucocorticoid discontinuation should be undertaken cautiously with careful monitoring 1

Dose Adjustments and Monitoring

Renal Impairment

• Critical consideration: The glucuronide metabolite (MPAG) accumulates approximately five times normal levels in end-stage renal disease, increasing susceptibility to adverse effects 3
• Dose reduction may be necessary when kidney function is significantly impaired 1

Gastrointestinal Intolerance

• Switch to mycophenolic acid 720-1080 mg twice daily (equivalent to MMF 1-1.5 g twice daily) 4
• Consider therapeutic drug monitoring with target MPA AUC of 20-60 µg·h/mL 4

Drug Interactions Affecting Absorption

• Avoid concurrent administration with aluminum/magnesium antacids, cholestyramine, iron, and activated charcoal, as these inhibit absorption 4, 3

Monitoring Requirements

Laboratory Monitoring Schedule

• First month: CBC weekly 3
• Months 2-3: CBC twice monthly 3
• Months 4-12: CBC monthly 3
• Beyond first year: CBC every 1-3 months indefinitely 3
• Renal and hepatic profiles: Every 1-3 months 3

Pre-Treatment Testing

• Complete blood count with differential 3
• Comprehensive metabolic panel including liver and renal function 3
• Hepatitis B, hepatitis C, and tuberculosis screening if using with highly immunosuppressive regimens 3
• Full body skin examination by dermatologist 3

Common Pitfalls to Avoid

Dose reduction pitfall: Altering MMF dose within the first post-transplant year correlates with significantly worse clinical outcomes, with acute rejection rates of 23.3% versus 3.7% in patients without dose changes (p < 0.001) and decreased 3-year graft survival (76.3% versus 88.3%, p = 0.003) 5. Maintain target doses whenever possible.

Pregnancy risk: FDA black box warning for teratogenic and embryocidal effects; severe cranial, facial, and cardiac abnormalities reported 3. Verify pregnancy status before initiation and counsel on contraception.

Live vaccine contraindication: Avoid all live vaccines during treatment 3

Azathioprine combination: Never combine with azathioprine due to increased purine metabolism inhibition 3

Clinical Response Expectations

Lupus Nephritis

• Target: Complete response (proteinuria <0.5-0.7 g/24 hours with near-normal GFR) by 12 months 1
• Clinical improvement: In observational studies, 88% of patients normalized serum aminotransferase and γ-globulin levels, usually within 3 months 1
• Histopathological improvement: Activity indices reduced significantly (9.56 ± 2.83 versus 5.22 ± 1.86, P < 0.01), though chronicity indices did not change significantly 6

Autoimmune Hepatitis

• Most patients achieve biochemical improvement within 3 months when used as salvage therapy 1
• Corticosteroid withdrawal achieved in 58% of patients, usually within 8 months 1