Should Cellcept (mycophenolate mofetil) be held in immunocompromised patients with influenza?

Should CellCept Be Held in Immunocompromised Patients with Influenza?

CellCept (mycophenolate mofetil) should NOT be automatically discontinued in immunocompromised patients with influenza—the decision requires careful individualized assessment of graft rejection risk versus infection severity, and the priority should be immediate initiation of oseltamivir rather than holding immunosuppression. 1

Primary Management Strategy

The cornerstone of managing influenza in immunocompromised patients on CellCept is aggressive antiviral therapy, not immunosuppression withdrawal:

• Start oseltamivir 75 mg twice daily immediately for all immunocompromised patients with suspected or confirmed influenza, regardless of symptom duration 1, 2
• Treatment provides significant mortality reduction (OR 0.21) even when initiated beyond 48 hours after symptom onset 1, 2
• Do not wait for laboratory confirmation during influenza season—start empirically based on clinical suspicion 1, 2

The Critical Pitfall to Avoid

The American College of Physicians explicitly recommends against automatically discontinuing CellCept without considering graft rejection risk 1. This is the most important clinical decision point:

• Transplant patients face dual risks: severe influenza complications AND potential graft rejection if immunosuppression is withdrawn 3
• The risk-benefit calculation depends on:
  • Severity of influenza illness (URI only vs. lower respiratory tract disease)
  • Type of transplant and time since transplantation
  • Baseline rejection risk of the specific patient
  • Adequacy of antiviral therapy response

Evidence Supporting Continued Immunosuppression

• Corticosteroid use in hematopoietic cell transplant recipients with influenza showed no adverse clinical outcomes regarding development of lower respiratory tract disease, hypoxemia, mechanical ventilation need, or death 4
• High-dose steroids (≥1 mg/kg/day) showed only a trend toward prolonged viral shedding but no increased mortality 4
• Early antiviral therapy is far more impactful than immunosuppression modification—it reduced lower respiratory tract disease risk (OR 0.04) and hypoxemia (OR 0.3) 4

When to Consider Dose Reduction

If CellCept dose reduction is contemplated, it should only occur in specific circumstances:

• Severe or progressive influenza despite adequate antiviral therapy 1
• Development of lower respiratory tract disease or pneumonia 3
• Prolonged viral shedding beyond expected timeframes 3
• After consultation with transplant team to assess rejection risk

Optimal Treatment Approach

Immediate Actions (Day 1)

• Initiate oseltamivir 75 mg twice daily for minimum 5 days 1, 2
• Consider longer courses (10 days) or treatment until symptom resolution in immunocompromised patients 1
• Continue CellCept at current dose unless severe complications develop 1

Monitoring Strategy

• Assess clinical response to antivirals within 48-72 hours 1
• Monitor for progression to lower respiratory tract disease 3, 4
• Watch for bacterial or fungal superinfections 3
• Track viral shedding duration if testing available 3, 4

Expected Benefits of Antiviral Therapy

• 50% reduction in pneumonia risk 1
• Significant mortality benefit in high-risk patients 1, 2
• Reduced viral shedding and transmission risk 1
• Prevention of progression from upper to lower respiratory tract disease 4

Additional Protective Measures

• The Centers for Disease Control and Prevention recommend against using corticosteroids as adjunctive therapy for influenza treatment unless clinically indicated for other reasons, as they may prolong viral shedding 1
• Ensure household contacts and healthcare workers are vaccinated 5, 6
• Consider antiviral prophylaxis for high-risk contacts 2

Key Takeaway

The evidence strongly supports maintaining immunosuppression while aggressively treating influenza with oseltamivir 1, 4. The decision to hold or reduce CellCept should be made collaboratively with the transplant team, reserved for severe cases not responding to antivirals, and balanced against the very real risk of graft rejection.