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Peng Z, Xian W, Sun H, Li E, Geng L, Tian J. Efficacy and Safety of a Quadruple Regimen Compared with Triple Regimens in Patients with Mycophenolic Acid-Related Gastrointestinal Complications After Renal Transplantation: A Short-Term Single-Center Study. Ann Transplant 2020; 25:e919875. [PMID: 32107364 PMCID: PMC7065508 DOI: 10.12659/aot.919875] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background At present, there is no ideal conventional triple regimen that can effectively treat gastrointestinal (GI) complications in patients after kidney transplantation. We aimed to investigate the efficacy and safety of a quadruple regimen including standard-dose tacrolimus, low-dose enteric-coated mycophenolate sodium (EC-MPS), low-dose mizoribine (MZR), and corticosteroids, compared with regimens containing standard-dose tacrolimus, corticosteroids, plus either low-dose EC-MPS or standard-dose MZR in patients with mycophenolic acid (MPA)-related GI complications after renal transplantation. Material/Methods Between August 2016 and October 2018 in Qilu Hospital of Shandong University, 115 living donor kidney transplant recipients with MPA-related GI complications were enlisted in a single-center, prospective, randomized, control study. Thirty-six recipients were assigned to the low-dose EC-MPS plus low-dose MZR group, 37 recipients were assigned to the low-dose EC-MPS group, and 39 recipients were assigned to the standard-dose MZR group. We analyzed the Gastrointestinal Symptom Rating Scale (GSRS), estimated glomerular filtration rate (eGFR), graft rejection, serum creatinine, human leukocyte antigen (HLA) antibody, and the occurrence of adverse events among the 3 groups. Results Compared with baseline, gastrointestinal symptoms improved significantly in all 3 groups. The reduction in mean subscale scores from baseline to month 3 was more significant in the standard-dose MZR group compared with the other 2 groups. The low-dose EC-MPS plus low-dose MZR group had better renal function. The incidence of graft rejection and cytomegalovirus (CMV) and polyomavirus BK (BKV) infection, as well as the incidence of hyperuricemia, in the low-dose EC-MPS plus low-dose MZR group were all significantly reduced. Conclusions This quadruple regimen may be equivalent to regimens containing standard-dose tacrolimus, corticosteroids plus either low-dose EC-MPS or standard-dose MZR in improving GI symptoms after kidney transplant, and is also advantageous for kidney function, graft rejection, and the rates of adverse events.
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Affiliation(s)
- Zhiguo Peng
- Department of Organ Transplantation, Qilu Hospital of Shan Dong University, Jinan, Shandong, China (mainland)
| | - Wanhua Xian
- Department of Organ Transplantation, Qilu Hospital of Shan Dong University, Jinan, Shandong, China (mainland)
| | - Huaibin Sun
- Department of Organ Transplantation, Qilu Hospital of Shan Dong University, Jinan, Shandong, China (mainland)
| | - Engang Li
- Department of Organ Transplantation, Qilu Hospital of Shan Dong University, Jinan, Shandong, China (mainland)
| | - Lina Geng
- Department of Organ Transplantation, Qilu Hospital of Shan Dong University, Jinan, Shandong, China (mainland)
| | - Jun Tian
- Department of Organ Transplantation, Qilu Hospital of Shan Dong University, Jinan, Shandong, China (mainland)
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Salting-out liquid–liquid microextraction to the determination of mycophenolic acid in plasma samples. CHEMICAL PAPERS 2019. [DOI: 10.1007/s11696-019-01018-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Gardiner KM, Tett SE, Staatz CE. Is Conversion from Mycophenolate Mofetil to Enteric-Coated Mycophenolate Sodium Justifiable for Gastrointestinal Quality of Life? Drugs R D 2018; 18:271-282. [PMID: 30426342 PMCID: PMC6277323 DOI: 10.1007/s40268-018-0254-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Globally, enteric-coated mycophenolate sodium (EC-MPS) is replacing mycophenolate mofetil (MMF) in maintenance immunosuppressant regimens. The predominant reason for conversion is the purported improvement in gastrointestinal (GI) quality of life. This paper considers the level of bias associated with studies comparing EC-MPS and MMF for GI-related improvement and provides insight into whether conversion is supported by evidence. METHODS Using a pre-determined protocol, a literature search was conducted. Full-text review, data extraction and risk of bias analysis was conducted by two independent authors using the Cochrane domain-based evaluation of risk of bias. The review was reported according to the preferred reporting items for systematic reviews and meta-analyses. RESULTS Twenty-nine studies were included in risk of bias analysis. Of these, only three were deemed a low risk of bias. Across these three studies, there were no statistically significant differences in the proportion of GI-related adverse events nor was there a significant difference in the GI-related quality of life between EC-MPS- and MMF-treated patients in these data. CONCLUSION There was a high risk of bias across the 29 studies investigating conversion from MMF to EC-MPS for potential improvement in GI-related quality of life. The consolidated results of the three studies with low risk of bias suggest no evidence to convert patients stabilised on MMF. If a patient experiences GI-related adverse events whilst taking MMF, other methods should be explored before conversion to EC-MPS.
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Affiliation(s)
- Kyle M Gardiner
- School of Pharmacy, University of Queensland, Brisbane, QLD, 4102, Australia.
- Discipline of Pharmacy, Queensland University of Technology, Gardens Point Campus, Level 9, Q Block, 2 George Street, Brisbane, QLD, 4000, Australia.
| | - Susan E Tett
- School of Pharmacy, University of Queensland, Brisbane, QLD, 4102, Australia
| | - Christine E Staatz
- School of Pharmacy, University of Queensland, Brisbane, QLD, 4102, Australia
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Jones-Hughes T, Snowsill T, Haasova M, Coelho H, Crathorne L, Cooper C, Mujica-Mota R, Peters J, Varley-Campbell J, Huxley N, Moore J, Allwood M, Lowe J, Hyde C, Hoyle M, Bond M, Anderson R. Immunosuppressive therapy for kidney transplantation in adults: a systematic review and economic model. Health Technol Assess 2018; 20:1-594. [PMID: 27578428 DOI: 10.3310/hta20620] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND End-stage renal disease is a long-term irreversible decline in kidney function requiring renal replacement therapy: kidney transplantation, haemodialysis or peritoneal dialysis. The preferred option is kidney transplantation, followed by immunosuppressive therapy (induction and maintenance therapy) to reduce the risk of kidney rejection and prolong graft survival. OBJECTIVES To review and update the evidence for the clinical effectiveness and cost-effectiveness of basiliximab (BAS) (Simulect(®), Novartis Pharmaceuticals UK Ltd) and rabbit anti-human thymocyte immunoglobulin (rATG) (Thymoglobulin(®), Sanofi) as induction therapy, and immediate-release tacrolimus (TAC) (Adoport(®), Sandoz; Capexion(®), Mylan; Modigraf(®), Astellas Pharma; Perixis(®), Accord Healthcare; Prograf(®), Astellas Pharma; Tacni(®), Teva; Vivadex(®), Dexcel Pharma), prolonged-release tacrolimus (Advagraf(®) Astellas Pharma), belatacept (BEL) (Nulojix(®), Bristol-Myers Squibb), mycophenolate mofetil (MMF) (Arzip(®), Zentiva; CellCept(®), Roche Products; Myfenax(®), Teva), mycophenolate sodium (MPS) (Myfortic(®), Novartis Pharmaceuticals UK Ltd), sirolimus (SRL) (Rapamune(®), Pfizer) and everolimus (EVL) (Certican(®), Novartis) as maintenance therapy in adult renal transplantation. METHODS Clinical effectiveness searches were conducted until 18 November 2014 in MEDLINE (via Ovid), EMBASE (via Ovid), Cochrane Central Register of Controlled Trials (via Wiley Online Library) and Web of Science (via ISI), Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects and Health Technology Assessment (The Cochrane Library via Wiley Online Library) and Health Management Information Consortium (via Ovid). Cost-effectiveness searches were conducted until 18 November 2014 using a costs or economic literature search filter in MEDLINE (via Ovid), EMBASE (via Ovid), NHS Economic Evaluation Database (via Wiley Online Library), Web of Science (via ISI), Health Economic Evaluations Database (via Wiley Online Library) and the American Economic Association's electronic bibliography (via EconLit, EBSCOhost). Included studies were selected according to predefined methods and criteria. A random-effects model was used to analyse clinical effectiveness data (odds ratios for binary data and mean differences for continuous data). Network meta-analyses were undertaken within a Bayesian framework. A new discrete time-state transition economic model (semi-Markov) was developed, with acute rejection, graft function (GRF) and new-onset diabetes mellitus used to extrapolate graft survival. Recipients were assumed to be in one of three health states: functioning graft, graft loss or death. RESULTS Eighty-nine randomised controlled trials (RCTs), of variable quality, were included. For induction therapy, no treatment appeared more effective than another in reducing graft loss or mortality. Compared with placebo/no induction, rATG and BAS appeared more effective in reducing biopsy-proven acute rejection (BPAR) and BAS appeared more effective at improving GRF. For maintenance therapy, no treatment was better for all outcomes and no treatment appeared most effective at reducing graft loss. BEL + MMF appeared more effective than TAC + MMF and SRL + MMF at reducing mortality. MMF + CSA (ciclosporin), TAC + MMF, SRL + TAC, TAC + AZA (azathioprine) and EVL + CSA appeared more effective than CSA + AZA and EVL + MPS at reducing BPAR. SRL + AZA, TAC + AZA, TAC + MMF and BEL + MMF appeared to improve GRF compared with CSA + AZA and MMF + CSA. In the base-case deterministic and probabilistic analyses, BAS, MMF and TAC were predicted to be cost-effective at £20,000 and £30,000 per quality-adjusted life-year (QALY). When comparing all regimens, only BAS + TAC + MMF was cost-effective at £20,000 and £30,000 per QALY. LIMITATIONS For included trials, there was substantial methodological heterogeneity, few trials reported follow-up beyond 1 year, and there were insufficient data to perform subgroup analysis. Treatment discontinuation and switching were not modelled. FUTURE WORK High-quality, better-reported, longer-term RCTs are needed. Ideally, these would be sufficiently powered for subgroup analysis and include health-related quality of life as an outcome. CONCLUSION Only a regimen of BAS induction followed by maintenance with TAC and MMF is likely to be cost-effective at £20,000-30,000 per QALY. STUDY REGISTRATION This study is registered as PROSPERO CRD42014013189. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Tracey Jones-Hughes
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Tristan Snowsill
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Marcela Haasova
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Helen Coelho
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Louise Crathorne
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Chris Cooper
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Ruben Mujica-Mota
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Jaime Peters
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Jo Varley-Campbell
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Nicola Huxley
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Jason Moore
- Exeter Kidney Unit, Royal Devon and Exeter Foundation Trust Hospital, Exeter, UK
| | - Matt Allwood
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Jenny Lowe
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Chris Hyde
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Martin Hoyle
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Mary Bond
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Rob Anderson
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
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Baker RJ, Mark PB, Patel RK, Stevens KK, Palmer N. Renal association clinical practice guideline in post-operative care in the kidney transplant recipient. BMC Nephrol 2017; 18:174. [PMID: 28571571 PMCID: PMC5455080 DOI: 10.1186/s12882-017-0553-2] [Citation(s) in RCA: 111] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 04/16/2017] [Indexed: 02/08/2023] Open
Abstract
These guidelines cover the care of patients from the period following kidney transplantation until the transplant is no longer working or the patient dies. During the early phase prevention of acute rejection and infection are the priority. After around 3-6 months, the priorities change to preservation of transplant function and avoiding the long-term complications of immunosuppressive medication (the medication used to suppress the immune system to prevent rejection). The topics discussed include organization of outpatient follow up, immunosuppressive medication, treatment of acute and chronic rejection, and prevention of complications. The potential complications discussed include heart disease, infection, cancer, bone disease and blood disorders. There is also a section on contraception and reproductive issues.Immediately after the introduction there is a statement of all the recommendations. These recommendations are written in a language that we think should be understandable by many patients, relatives, carers and other interested people. Consequently we have not reworded or restated them in this lay summary. They are graded 1 or 2 depending on the strength of the recommendation by the authors, and AD depending on the quality of the evidence that the recommendation is based on.
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Affiliation(s)
- Richard J Baker
- Renal Unit, St. James's University Hospital, Leeds, England.
| | - Patrick B Mark
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, Scotland
| | - Rajan K Patel
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, Scotland
| | - Kate K Stevens
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, Scotland
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Howell M, Wong G, Turner RM, Tan HT, Tong A, Craig JC, Howard K. The Consistency and Reporting of Quality-of-Life Outcomes in Trials of Immunosuppressive Agents in Kidney Transplantation: A Systematic Review and Meta-analysis. Am J Kidney Dis 2016; 67:762-74. [DOI: 10.1053/j.ajkd.2015.11.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2015] [Accepted: 11/13/2015] [Indexed: 11/11/2022]
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Abstract
BACKGROUND Gastrointestinal disorders (GDs) are common in renal transplant recipients. The main cause of GDs seems to be the use of immunosuppressive medications, especially mycophenolic acid in the form of mycophenolate mofetil (MMF). OBJECTIVE The aim of this study was to estimate the frequency and severity of GDs in renal allograft recipients with the use of the Gastrointestinal Symptom Rating Scale (GSRS). METHODS Eighty-five renal allograft recipients, 50 ± 12 years old, treated with methylprednisolone, calcineurin inhibitor (cyclosporine [CsA], n = 42; tacrolimus (TAC), n = 43), and MMF were studied. RESULTS At the time of completion of the GSRS questionnaire, 38 of the 85 patients (45%) already had their MMF dose reduced because of GDs. Only 15 patients (18%) were totally free from GDs. The most frequent and severe GDs recorded were indigestion and diarrhea who were significantly more frequent in women (P = .045). GDs were recorded in patients receiving both standard and reduced dose of MMF. MMF dose was significantly associated only with diarrhea. Although TAC-treated patients had the highest mean GSRS scores, no statistically significant differences were observed compared with CsA-treated patients. In 31 patients, MMF was replaced by enteric-coated mycophenolate sodium (EC-MPS) and new questionnaires were completed 1 month later. Significant improvement in total and all subscores of GSRS was demonstrated (P < .001). Although EC-MPS dose tolerated by the patients was higher than MMF dose, the difference was not statistically significant. CONCLUSIONS Female sex and the use of MMF, especially in combination with TAC, are related to the occurrence of severe gastrointestinal symptoms. Substitution of MMF with EC-MPS significantly reduces the severity of symptoms and permits the use of higher doses.
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Manger B, Hiepe F, Schneider M, Worm M, Wimmer P, Paulus EM, Schwarting A. Impact of switching from mycophenolate mofetil to enteric-coated mycophenolate sodium on gastrointestinal side effects in patients with autoimmune disease: a Phase III, open-label, single-arm, multicenter study. Clin Exp Gastroenterol 2015; 8:205-13. [PMID: 26229499 PMCID: PMC4516030 DOI: 10.2147/ceg.s81922] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND The purpose of this study was to assess changes in gastrointestinal symptom severity in patients with autoimmune disease who were switched from mycophenolate mofetil to enteric-coated mycophenolate sodium (EC-MPS). METHODS In this national, explorative, single-arm study, 111 patients were enrolled and switched to equimolar EC-MPS at baseline. The primary endpoint was change in the Gastrointestinal Symptom Rating Scale (GSRS) total score after 6-8 weeks of treatment (Visit 2). The optional follow-up visit was 6-12 weeks after completion of the study (Visit 2). Secondary endpoints were changes in GSRS subscale score; changes in gastrointestinal-related quality of life measured by the Gastrointestinal Quality of Life Index (GIQLI); and general health-related quality of life (HRQoL) measured by Psychological General Well-Being Index and assessment of overall treatment effect (OTE). Change was evaluated by paired t-tests. RESULTS At Visit 2, the mean ± standard deviation GSRS total score improved from 2.28±1.13 to 2.02±0.93 points. The change (-0.28±0.92 points, P=0.002) was statistically significant. The change at the follow-up visit (-0.36±0.94 points, P=0.001) was statistically significant and more than the minimal clinical important difference. GSRS subscores showed statistically significant and clinically relevant improvement for abdominal pain (-0.51±1.2 points, P<0.001) and indigestion (-0.42±1.33 points, P=0.002). Overall GIQLI score showed significant improvement from baseline to Visit 2 (-5.8±18.6 points, P=0.002). Per OTE, improvement was reported in 44.1% and 34.2% patients as rated by physicians and patients, respectively. The majority of patients (55%) reported OTE-HRQoL as unchanged. Diarrhea and nausea were the commonly reported adverse events. CONCLUSION Patients switched to EC-MPS experienced less gastrointestinal symptom burden and showed improvement in HRQoL.
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Affiliation(s)
- Bernhard Manger
- University Hospital Erlangen, Med Clinic III Polyclinic, Erlangen, Germany
| | - Falk Hiepe
- Rheumatology, University Hospital Charité, Campus Mitte, Berlin, Germany
| | - Matthias Schneider
- Policlinic of Rheumatology, Heinrich-Heine-Universität, Düsseldorf, Germany
| | - Margitta Worm
- Department of Dermatology, Venereology and Allergology, University Hospital Charité, Campus Mitte, Berlin, Germany
| | | | | | - Andreas Schwarting
- Department of Internal Medicine, Johannes Gutenberg University, Mainz, Germany
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Cai L, Zeng F, Liu B, Wei L, Chen Z, Jiang J. A single-centre, open-label, prospective study of an initially short-term intensified dosing regimen of enteric-coated mycophenolate sodium with reduced cyclosporine A exposure in Chinese live-donor kidney transplant recipients. Int J Clin Pract 2015:23-30. [PMID: 24673716 DOI: 10.1111/ijcp.12403] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
AIMS The nephrotoxicity of cyclosporine A (CsA) accounts for dysfunction of kidney allografts in the clinic. Short-term intensified dosing using enteric-coated mycophenolate sodium (EC-MPS) may facilitate CsA sparing after kidney transplantation without compromising safety. METHODS In a 12-month, single-centre open-label prospective trial, 180 de novo live-donor kidney transplant recipients at low-immunological risk were randomised to a low-dose cyclosporine group which received a low dose of cyclosporine, short-term intensified EC-MPS dosing (2160 mg/day to week 6, 1440 mg/day thereafter) and corticosteroids or a standard-dose cyclosporine group which received a standard dose of cyclosporine, standard EC-MPS dosing (1440 mg/day) and corticosteroids. The primary end-point [treatment failure including biopsy-proven acute rejection (BPAR), graft loss, death], secondary end-point and adverse events were monitored. RESULTS The primary end-point (treatment failure) occurred in 13.3% (12/90) of the low-dose cyclosporine group and 16.7% (15/90) of the standard-dose cyclosporine group (p = 0.53) (difference -3.4%, 95% confidence interval -11.7% to 7.5%, based on a noninferiority margin of 20%). BPAR occurred in 11.1% and 13.3% of patients in the low-dose cyclosporine group and standard-dose cyclosporine group, respectively (p = 0.65). The estimated glomerular filtration rate, as calculated by the Cockcroft-Gault formula, was similar at 12 months after transplantation (low-dose cyclosporine group 63 ± 19 ml/min/1.73 m(2) and standard-dose cyclosporine group 59 ± 15 ml/min/1.73 m(2) ; p = 0.43). The levels of serum creatinine and occurrence of adverse events between the two groups were not statistically different. CONCLUSIONS A regimen of early intensified EC-MPS dosing permits low-dose cyclosporine in live-donor kidney transplant patients at low-immunological risk without compromising efficacy at 12 months' follow-up.
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Affiliation(s)
- L Cai
- The Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; Key Laboratory of Ministry of Health and Key Laboratory of Ministry of Education, Wuhan, China; Department of Otolaryngology-Head and Neck Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Sterneck M, Settmacher U, Ganten T, Sarrazin C, Speidel N, Broering D, Heyne N, Paulus E, Mertens M, Fischer L. Improvement in gastrointestinal and health-related quality of life outcomes after conversion from mycophenolate mofetil to enteric-coated mycophenolate sodium in liver transplant recipients. Transplant Proc 2015; 46:234-40. [PMID: 24507058 DOI: 10.1016/j.transproceed.2013.09.026] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2013] [Accepted: 09/26/2013] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To evaluate improvement in gastrointestinal (GI) symptoms and health-related quality of life (HRQoL) in liver transplant recipients switched from mycophenolate mofetil (MMF) to enteric-coated mycophenolate sodium (EC-MPS). METHODS A multicenter, open-label, single-arm study was undertaken in maintenance liver transplant recipients who reported GI complications with MMF therapy. The patients were switched to equimolar doses of EC-MPS at baseline. The primary end point was the change in the Gastrointestinal Symptom Rating Scale (GSRS) total score after 6 to 8 weeks of treatment with EC-MPS. Other key assessments for GI symptoms and HRQoL included the GSRS subscores, the Gastrointestinal Quality of Life Index (GIQLI), the Psychological General Well-Being Index, and the Overall Treatment Effect (OTE). Paired t-test was used to assess the difference in the mean score changes over time. RESULTS A total of 34 patients were enrolled and switched to equimolar doses of EC-MPS. After 6 to 8 weeks of EC-MPS treatment, mean GSRS total score improved significantly from 2.88 ± 0.66 to 2.10 ± 0.78. Mean improvement in GSRS total score (-0.77 score points; P = .001) exceeded the minimal clinically important difference. Significant improvements were observed in all GSRS subscales (P < .05), GIQLI total scores (P = .001), and GIQLI subscales "GI symptoms" (P < .001) and "physical function" (0.013). Patients who continued EC-MPS reported sustained benefits compared with patients who switched back to MMF after 6 to 8 weeks of treatment with EC-MPS. On the OTE scale, improvement in symptoms was reported in 76.5% and 61.8% of the patients as perceived by the physicians and the patients. Improvement in HRQoL was reported by 41.2% of the patients. No deaths, biopsy proven acute rejections, or graft losses were reported during the study. CONCLUSION Conversion from MMF to EC-MPS was associated with a significant improvement in GI symptoms and HRQoL in liver transplant recipients.
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Affiliation(s)
- M Sterneck
- Universitätsklinikum, Hamburg-Eppendorf, Hamburg, Germany.
| | - U Settmacher
- Universitätsklinikum Jena, Lobeda, Jena, Germany
| | - T Ganten
- Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - C Sarrazin
- (d)Klinikum Joh.Wolfg.Goethe-UNI Zentrum d.Inneren Medizin Medizinische Klinik I, Frankfurt, Hessen, Deutschland, Germany
| | - N Speidel
- (e)Universitätsklinikum Bonn (AöR), Bonn, Germany
| | - D Broering
- Klinik für Allgemeine Chirurgie und Thoraxchirurgie, Kiel, Germany
| | - N Heyne
- Universitätsklinikum Tübingen, Medizinische Klinik IV, Sektion Nieren- und Hochdruckkrankheiten, Tübingen, Germany
| | - E Paulus
- Stefan Scheidl, Novartis Pharma GmbH, Nuernberg, Germany
| | - M Mertens
- Stefan Scheidl, Novartis Pharma GmbH, Nuernberg, Germany
| | - L Fischer
- Universitätsklinikum, Hamburg-Eppendorf, 20246 Hamburg, Germany
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Jones RB, Walsh M, Chaudhry AN, Smith KGC, Jayne DRW. Randomized trial of enteric-coated mycophenolate sodium versus mycophenolate mofetil in multi-system autoimmune disease. Clin Kidney J 2014; 7:562-8. [PMID: 25859373 PMCID: PMC4389135 DOI: 10.1093/ckj/sfu096] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2014] [Accepted: 08/19/2014] [Indexed: 12/13/2022] Open
Abstract
Background The use of mycophenolate mofetil (MMF) in autoimmune disease is often limited by adverse effects. In this single-centre, open label, parallel design study, we investigated whether enteric-coated mycophenolate sodium (MS) is better tolerated and therefore more efficacious than MMF in primary systemic vasculitis (PSV) and systemic lupus erythematosus (SLE). Methods Forty patients with vasculitis or systemic lupus erythematosus (SLE) due to commence MMF for active disease or remission maintenance were randomized to receive either 1440 mg/day MS or 2000 mg/day MMF (18 PSV, 2 SLE per group) in addition to corticosteroids. Random allocation was performed by minimization for age, diagnosis and renal function using a computer algorithm. Twenty-five were treated for active disease (5 first-line therapy, 20 salvage therapy) and 15 for remission maintenance. The composite primary end point was treatment failure and/or drug intolerance over 12 months. Treatment failure was defined as failure to achieve remission by 6 months or disease relapse and treatment intolerance was defined as inability to tolerate and maintain the target dose of MS or MMF within 12 months. Results Forty patients were included in the analyses. MS was associated with a lower primary end point rate [hazard ratio (HR) 0.37; 95% CI 0.17–0.80; P = 0.012] (11/20, 55% patients) compared with MMF (17/20, 85% patients). Treatment failure alone was less common in the MS group (HR 0.28; 95% CI 0.095–0.82; P = 0.020), although drug intolerance did not differ between groups (HR 0.53; 95% CI 0.20–1.42; P = 0.21). Despite randomization, patients in the MMF group may have had a higher baseline risk for treatment failure; more MMF patients had refractory disease and granulomatosis with polyangiitis (Wegener's). A glomerular filtration rate (GFR) ≤40 mL/min was associated with intolerance. Serious adverse events were common (55% MMF and 45% MS patients). Conclusions No differences in treatment tolerance were observed between the MS and MMF groups. Despite similar treatment intolerance, MS was associated with improved efficacy in PSV and SLE compared with MMF. However, baseline group imbalances in factors potentially affecting remission and relapse may have influenced the results. Treatment intolerance was common and strongly associated with low GFR. Further treatment trials are warranted to investigate the effect of GFR on mycophenolic acid pharmacokinetics and clinical outcomes (ISRCTN83027184; EUDRACT 2005-002207-16; Funding Novartis UK).
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Affiliation(s)
- Rachel B Jones
- Vasculitis and Lupus Clinic , Addenbrooke's Hospital , Cambridge , UK
| | - Michael Walsh
- Departments of Medicine and Clinical Epidemiology & Biostatistics , McMaster University , Hamilton, Canada
| | - Afzal N Chaudhry
- Vasculitis and Lupus Clinic , Addenbrooke's Hospital , Cambridge , UK
| | - Kenneth G C Smith
- Vasculitis and Lupus Clinic , Addenbrooke's Hospital , Cambridge , UK ; Cambridge Institute of Medical Research , University of Cambridge School of Clinical Medicine , Cambridge , UK ; Department of Medicine , University of Cambridge School of Clinical Medicine , Cambridge , UK
| | - David R W Jayne
- Vasculitis and Lupus Clinic , Addenbrooke's Hospital , Cambridge , UK ; Department of Medicine , University of Cambridge School of Clinical Medicine , Cambridge , UK
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Langone A, Shihab F, Pankewycz O, Doria C, Wiland A, McCague K, Chan L. Long-term dosing patterns of enteric-coated mycophenolate sodium or mycophenolate mofetil with tacrolimus after renal transplantation. Clin Transplant 2014; 28:961-7. [PMID: 24893821 DOI: 10.1111/ctr.12392] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2014] [Indexed: 11/29/2022]
Abstract
MORE was a four-yr, prospective, observational study at 40 transplant centers in the US. Data were analyzed to evaluate changes in mycophenolic acid (MPA) dosing over time in 904 de novo kidney transplant recipients receiving enteric-coated mycophenolate sodium (EC-MPS, n = 616) or mycophenolate mofetil (MMF, n = 288) with tacrolimus. Induction therapy and steroid treatment were similar in the two subpopulations. The proportion of patients receiving the maximal recommended MPA dose was 80.5%, 43.9%, 39.2%, 34.6%, and 30.1% at baseline and years 1, 2, 3, and 4, respectively. More patients received the maximal recommended MPA dose with EC-MPS vs. MMF at month 1 (79.2% vs. 71.7%, p = 0.016), month 3 (68.5% vs. 56.9%, p = 0.001), and month 6 (52.9% vs. 44.0%, p = 0.028). Multivariate analysis showed the risk of biopsy-proven acute rejection, graft loss or death to be similar for EC-MPS vs. MMF. Estimated glomerular filtration rate (GFR) was similar with EC-MPS vs. MMF at all time points. There were no significant differences in any category of adverse event between the EC-MPS and MMF cohorts during follow-up, including gastrointestinal events. In conclusion, MPA dose was maintained more effectively in the first six months after kidney transplantation using EC-MPS vs. MMF, without an increase in adverse events.
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Zhang W, Ding C, Zheng S. Enteric-coated mycophenolate sodium: an update. Int J Clin Pract 2014:1-3. [PMID: 24673712 DOI: 10.1111/ijcp.12399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- W Zhang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China; Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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Alemtuzumab Induction in Renal Transplantation Permits Safe Steroid Avoidance with Tacrolimus Monotherapy. Transplantation 2013; 96:1082-8. [DOI: 10.1097/tp.0b013e3182a64db9] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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15
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Narayanan M, Pankewycz O, Shihab F, Wiland A, McCague K, Chan L. Long-term outcomes in African American kidney transplant recipients under contemporary immunosuppression: a four-yr analysis of the Mycophenolic acid Observational REnal transplant (MORE) study. Clin Transplant 2013; 28:184-91. [PMID: 24372743 DOI: 10.1111/ctr.12294] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2013] [Indexed: 12/01/2022]
Abstract
Mycophenolic acid Observational REnal transplant (MORE) was a prospective, observational study of de novo kidney transplant patients receiving mycophenolic acid (MPA). Four-yr data on 904 patients receiving tacrolimus and enteric-coated mycophenolate sodium (EC-MPS) or mycophenolate mofetil (MMF) were analyzed to evaluate immunosuppression and graft outcomes in African American (AA, n = 218) vs. non-AA (n = 686) patients. Mean tacrolimus dose was higher in AA vs. non-AA patients but mean tacrolimus trough concentration was similar. Use of the recommended MPA dose in AA patients decreased from 78.9% at baseline to 33.1% at year 3. More AA patients received the recommended MPA dose with EC-MPS than MMF at month 6 (56.2% vs. 35.7%, p = 0.016) and month 36 (46.6% vs. 16.7%, p = 0.029), with no safety penalty. Significantly, more AA patients received corticosteroids than non-AA patients. Biopsy-proven acute rejection was higher in AA vs. non-AA patients (18.9% vs. 10.7%, p = 0.003), as was graft loss (10.9% vs. 4.4%, p = 0.003); differences were confirmed by Cox regression analysis. Patient survival was similar. Estimated GFR was comparable in AA vs. non-AA patients. Kidney allograft survival remains lower for AA vs. non-AA recipients even under the current standard of care.
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Jakes AD, Roy A, Veerasamy M, Bhandari S. Case report: Crohn's-like mycophenolate-induced colitis, a fallout in steroid-free regimens. Transplant Proc 2013; 45:842-4. [PMID: 23498833 DOI: 10.1016/j.transproceed.2012.11.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2012] [Accepted: 11/13/2012] [Indexed: 12/24/2022]
Abstract
BACKGROUND Diarrhea is considered to be a common side effect after renal transplantation, due to a number of infective or drug-related causes. Over the past decade the etiology has perhaps changed with the evolution of immunosuppression. In an attempt to minimize early acute rejection and potential steroid use, the recent introduction of mycophenolic acid-based therapies has increased the incidence of diarrheal symptoms. Histologic and macroscopic appearance of mycophenolate-induced colitis is not well documented. CASE REPORT Three patients with immunosuppression-induced colitis had received deceased-donor renal transplantations and presented with diarrhea and/or abdominal pain. All patients made a full recovery after decreasing the dose or withdrawing mycophenolate mofetil or myfortic with corticosteroid-free regimens. CONCLUSIONS Patients with immunosuppression-induced colitis require prompt intervention by dose reduction or withdrawal. Both myocophenolate mofetil and myfortic can induce a Crohn's-like colitis even after a long period of exposure. The symptoms may require 6 months to resolve, suggesting that surgery should be considered only as a last resort after a significant period off therapy.
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Affiliation(s)
- A D Jakes
- Hull York Medical School, University of Hull, Hull, United Kingdom
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Doria C, Greenstein S, Narayanan M, Ueda K, Wiland A, McCague K, Sankari B, Chan L. Association of mycophenolic acid dose with efficacy and safety events in kidney transplant patients receiving tacrolimus: an analysis of the Mycophenolic acid Observational REnal transplant registry. Clin Transplant 2012; 26:E602-11. [PMID: 23121178 PMCID: PMC3556697 DOI: 10.1111/ctr.12035] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2012] [Indexed: 01/30/2023]
Abstract
Background Dose-finding studies for mycophenolic acid (MPA) in tacrolimus-treated kidney transplant patients are lacking. Methods Data from 901 de novo kidney transplant recipients enrolled in the prospective, non-interventional Mycophenolic acid Observational REnal (MORE) transplant registry were analyzed according to baseline daily MPA dose (<2000, 2000 or >2000 mg). Results The proportion of patients receiving 2000 and <2000 mg was 77.6% and 19.9% at baseline, 74.5% and 23.3% at month 1, 62.4% and 35.5% at month 3, 48.5% and 50.2% at month 6, and 44.1% and 55.2% at month 12. More patients were maintained on 2000 mg with enteric-coated mycophenolate sodium (EC-MPS) vs. mycophenolate mofetil (month 6, 52.7% vs. 43.0% [p = 0.02]; month 12, 47.3% vs. 39.4% [p = 0.08]). Multivariate modeling showed no significant effect of baseline MPA dose on 12-month risk of biopsy-proven acute rejection, graft loss or estimated GFR, or on safety events including MPA discontinuation other than a higher rate of gastrointestinal adverse events in patients with an initial MPA dose >2000 mg (p = 0.029) vs. 2000 mg. Conclusions These findings suggest that an initial MPA dose of <2000 mg does not compromise 12-month efficacy in tacrolimus-treated kidney transplants, but controlled trials are required and the lower threshold for MPA dose remains to be defined.
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Affiliation(s)
- Cataldo Doria
- Department of Transplant Surgery, Thomas Jefferson University Hospital, Philadelphia, PA 19107-5563, USA.
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Enteric-coated mycophenolate sodium immunosuppression in renal transplant patients: efficacy and dosing. Transplant Rev (Orlando) 2012; 26:233-40. [DOI: 10.1016/j.trre.2012.02.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2011] [Accepted: 02/11/2012] [Indexed: 12/16/2022]
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Langone A, Doria C, Greenstein S, Narayanan M, Ueda K, Sankari B, Pankewycz O, Shihab F, Chan L. Does reduction in mycophenolic acid dose compromise efficacy regardless of tacrolimus exposure level? An analysis of prospective data from the Mycophenolic Renal Transplant (MORE) Registry. Clin Transplant 2012; 27:15-24. [PMID: 22861144 PMCID: PMC3593178 DOI: 10.1111/j.1399-0012.2012.01694.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2012] [Indexed: 11/28/2022]
Abstract
Prospective data are lacking concerning the effect of reduced mycophenolic acid (MPA) dosing on efficacy and the influence of concomitant tacrolimus exposure. The Mycophenolic Renal Transplant (MORE) Registry is a prospective, observational study of de novo kidney transplant patients receiving MPA therapy under routine management. The effect of MPA dose reduction, interruption, or discontinuation (dose changes) was assessed in 870 tacrolimus-treated patients: 375 (43.1%) reduced tacrolimus (≤7 ng/mL at baseline) and 495 (56.9%) standard tacrolimus (>7 ng/mL); enteric-coated mycophenolate sodium 589 (67.7%) and mycophenolate mofetil 281 (32.3%). During baseline to month 1, months 1–3, months 3–6, and months 6–12, 9.3% (78/838), 16.6% (132/794), 20.7% (145/701), and 13.1% (70/535) patients, respectively, required MPA dose changes. These patients experienced an increased risk of biopsy-proven acute rejection at one yr with tacrolimus exposure either included in the model (hazard ratio [HR] 2.60, 95% CI 1.28–5.29, p = 0.008) or excluded (HR 2.58, 95% CI 1.28–5.23, p = 0.008). MPA dose changes were significantly associated with one yr graft failure when tacrolimus exposure was included (HR 2.23; 95% CI 1.01–4.89, p = 0.047) but not when tacrolimus exposure was excluded (HR 2.16; 95% CI 0.99–4.79; p = 0.054). These results suggest that reducing or discontinuing MPA can adversely affect graft outcomes regardless of tacrolimus trough levels.
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Affiliation(s)
- Anthony Langone
- Vanderbilt University Medical Center, Nashville, TN 37232, USA.
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Impact of conversion to a once daily tacrolimus-based regimen in kidney transplant recipients with gastrointestinal complications. Transplantation 2012; 93:895-9. [PMID: 22298033 DOI: 10.1097/tp.0b013e318248ca90] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Gastrointestinal (GI) complications may affect up to 64% of kidney transplant recipients, with a higher incidence of symptoms in patients receiving tacrolimus-based immunosuppression. Tacrolimus extended release once-daily (OD) formulation offers the benefit of OD administration over standard tacrolimus, with a similar rate of GI complications when compared with the standard tacrolimus. We hypothesized that patients with tacrolimus-based immunosuppressive regimen with posttransplant gastrointestinal symptoms may benefit from a conversion to a tacrolimus OD regimen. METHODS In this pilot study, 27 kidney transplant recipients with tacrolimus-related GI complications were converted to a tacrolimus OD regimen (group 1). This group was compared with a historical cohort of 30 patients on standard tacrolimus therapy with GI symptoms (group 2). Patients were followed up for 1 year after initial enrollment. RESULTS Patients in group 1 reported a significant improvement in GI symptoms, as expressed by the change in the Gastrointestinal Symptom Rating Scale scores (1.7±0.3 vs. 1.2±0.2, P<0.001) and GI-specific health-related quality of life scores (87±26.3 vs. 97±24.6, P<0.05). After comparing changes in Gastrointestinal Symptom Rating Scale total scores and subscale scores at 12 months, patients in Group 1 scored better than patients in Group 2 in total scores (-0.5 vs. -0.12, P<0.0001), abdominal pain (P<0.001), diarrhea (P<0.001), and reflux (P=0.013). CONCLUSIONS Preliminary results from this study demonstrate that kidney transplant recipients experiencing tacrolimus-induced GI symptoms may benefit from a conversion to a tacrolimus OD regimen.
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Gozdowska J, Urbanowicz AL, Galazka Z, Chmura A, Durlik M. Tolerance of enteric-coated mycophenolate sodium in combination with calcineurin inhibitor in kidney transplant recipients: Polish experience. Transplant Proc 2011; 43:2946-9. [PMID: 21996197 DOI: 10.1016/j.transproceed.2011.08.056] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Enteric-coated mycophenolate sodium (EC-MPS) was developed to reduce the incidence of gastrointestinal adverse effects. This multicenter observational study was designed to evaluate the safety profile and drug tolerance in kidney transplant recipients. METHODS Three hundred adult kidney recipients (median age 48 years) were enrolled over 3 years to receive EC-MPS de novo (n=175), as a switch from azathioprine (n=62) or mycophenolate mofetil MMF (n=63); in combination with calcineurin inhibitor. Drug doses, serum creatinine, estimated glomerular filtration rate (eGFR), as well as drug tolerance, patient and physician evaluation of therapy (on a 4-point scale) were recorded at enrollment and followed over 28 weeks. We modeled the probability of the highest level (ie, best result) of the categorical outcome variable. RESULTS Two hundred seventy-three patients completed the study (91%). In the pooled study group (1) best drug tolerance was expected more frequently with tacrolimus versus cyclosporine (odds ratio [OR] 2.12, P<.05); (2) best physician evaluation, with earlier EC-MPS introduction (OR for 4-week delay: 0.99, P<.03) and higher eGFR (OR for 5 mL/min increase: 1.21, P<.01). Among the EC-MPS de novo administrations group: (1) best drug tolerance was expected more frequently with coadministered tacrolimus versus cyclosporine (OR 3.14, P<.02); (2) best patient evaluation, with higher eGFR (OR for 1 mL/min increase: 1.04, P<.04); and (3) best physician evaluation, with higher eGFR (OR for 1 mL/min increase: 1.04, P<.001) and earlier EC-MPS introduction (OR for 4-week delay: 0.99, P<.03). In the conversion from MMF to EC-MPS group: (1) best drug tolerance was expected less frequently with coadministered cyclosporine versus tacrolimus (OR 0.05, P<.04) and more frequently with younger recipients (OR .001, P<.04); (2) best physician evaluation was expected more frequently with lower EC-MPS dose (OR for 360-mg dose increase: 0.4, P<.01) and with higher eGFR (OR for 5 mL/min increase: 1.42, P<.002). Adverse events were reported among 49/300 patients (16 serious adverse events). CONCLUSIONS EC-MPS was tolerated better by younger kidney recipients, when combined with tacrolimus versus cyclosporine, and when introduced earlier after transplantation. EC-MPS tolerance decreased gradually with renal function deterioration.
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Affiliation(s)
- J Gozdowska
- Department of Transplantation Medicine and Nephrology, Medical University of Warsaw, Warsaw, Poland.
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Gastrointestinal quality of life improvement of renal transplant recipients converted from mycophenolate mofetil to enteric-coated mycophenolate sodium drugs or agents: mycophenolate mofetil and enteric-coated mycophenolate sodium. Transplantation 2011; 92:426-32. [PMID: 21760569 DOI: 10.1097/tp.0b013e31822527ca] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND In renal transplant (RT) recipients, treatment with enteric-coated mycophenolate sodium (EC-MPS) improves gastrointestinal (GI) tolerability compared with mycophenolate mofetil (MMF). The impact of conversion from MMF to EC-MPS on patient's health-related quality of life (HRQoL) using GI-specific instruments has been scarcely evaluated in randomized trials. METHODS The present randomized, multicenter, open-labeled, 12-week study included RT recipients experiencing GI adverse events due to MMF treatment. Patients were randomized to continue with MMF (n=54) or change to EC-MPS (n=59). Patients were converted at equimolar doses, and dose was optimized between weeks 2 and 6 to achieve maximum tolerated dose. RESULTS Incidence of GI complications (particularly diarrhea) was significantly lower in the EC-MPS group (67.8% vs. 87.0%, P=0.015). The baseline-adjusted mean global scores at 12 weeks in GI quality of life index were significantly higher in the EC-MPS group versus MMF (P=0.014). Results at 12 weeks for all secondary scales indicated better HRQoL in the EC-MPS group compared with the MMF group (Gastrointestinal Symptom Rating Scale, Psychological General Well-Being Index, and overall treatment effect). In the EC-MPS group, a higher percentage of patients were receiving intermediate doses of mycophenolic acid (720 mg/day) at 12 weeks compared with MMF (55.4% vs. 27.4%, P=0.003), whereas no differences were observed for high doses (>720 mg/day). CONCLUSIONS In RT patients with GI undesirable effects due to MMF, switching from MMF to EC-MPS may enable an increase in the maximum tolerated dose of mycophenolic acid and reduce GI complications, thus enhancing patients' GI HRQoL.
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Bolin P, Gohh R, Kandaswamy R, Shihab FS, Wiland A, Akhlaghi F, Melancon K. Mycophenolic acid in kidney transplant patients with diabetes mellitus: does the formulation matter? Transplant Rev (Orlando) 2011; 25:117-23. [DOI: 10.1016/j.trre.2010.12.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2010] [Revised: 11/18/2010] [Accepted: 12/21/2010] [Indexed: 10/18/2022]
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Baker R, Jardine A, Andrews P. Renal Association Clinical Practice Guideline on post-operative care of the kidney transplant recipient. Nephron Clin Pract 2011; 118 Suppl 1:c311-47. [PMID: 21555902 DOI: 10.1159/000328074] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2010] [Accepted: 02/05/2011] [Indexed: 11/19/2022] Open
Affiliation(s)
- R Baker
- Renal Unit, Lincoln Wing, St. James's University Hospital, Beckett Street, Leeds.
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Aptaramanov B, Seyahi N, Alagoz S, Pekmezci S, Ataman R, Tasci H, Serdengecti K. A Comparison of Mycophenolate Mofetil With Mycophenolate Sodium in Renal Transplant Recipients on Tacrolimus-Based Treatment. Transplant Proc 2011; 43:833-6. [DOI: 10.1016/j.transproceed.2011.01.096] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Haeck IM, Knol MJ, Ten Berge O, van Velsen SGA, de Bruin-Weller MS, Bruijnzeel-Koomen CAFM. Enteric-coated mycophenolate sodium versus cyclosporin A as long-term treatment in adult patients with severe atopic dermatitis: a randomized controlled trial. J Am Acad Dermatol 2011; 64:1074-84. [PMID: 21458107 DOI: 10.1016/j.jaad.2010.04.027] [Citation(s) in RCA: 123] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2010] [Revised: 04/10/2010] [Accepted: 04/12/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND Cyclosporin A (CsA) is frequently used in the treatment of severe atopic dermatitis (AD). Enteric-coated mycophenolate sodium (EC-MPS) may be an alternative with equal efficacy and fewer side effects. OBJECTIVE The aim of this observer-blinded randomized controlled trial was to compare EC-MPS with CsA as long-term treatment in adult patients with severe AD. METHODS Fifty five patients with AD were treated with CsA (5 mg/kg) in a 6-week run-in period. Thereafter, patients either received CsA (3 mg/kg; n = 26) or EC-MPS (1440 mg; n = 24) during a maintenance phase of 30 weeks and there was a 12-week follow-up period. Disease activity was measured using the objective SCORAD and serum thymus and activation-regulated chemokine (TARC) levels and side effects were registered. RESULTS During the first 10 weeks the objective SCORAD and serum TARC levels in the EC-MPS study arm were higher in comparison with the CsA study arm. In addition, 7 of the 24 patients treated with EC-MPS required short oral corticosteroid courses. During maintenance phase disease activity was comparable in both study arms. Side effects in both study arms were mild and transient. After study medication withdrawal, disease activity of the patients in the CsA study arm significantly increased compared with the EC-MPS study arm. LIMITATION The nonblinding of patients and prescriber of rescue medication are limitations. CONCLUSIONS This study shows that EC-MPS is as effective as CsA as maintenance therapy in patients with AD. However, clinical improvement with EC-MPS is delayed in comparison with CsA. Clinical remission after stopping EC-MPS lasts longer compared with CsA.
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Affiliation(s)
- Inge M Haeck
- Department of Dermatology and Allergology, University Medical Center Utrecht, Utrecht, The Netherlands.
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Enteric-coated Mycophenolate Sodium as a Corticosteroid-sparing Agent for the Treatment of Autoimmune Scleritis. Cornea 2011; 30:260-4. [DOI: 10.1097/ico.0b013e3181e9af18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Hwang HS, Hyoung BJ, Kim S, Oh HY, Kim YS, Kim JK, Kim YH, Kim YL, Kim CD, Shin GT, Yang CW. Improved gastrointestinal symptoms and quality of life after conversion from mycophenolate mofetil to enteric-coated mycophenolate sodium in renal transplant patients receiving tacrolimus. J Korean Med Sci 2010; 25:1759-65. [PMID: 21165291 PMCID: PMC2995230 DOI: 10.3346/jkms.2010.25.12.1759] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2010] [Accepted: 08/19/2010] [Indexed: 11/20/2022] Open
Abstract
It is reported that a conversion from mycophenolate mofetil (MMF) to enteric-coated mycophenolate sodium (EC-MPS) relieves gastrointestinal (GI) symptom burden and improves health-related quality of life (HRQoL). However, it is unclear whether renal transplant recipients using tacrolimus receive the same benefit from the conversion. In this prospective, multi-center, open-label trial, patients were categorized into two groups by their GI symptom screening. Equimolar EC-MPS (n=175) was prescribed for patients with GI burdens; those with no complaints remained on MMF (n=83). Gastrointestinal Symptom Rating Scale (GSRS) and Gastrointestinal Quality of Life Index (GIQLI) were evaluated at baseline and after one month. Patients and physicians completed Overall Treatment Effect (OTE) at one month. EC-MPS-converted patients had worse GSRS and GIQLI scores at baseline than MMF-continued patients (all P<0.001). Significant improvements in GSRS and GIQLI scores were observed for EC-MPS-converted patients at one month, but MMF-continued patients showed worsened GSRS scores (all P<0.05). OTE scale indicated that EC-MPS patients improved in overall GI symptoms and HRQoL more than MMF patients did (P<0.001). In tacrolimus-treated renal transplant recipients with GI burdens, a conversion from MMF to EC-MPS improves GI-related symptoms and HRQoL.
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Affiliation(s)
- Hyeon Seok Hwang
- Division of Nephrology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Bok Jin Hyoung
- Division of Nephrology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sol Kim
- Department of Bioengineering, University of Pensylvania, Philadelphia, PA, USA
| | - Ha Young Oh
- Division of Nephrology, Department of Internal Medicine, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Korea
| | - Yon Su Kim
- Division of Nephrology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Jung Kyung Kim
- Division of Nephrology, Department of Internal Medicine, Bong Seng Memorial Hospital, Busan, Korea
| | - Yeong Hoon Kim
- Division of Nephrology, Department of Internal Medicine, Busan Paik Hospital College of Medicine, Inje University, Busan, Korea
| | - Yong Lim Kim
- Division of Nephrology, Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Chan Duck Kim
- Division of Nephrology, Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Gyu Tae Shin
- Department of Nephrology, Ajou University School of Medicine, Suwon, Korea
| | - Chul Woo Yang
- Division of Nephrology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Budde K, Dürr M, Liefeldt L, Neumayer HH, Glander P. Enteric-coated mycophenolate sodium. Expert Opin Drug Saf 2010; 9:981-94. [DOI: 10.1517/14740338.2010.513379] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Ponticelli C, Colombo D, Novara M, Basilisco G. Gastrointestinal symptoms impair quality of life in Italian renal transplant recipients but are under-recognized by physicians. Transpl Int 2010; 23:1126-34. [DOI: 10.1111/j.1432-2277.2010.01115.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Bilodeau JF, Montambault P, Wolff JL, Lemire J, Masse M. Evaluation of Tolerability and Ability to Increase Immunosuppression in Renal Transplant Patients Converted From Mycophenolate Mofetil to Enteric-Coated Mycophenolate Sodium. Transplant Proc 2009; 41:3683-9. [DOI: 10.1016/j.transproceed.2009.06.183] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2009] [Accepted: 06/24/2009] [Indexed: 11/29/2022]
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