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Abstract
BACKGROUND Activated T and B lymphocytes are the predominant inflammatory cells in atopic eczema (AE) lesions. Mycophenolic acid, the active form of mycophenolate mofetil (MMF), blocks the proliferative responses of T and B lymphocytes. OBJECTIVES In this pilot study, we examined the efficacy of MMF (CellCept(R), Hoffman La Roche, Grenzach-Wyhlen, Germany) in severe AE. METHODS Ten patients with severe AE (severity index > 50) according to the Severity Scoring of Atopic Dermatitis (SCORAD) index were treated with oral MMF at an initial dose of 1 g daily during the first week and 2 g daily for a further 11 weeks. Laboratory examination including full blood count, lymphocyte subset analysis, serum immunoglobulins (IgE, IgG, IgM, IgA), total bilirubin, alkaline phosphatase, aminotransferases, lactate dehydrogenase and creatinine was performed every 2 weeks. Additionally, interleukin (IL)-10 and interferon (IFN)-gamma in serum were measured. RESULTS None of the 10 patients who received MMF discontinued the trial because of lack of efficacy or adverse events. Compared with the baseline, the median scores for disease severity (SCORAD index) improved by 68% during treatment with MMF. The median serum IgE level decreased significantly, from 10,300 kU L-1 before treatment to 7830 kU L-1 after 12 weeks. MMF induced a significant increase in the T-helper (Th)-1-related cytokine IFN-gamma and a significant decrease in IL-10, mainly produced by Th2 cells. CONCLUSIONS The present study demonstrates that oral MMF at a dose of 2 g daily is an effective, safe and well-tolerated immunosuppressive therapy for severe AE in adults.
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Affiliation(s)
- K Neuber
- Department of Dermatology, University Hospital Eppendorf, Martinistr. 52, D-20246 Hamburg, Germany.
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52
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Satchell AC, Barnetson RS. Staphylococcal septicaemia complicating treatment of atopic dermatitis with mycophenolate. Br J Dermatol 2000; 143:202-3. [PMID: 10886168 DOI: 10.1046/j.1365-2133.2000.03623.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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53
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Affiliation(s)
- C L Haupert
- Department of Ophthalmology, Duke University Eye Center, Durham, NC 27710, USA
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54
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Grundmann-Kollmann M, Mooser G, Schraeder P, Zollner T, Kaskel P, Ochsendorf F, Boehncke WH, Kerscher M, Kaufmann R, Peter RU. Treatment of chronic plaque-stage psoriasis and psoriatic arthritis with mycophenolate mofetil. J Am Acad Dermatol 2000; 42:835-7. [PMID: 10775866 DOI: 10.1067/mjd.2000.104890] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Mycophenolate mofetil (MMF), a widely used immunosuppressant in organ transplantation, is a recent addition to the therapeutic armamentarium of autoimmune and inflammatory skin disorders in dermatology. We describe 5 patients with moderate to severe chronic plaque psoriasis and 6 patients with psoriatic arthritis that was refractory to conventional systemic and/or topical antipsoriatic treatment who were treated with MMF monotherapy (2 g/d) in a 10-week study. Although MMF was tolerated well in all patients, only patients with moderate psoriasis and psoriatic arthritis improved with therapy, whereas patients with severe psoriasis did not respond to MMF. Although MMF seems to be effective and safe for blistering autoimmune diseases and pyoderma gangrenosum, our data do not allow optimistic statements on the use of MMF in severe plaque-stage psoriasis. However, MMF may develop into an interesting therapeutic alternative for patients with psoriatic arthritis.
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Affiliation(s)
- M Grundmann-Kollmann
- Department of Dermatology, Johann Wolfgang Goethe University, Frankfurt/Main, Germany
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55
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Williams JV, Marks JG, Billingsley EM. Use of mycophenolate mofetil in the treatment of paraneoplastic pemphigus. Br J Dermatol 2000; 142:506-8. [PMID: 10735959 DOI: 10.1046/j.1365-2133.2000.03365.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Paraneoplastic pemphigus (PNP) is a rare autoimmune blistering disease with circulating antibodies that bind the cell surface of the epidermis and other non-stratifying epithelia, and immunoprecipitate a complex of four or five proteins (250 kDa, 230 kDa, 210 kDa, 190 kDa and occasionally 170 kDa).1,2 Combinations of immunosuppressive agents are usually required to obtain even partial control of the skin lesions.3 Mucous membrane lesions are refractory to treatment. We describe a patient with PNP whose skin and oral lesions are quiescent following treatment with oral mycophenolate mofetil.
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Affiliation(s)
- J V Williams
- Section of Dermatology, The Penn State University College of Medicine, Penn State Geisinger Health System, The Milton S. Hershey Medical Center, Hershey, Pennsylvania, PA, USA
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56
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Katz KH, Marks JG, Helm KF. Pemphigus foliaceus successfully treated with mycophenolate mofetil as a steroid-sparing agent. J Am Acad Dermatol 2000; 42:514-5. [PMID: 10688729 DOI: 10.1016/s0190-9622(00)90231-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Pemphigus foliaceus is an autoimmune blistering disease of unknown origin with antibodies produced against desmoglein 1, an adhesive protein found in the desmosomal cell junction in the suprabasal layers of the epidermis. The disease is primarily treated with corticosteroids and corticosteroid-sparing immunosuppressive agents. We report a case of pemphigus foliaceus successfully treated with mycophenolate mofetil. It remains to be seen whether this agent has a significant effect on the course of the disease and remission induction.
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Affiliation(s)
- K H Katz
- Department of Medicine, Section of Dermatology, Penn State University, Milton S. Hershey Medical Center, Pennsylvania, USA
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57
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Abstract
It is obvious from the review of the literature that most treatments for oral diseases such as lichen planus, pemphigoid, and pemphigus are based on case reports, anecdotes, and small uncontrolled studies. Efforts must be made to perform more controlled studies to evaluate the efficacy of new treatments. Small numbers of patients at each site and multiple-drug therapy make this task difficult. Dermatologists should familiarize themselves with the newer immunosuppressive agents available. Use of these drugs requires knowledge of their pharmacokinetics and potential side effects, so that they may be used effectively and safely. Relatively low doses of azathioprine, cyclophosphamide, and cyclosporine should then be added to the dermatologist's armamentarium for the treatment of severe or recalcitrant diseases. Old drugs are resurfacing with new (but often off-label) uses as the underlying mechanisms of disease become understood. Thalidomide and mycophenolate mofetil are two examples of promising drugs for the future of dermatology.
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Affiliation(s)
- J L Popovsky
- Department of Dermatology, Cleveland Clinic Foundation, Ohio, USA
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58
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Gaubitz M, Schorat A, Schotte H, Kern P, Domschke W. Mycophenolate mofetil for the treatment of systemic lupus erythematosus: an open pilot trial. Lupus 1999; 8:731-6. [PMID: 10602445 DOI: 10.1191/096120399678840927] [Citation(s) in RCA: 78] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To investigate the effectiveness and safety of mycophenolate mofetil in patients with systemic lupus erythematosus who were inadequately controlled with corticosteroids, antimalarials, and other immunosuppressive agents. METHODS Ten patients with systemic lupus erythematosus (SLE) were treated with 1500-2000 mg mycophenolae mofetil (MMF) daily for a median observation time of 11. 2+/-2.4 (8-16) months in an open clinical trial. The effectiveness and safety of treatment were analyzed using an established disease activity score, clinical status, and laboratory parameters. RESULTS All patients improved under treatment with no or only minor side effects. The disease activity score (SLAM) decreased statistically significantly from a median of 15.6+/-5.5 to 9.9+/-4.1 after three months (P<0.01) and to 8.0+/-3.3 after six months (P<0.01). Hematologic parameters did not change significantly whereas a reduction of inflammatory markers was observed. Four patients with SLE-nephritis already treated with cyclophosphamide pulse therapy continuously showed a slight improvement of renal function. Prednisolone dosages could be reduced significantly from a median level of 10.0+/-5.1 mg/d before treatment to 4.6+/-3.5 mg/d after six months (P<0.01). CONCLUSION Mycophenolate mofetil is a promising option in immunosuppressive treatment of patients with moderate and severe systemic lupus erythematosus who did not show a satisfactory response to other immunosuppressives.
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Affiliation(s)
- M Gaubitz
- Department of Medicine B, University of Münster, Münster, Germany.
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59
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Bredlich RO, Grundmann-Kollmann M, Behrens S, Kerscher M, Peter RU. Mycophenolate mofetil monotherapy for pemphigus vulgaris. Br J Dermatol 1999; 141:934. [PMID: 10583186 DOI: 10.1046/j.1365-2133.1999.03177.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Schattenkirchner S, Eming S, Hunzelmann N, Krieg T, Smola H. Treatment of epidermolysis bullosa acquisita with mycophenolate mofetil and autologous keratinocyte grafting. Br J Dermatol 1999; 141:932-3. [PMID: 10583185 DOI: 10.1046/j.1365-2133.1999.03176.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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61
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Abstract
A woman with a long history of widespread plaque psoriasis unresponsive to and/or intolerant of phototherapy, retinoids, methotrexate and cyclosporin was successfully treated with mycophenolate mofetil. Remission was maintained on doses between 1 and 1.5 g/day for 18 months without adverse effects.
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Affiliation(s)
- D W Tong
- Department of Dermatology, Prince of Wales Hospital, Randwick, New South Wales, Australia
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62
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Grundmann-Kollmann M, Korting HC, Behrens S, Leiter U, Krähn G, Kaufmann R, Peter RU, Kerscher M. Successful treatment of severe refractory atopic dermatitis with mycophenolate mofetil. Br J Dermatol 1999; 141:175-6. [PMID: 10417549 DOI: 10.1046/j.1365-2133.1999.02952.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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63
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Jonsson CA, Svensson L, Carlsten H. Beneficial effect of the inosine monophosphate dehydrogenase inhibitor mycophenolate mofetil on survival and severity of glomerulonephritis in systemic lupus erythematosus (SLE)-prone MRLlpr/lpr mice. Clin Exp Immunol 1999; 116:534-41. [PMID: 10361247 PMCID: PMC1905307 DOI: 10.1046/j.1365-2249.1999.00901.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The aim of the present study was to evaluate the therapeutic effect of mycophenolate mofetil (MMF) on the course of disease in SLE-prone MRLlpr/lpr mice. Three-months-old mice displaying clinical symptoms of glomerulonephritis were given MMF (100 mg/kg per day) orally via the drinking water. Control mice received i.p. injections of cyclophosphamide (CYC) (1.8 mg/mouse per week) or saline. Survival, albuminuria and haematuria, immunoglobulin levels and anti-dsDNA antibodies in serum, frequencies of immunoglobulin-producing B lymphocytes and glomerular deposits of immunoglobulin and C3 were analysed. The results showed that MMF treatment significantly prolonged survival and reduced the occurrence of albuminuria and haematuria in MRLlpr/lpr mice. In addition, the number of immunoglobulin-producing B cells and serum levels of IgG and IgG anti-dsDNA antibodies were reduced after MMF and CYC treatment. MMF treatment significantly reduced the extent of deposition of C3 in glomeruli. We conclude that the reduced severity of glomerulonephritis following treatment of lupus-prone mice with MMF was as efficacious as that of CYC. These results warrant clinical trials of MMF in SLE patients with glomerulonephritis.
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Affiliation(s)
- C A Jonsson
- Department of Rheumatology, University of Göteborg, Sweden.
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64
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Grundmann-Kollmann M, Korting HC, Behrens S, Kaskel P, Leiter U, Krähn G, Kerscher M, Peter RU. Mycophenolate mofetil: a new therapeutic option in the treatment of blistering autoimmune diseases. J Am Acad Dermatol 1999; 40:957-60. [PMID: 10365927 DOI: 10.1016/s0190-9622(99)70084-8] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Mycophenolate mofetil (MMF), an ester of mycophenolic acid (MPA), was approved by the Food and Drug Administration in 1995 and is currently primarily indicated for the prophylaxis of rejection in renal transplant patients. The drug seems also to be of value in the treatment of psoriasis and rheumatic arthritis. Recently there have been 6 reported cases of successful treatment of blistering autoimmune diseases with MMF in combination with high dose prednisone therapy. OBJECTIVE On the basis of these reports we administered this new treatment regimen to several patients with blistering autoimmune diseases. Besides using a combination of MMF and high-dose prednisone we wanted to evaluate whether MMF monotherapy is also effective in the treatment of blistering autoimmune diseases. METHODS We administered MMF to 5 patients who had severe pemphigus vulgaris or bullous pemphigoid. Two patients received MMF in combination with high-dose prednisone therapy and 3 patients received MMF monotherapy. To our knowledge, this is the first report of successful treatment of pemphigus vulgaris and bullous pemphigoid with MMF monotherapy. RESULTS All patients were completely free of symptoms within 8 to 11 weeks of therapy. Patients who had received MMF monotherapy responded as well to treatment as those who received a combination of MMF and high-dose prednisone. CONCLUSION Our experiences strongly suggest that MMF monotherapy may be effective for patients even with severe pemphigus vulgaris and bullous pemphigoid. In addition, MMF monotherapy, at least over the short term, offers the advantage of fewer side effects in comparison to immunosuppressive combination therapy and was well tolerated by our patients.
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65
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Abstract
The treatment of autoimmune blistering diseases remains therapeutically challenging. Significant improvement in the management of autoimmune bullous diseases has occurred as a consequence of improvements in our ability to predict, monitor, and treat the deleterious effects associated with the drugs used to treat these conditions and the introduction of new agents with lower toxicity. Examples include improvements in monitoring and preventing osteoporosis in patients on long-term systemic corticosteroids, the detection of those at risk for azathioprine toxicity bowing to low thiopurine methyltransferase activity, and the addition of agents such as mycophenolate mofetil and IVIG to our therapeutic armamentarium. These advances offer the promise of improved disease control with fewer side-effects and long-term toxicity for our patients.
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Affiliation(s)
- M Levy
- University of Toronto School of Medicine, Toronto, Ontario, Canada
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66
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Shipkova M, Armstrong VW, Wieland E, Niedmann PD, Schütz E, Brenner-Weiss G, Voihsel M, Braun F, Oellerich M. Identification of glucoside and carboxyl-linked glucuronide conjugates of mycophenolic acid in plasma of transplant recipients treated with mycophenolate mofetil. Br J Pharmacol 1999; 126:1075-82. [PMID: 10204993 PMCID: PMC1565876 DOI: 10.1038/sj.bjp.0702399] [Citation(s) in RCA: 167] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
1. Mycophenolic acid (MPA), is primarily metabolized in the liver to 7-O-MPA-beta-glucuronide (MPAG). Using RP-h.p.l.c. we observed three further MPA metabolites, M-1, M-2, M-3, in plasma of transplant recipients on MMF therapy. To obtain information on the structure and source of these metabolites: (A) h.p.l.c. fractions containing either metabolite or MPA were collected and analysed by tandem mass spectrometry; (B) the metabolism of MPA was studied in human liver microsomes in the presence of UDP-glucuronic acid, UDP-glucose or NADPH; (C) hydrolysis of metabolites was investigated using beta-glucosidase, beta-glucuronidase or NaOH; (D) cross-reactivity of each metabolite was tested in an immunoassay for MPA (EMIT). 2. Mass spectrometry of M-1, M-2, MPA and MPAG in the negative ion mode revealed molecular ions of m/z 481, m/z 495, m/z 319 and m/z 495 respectively. 3. Incubation of microsomes with MPA and UDP-glucose produced M-1, with MPA and UDP-glucuronic acid MPAG and M-2 were formed, while with MPA and NADPH, M-3 was observed. 4. Beta-Glucosidase hydrolysed M-1 completely. Beta-Glucuronidase treatment led to a complete disappearance of MPAG whereas the amount of M-2 was reduced by approximately 30%. Only M-2 was labile to alkaline treatment. 5. M-2 and MPA but not M-1 and MPAG cross-reacted in the EMIT assay. 6. These results suggest that: (i) M-1 is the 7-OH glucose conjugate of MPA; (ii) M-2 is the acyl glucuronide conjugate of MPA; (iii) M-3 is derived from the hepatic CYP450 system.
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Affiliation(s)
- M Shipkova
- Abteilung Klinische Chemie, George-August-Universität Göttingen, Germany.
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67
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Nousari HC, Sragovich A, Kimyai-Asadi A, Orlinsky D, Anhalt GJ. Mycophenolate mofetil in autoimmune and inflammatory skin disorders. J Am Acad Dermatol 1999; 40:265-8. [PMID: 10025760 DOI: 10.1016/s0190-9622(99)70203-3] [Citation(s) in RCA: 106] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Mycophenolate mofetil (MMF) has been widely used as an immunosuppressant in organ transplantation. MMF has recently been added to therapeutic regimens for skin disorders. Expanding the use of MMF in dermatology, we describe additional patients with autoimmune and inflammatory skin diseases, including 4 cases of pemphigus vulgaris, 1 case of pemphigus foliaceus, 1 case of perineal and metastatic cutaneous Crohn's disease, 1 case of bullous pemphigoid and psoriasis, and 1 case of psoriasis. Most of these patients had refractory disease or had developed significant side effects to conventional therapy, including azathioprine, methotrexate, prednisone, cyclosporine, acitretin, PUVA, UVB, and tacrolimus. MMF was effective and well tolerated in all these patients. The dosages of MMF ranged from 500 mg twice daily (for psoriasis and Crohn's disease) to 1250mg twice daily (for 3 of 4 patients with pemphigus vulgaris). MMF is an effective and relatively safe immunosuppressant in autoimmune and inflammatory skin diseases.
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Affiliation(s)
- H C Nousari
- Department of Dermatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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68
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Larkin G, Lightman S. Mycophenolate mofetil. A useful immunosuppressive in inflammatory eye disease. Ophthalmology 1999; 106:370-4. [PMID: 9951492 DOI: 10.1016/s0161-6420(99)90078-7] [Citation(s) in RCA: 117] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
OBJECTIVE To assess the usefulness of mycophenolate mofetil (MMF) (Cellcept, Roche), a potent selective uncompetitive and reversible inhibitor of ionisine monophosphate dehydrogenase involved in purine synthesis, as an immunosuppressive and steroid-sparing agent in the management of ocular inflammatory disease. DESIGN Open-label, prospective, uncontrolled pilot study. PARTICIPANTS Eleven patients with uncontrolled ocular inflammation. INTERVENTION Mycophenolate mofetil, at a dosage of 1 g twice daily, was given in conjunction with steroids, as a steroid-sparing agent, or as an additional agent with cyclosporine (CsA), or instead of CsA or azathioprine. MAIN OUTCOME MEASURES The inflammatory response, side effects, and toxicity were monitored. RESULTS The addition of MMF to immunosuppressive regimens led to the improvement in symptoms and the ability to reduce the dose of prednisone in most patients. Ten of 11 patients showed a favorable response to MMF, with few side effects noted. CONCLUSION These findings suggest that MMF is a useful immunosuppressive drug for controlling ocular inflammation with minimal side effects.
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Affiliation(s)
- G Larkin
- Moorfields Eye Hospital, London, England
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69
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Neurath MF, Wanitschke R, Peters M, Hildner K, Tufan R, Meyer zum Büschenfelde KH, Schlaak JF. Mycophenolate mofetil for treatment of active inflammatory bowel disease. Clinical and immunological studies. Ann N Y Acad Sci 1998; 859:315-8. [PMID: 9928412 DOI: 10.1111/j.1749-6632.1998.tb11154.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- M F Neurath
- I. Department of Medicine, University of Mainz, Germany
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70
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Nousari HC, Griffin WA, Anhalt GJ. Successful therapy for bullous pemphigoid with mycophenolate mofetil. J Am Acad Dermatol 1998; 39:497-8. [PMID: 9738791 DOI: 10.1016/s0190-9622(98)70334-2] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- H C Nousari
- Department of Dermatology, Johns Hopkins University, Baltimore, Maryland 21205, USA
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71
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Enk AH, Knop J. Treatment of relapsing idiopathic nodular panniculitis (Pfeifer-Weber-Christian disease) with mycophenolate mofetil. J Am Acad Dermatol 1998; 39:508-9. [PMID: 9738797 DOI: 10.1016/s0190-9622(98)70340-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- A H Enk
- Department of Dermatology, University of Mainz, Germany
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72
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Affiliation(s)
- R J Powell
- Department of Clinical Immunology, Queen's Medical Centre, Nottingham, UK
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