Mycophenolate mofetil for the treatment of systemic lupus erythematosus: an open pilot trial

Fatal attractions that trigger inflammation and drive atherosclerotic disease

BACKGROUND

Atherosclerosis is the salient, underlying cause of cardiovascular diseases, such as arrhythmia, coronary artery disease, cardiomyopathy, pulmonary embolism and myocardial infarction. In recent years, atherosclerosis pathophysiology has evolved from a lipid-based to an inflammation-centric ideology.

METHODS

This narrative review is comprised of review and original articles that were found through the PubMed search engine. The following search terms or amalgamation of terms were used: "cardiovascular disease," "atherosclerosis," "inflammation," "GRP78," "Hsp60," "oxidative low-density lipoproteins," "aldehyde dehydrogenase," "β2-glycoprotein," "lipoprotein lipase A," "human cytomegalovirus." "SARS-CoV-2," "chlamydia pneumonia," "autophagy," "thrombosis" and "therapeutics."

RESULTS

Emerging evidence supports the concept that atherosclerosis is associated with the interaction between cell surface expression of stress response chaperones, including GRP78 and Hsp60, and their respective autoantibodies. Moreover, various other autoantigens and their autoantibodies have displayed a compelling connection with the development of atherosclerosis, including oxidative low-density lipoproteins, aldehyde dehydrogenase, β2-glycoprotein and lipoprotein lipase A. Atherosclerosis progression is also concurrent with viral and bacterial activators of various diseases. This narrative review will focus on the contributions of human cytomegalovirus as well as SARS-CoV-2 and chlamydia pneumonia in atherosclerosis development. Notably, the interaction of an autoantigen with their respective autoantibodies or the presence of a foreign antigen can enhance inflammation development, which leads to atherosclerotic lesion progression.

CONCLUSION

We will highlight and discuss the complex role of the interaction between autoantigens and autoantibodies, and the presence of foreign antigens in the development of atherosclerotic lesions in relationship to pro-inflammatory responses.

A pharmacoeconomic study comparing the use of mycophenolate mofetil or cyclophosphamide as induction therapy in lupus nephritis patients in Egypt

INTRODUCTION/OBJECTIVES

Lupus nephritis (LN) is a major and serious complication of systemic lupus erythematosus (SLE) and is associated with morbidity and mortality. The difference in drug cost between mycophenolate mofetil (MMF) and cyclophosphamide (CYC) inducing regimens becomes a relevant and realistic issue, especially in developing countries. Thus, this study aims to estimate and compare the costs and outcomes of CYC and MMF for better allocation of resources to reduce the burden on the Egyptian healthcare system.

METHODS

A prospective, parallel observational study was conducted at Kasr Al-Aini Hospital between 2018 and 2020. One hundred and twenty-two LN patients were followed up monthly during the study period. Remission and maintenance of renal remission were assessed at 6 and 12 months from the start of therapy. Total direct medical costs associated with both regimens were examined. We applied the cost-minimization analysis method from governmental perspective. Besides, a prospective evaluation of reported changes in health-related quality of life using SF-36 was included in our study.

RESULTS

There was no statistically significant difference in treatment response at 6 and 12 months (RR 0.6 [0.26;1.43] and 0.8 [0.27;2.33]), respectively, as well as the incidence of infection episodes between MMF and CYC group (71.4% versus 70.45%, p > 0.05). The average direct medical expenditures per patient in the MMF group were approximately one and half times more than the CYC group (2339.69 $ versus 1329.03 $, p <0.001).

CONCLUSION

The CYC arm was associated with lower costs than the MMF arm, with equally effective outcomes indicating that CYC is an attractive treatment option.

Real-World Experience of Safety of Mycophenolate Mofetil in 119 Japanese Patients with Systemic Lupus Erythematosus: A Retrospective Single-Center Study

Objectives

Mycophenolate mofetil (MMF) is the standard treatment for lupus nephritis. In Japan, it was approved for lupus nephritis in 2015. We investigated its real-world safety and effectiveness in Japanese patients with systemic lupus erythematosus (SLE).

Methods

We analyzed the continuation rate, adverse events, and reasons for discontinuation of MMF in Japanese patients with SLE in a retrospective single-center study. We included 119 patients who received MMF from 31 July 2015 to 31 May 2019. To compare demographic and clinical characteristics between groups, the Mann–Whitney U-test was used for nonnormally distributed variables. Categorical variables were compared using Fisher's exact test. Kaplan–Meier curves were plotted for the discontinuation rate of MMF.

Results

Patients consisted of 18 males and 101 females. Thirty-five patients discontinued MMF. The cumulative discontinuation rate was 42.4%. Twenty-nine patients discontinued MMF due to adverse events, and six patients discontinued MMF due to remission of SLE or desire for childbearing. At the time of the last observation, the lupus low disease activity state achievement rate was significantly lower in patients who experienced adverse events than those who did not (64% vs. 35%, P = 0.009). We examined the concentration of mycophenolate acid (trough level) in stored frozen serum in 11 patients. Two patients had irreversible complications due to viral meningitis; their trough mycophenolate acid concentrations were 8.3 and 6.3 μg/mL, respectively.

Conclusions

Although MMF may be effective in Japanese patients with SLE, physicians should pay attention to infections in patients with high mycophenolate acid concentrations.

Mycophenolic acid, the active form of mycophenolate mofetil, interferes with IRF7 nuclear translocation and type I IFN production by plasmacytoid dendritic cells

BACKGROUND

Both humoral and cellular immune mechanisms are involved in the onset and progression of autoimmune responses in systemic lupus erythematosus (SLE). Plasmacytoid dendritic cells (pDCs) play a central role in the pathogenesis of SLE via the dysregulation of type I interferon (IFN) production; these cells act together with activated myeloid DCs (mDCs) to amplify the vicious pathogenic spiral of autoimmune disorders. Therefore, control of aberrant DC activation in SLE may provide an alternative treatment strategy against this disease. Mycophenolate mofetil (MMF), which has been used to treat lupus nephritis, specifically blocks the proliferation of B and T lymphocytes via inhibition of inosine-5-monophosphate dehydrogenase. Here, we focus on the effects of MMF in targeting DC functions, especially the IFN response of pDCs.

METHODS

We isolated human blood pDCs and mDCs by flow cytometry and examined the effect of mycophenolic acid (MPA), which is a metabolic product of MMF, on the toll-like receptor (TLR) ligand response of DC subsets. Additionally, we cultured pDCs with serum from SLE patients in the presence or absence of MPA and then examined the inhibitory function of MPA on SLE serum-induced IFN-α production.

RESULTS

We found that treatment with 1-10 μM of MPA (covering the clinical trough plasma concentration range) dose-dependently downregulated the expression of CD80 and CD86 on mDCs (but not pDCs) without inducing apoptosis, in response to R848 or CpG-ODN, respectively. Notably, in pDCs, MPA significantly suppressed IFN-α production with IRF7 nuclear translocation and repressed the AKT activity. In addition, MPA inhibited IL-12 production with STAT4 expression in mDCs. We further identified that MPA had an inhibitory effect on SLE serum-induced IFN-α production by pDCs.

CONCLUSIONS

Our data suggest that MPA can interrupt the vicious pathogenic spiral of autoimmune disorders by regulating the function of DC subsets. This work unveiled a novel mechanism for the therapeutic ability of MMF against SLE.

Mycophenolate Mofetil Treatment of Myasthenia Gravis

Objective:

To review published literature evaluating the effectiveness of mycophenolate mofetil for the treatment of myasthenia gravis (MG).

Data Sources:

Searches of MEDLINE (1966–August 2005) and Cochrane Database (1993–August 2005) were conducted. Studies conducted in humans and published in English were retrieved. Additional data were identified through subsequent bibliographic reviews.

Data Synthesis:

Interruption of T- and B-lymphocyte proliferation in various autoimmune diseases has been investigated. Mycophenolate is known to inhibit lymphocyte proliferation and has shown improved clinical responses in several autoimmune diseases including lupus erythematosus, rheumatoid arthritis, and systemic vasculitis. Data suggesting similar benefits in MG treatment have been reported in case reports, retrospective analyses, an open-label trial, and a randomized, double-blind trial.

Conclusions:

Limited evidence from retrospective analyses and clinical trials suggests that mycophenolate is a possible treatment option for patients with MG. Improvement in clinical symptoms and a steroid-sparing effect have been reported when mycophenolate is used in this patient population. Larger, randomized, controlled, and comparative trials are needed to establish optimal dose, time to effect, specific therapeutic role, and long-term safety for mycophenolate when used for treating MG.

Mycophenolate Mofetil and Systemic Lupus Erythematosus: An Overview

Mycophenolate mofetil (MMF) is an immunosuppressive agent used in transplantation, with evidence of superior protection against acute transplant rejection compared to azathioprine-containing regimens. Subsequently MMF has been used in a variety of autoimmune conditions. The major experience in systemic lupus erythematosus (SLE) has focused on proliferative lupus nephritis. Following its success in the treatment of lupus nephritis, MMF is now being used to control other SLE manifestations such as, lupus disease activity, haematological manifestations and resistant skin lupus. In this review, we discuss our own experience and the literature report about the use of MMF in SLE.

Mycophenolate mofetil and skin diseases

Mycophenolate mofetil (MMF) is an immunosuppressive drug the efficiency of which has been established in renal transplantation. Recent studies suggest that it may also be effective in the treatment of variant skin diseases especially if the skin lesions are triggered by lymphocytes. Studies have shown efficacy in autoimmune bullous dermatoses, atopic dermatitis and psoriasis. However, there are no placebo-controlled trials that support the use of MMF as first line therapy in these skin diseases.

Mycophenolate mofetil and skin diseases

Mycophenolate mofetil (MMF) is an immunosuppressive drug the efficiency of which has been established in renal transplantation. Recent studies suggest that it may also be effective in the treatment of variant skin diseases especially if the skin lesions are triggered by lymphocytes. Studies have shown efficacy in autoimmune bullous dermatoses, atopic dermatitis and psoriasis. However, there are no placebo-controlled trials that support the use of MMF as first line therapy in these skin diseases.

Mycophenolate mofetil and systemic lupus erythematosus: an overview

Mycophenolate mofetil (MMF) is an immunosuppressive agent used in transplantation, with evidence of superior protection against acute transplant rejection compared to azathioprine-containing regimens. Subsequently MMF has been used in a variety of autoimmune conditions. The major experience in systemic lupus erythematosus (SLE) has focused on proliferative lupus nephritis. Following its success in the treatment of lupus nephritis, MMF is now being used to control other SLE manifestations such as, lupus disease activity, haematological manifestations and resistant skin lupus. In this review, we discuss our own experience and the literature report about the use of MMF in SLE.

Mycophenolate mofetil and systemic lupus erythematosus

Mycophenolate mofetil (MMF) is an immunosuppressive agent which provides protection against acute transplant rejection, in patients who undergo kidney, heart and liver transplantation. Recently MMF has been used in various autoimmune conditions, including systemic lupus erythematosus (SLE). In SLE, MMF has been more extensively used in the treatment of proliferative lupus glomerulonephritis (GLN) and following the success in this field, it has also been used to control extra-renal manifestations. However, in the majority of cases MMF was administered to patients with refractory SLE manifestations and, therefore, no definite conclusion could be drawn from these experiences.

In this paper, after a brief description of the mechanisms of action, the pharmacokinetics and metabolism of MMF which are relevant in SLE, and after a short discussion on the utility of performing therapeutic dose monitoring of mycphenolic acid, the experiences with the use of this drug in the different SLE manifestations were summarized and some personal data in patients with GLN were reported. Finally, the hypothetical use of MMF as a preventive strategy against the occurrence of severe manifestations in patients with mild SLE has been put forward and discussed.

Mycophenylate mofetil: what role in the treatment of lupus?

Improved patient survival following lupus nephritis with the institution of corticosteroids, immunosuppressants and renal replacement therapy allows greater emphasis on long-term management issues. In particular, the recent focus has been on therapies to treat nephritis with fewer adverse effects of cyclophosphamide-including immunosuppressive regimens. Mycophenolate mofetil (MMF) has been used in the field of transplantation for more than 10 years. Following initial anecdotal reports describing benefits of MMF in the treatment of lupus nephritis, randomized, controlled trials have established a role for MMF in the treatment of lupus nephritis. MMF use to treat other lupus manifestations has been evaluated only in anecdotal case reports or series with few well-designed trials. Issues complicating clinical trial design in lupus including appropriate use and interpretation of activity and damage indices, comparable remission and response criteria and stratification of high risk populations have been the subject of much discussion and emerging consensus. As long-term outcomes in lupus improve, the toxicity of therapy and risk of relapse become increasingly important determinants of choice of therapeutic agents.

Review: Systemic lupus erythematosus in the young: the importance of a transition clinic

The objective of this report is to focus on the problems of patients with childhood onset systemic lupus erythematosus (SLE) at the age of transition to an adult care Unit. SLE is a multisystem disease characterised by diffuse internal organ involvement and by the presence of antinuclear and anti DNA antibodies. Central nervous system and renal damage are the main complications especially in children. Transition in health-care is a multifaceted, active process that attends to the medical, psychosocial and educational-vocational needs of adolescents when they move from child to adult-oriented lifestyles and systems. Lack of institutional support and difficulty in communicating and in identifying adult specialists are the major concerns in a transition care Unit. Psychosocial matters can make this change dramatic and hard for young people and their families. Patients with juvenile-onset SLE require specialised and multidisciplinary care when entering a transition clinic; physicians need to focus on preventing long-term complications of SLE, including atherosclerosis, obesity, osteoporosis and their treatment. We report on our experience in a cohort of patients with juvenile SLE cared for at our transition clinic over last six years. Lupus (2007) 16: 613—617.

Mycophenolate mofetil combined with prednisone for diffuse proliferative lupus nephritis: a histopathological study

Mycophenolate mofetil (MMF) is a potential new treatment for diffuse proliferative lupus nephritis. This study examines the clinical and histopathological effects, and potential mechanisms, of combination MMF/prednisone therapy in diffuse proliferative lupus nephritis. Nine patients with diffuse proliferative lupus nephritis confirmed by renal biopsy received MMF/prednisone for six months when repeat biopsies were performed. Clinical and histopathological parameters of activity and chronicity were studied. Collagens were detected by Sirus red staining; leucocyte phenotype, osteopontin (OPN), fibrinectin (FN), a-smooth muscle actin (a-SMA) and TGF-b1 were detected by immunohistochemistry. The changes of clinical and histopathologic parameters were assessed and compared to histopathologic indicators. Eight of the nine patients achieved clinical remission; renal function deteriorated in one. Histopathological activity indices reduced significantly (9.56 + 2.83 versus 5.22 + 1.86, P < 0.01); however, the chronicity indices did not change (3.56 + 1.42 versus 3.22 + 1.20). T-cell and monocyte/macrophage infiltration, OPN expression and the percentage of proliferative cells in both glomerulus and tubulo-interstitiumdecreased significantly. Other features of chronic lesions, except for glomerular collagen deposition, did not change. In conclusion, MMF/prednisone therapy was effective for our patients with proliferative lupus nephritis. The active inflammatory lesions could be ameliorated through reduction of lymphocyte and monocyte/macrophage infiltration, inhibition of cell proliferation and downregulation of adhesive molecules. However, the chronic fibrotic lesions could not be significantly reduced.

Drugs used in incident systemic lupus erythematosus – results from the Finnish nationwide register 2000–2007

The objectives of the study were to examine the initial, first-year anti-rheumatic outpatient therapy in patients with incident SLE, as well as the concomitant use of drugs for certain comorbidities, compared to the use in the general population. The Finnish nationwide register data on special reimbursements for medication costs was screened to identify the inception cohort of 566 adult SLE patients (87% females, mean age 46.5 ± 15.9 years) over the years 2000–2007. The patients were linked to the national Drug Purchase Register. Of those, 90% had purchased at least once some disease-modifying anti-rheumatic drugs (DMARDs) during the first year. Hydroxychloroquine was the most common (76%), followed by azathioprine (15%) and methotrexate (13%). With the exception of increase in mycophenolate mofetil, the proportions remained stable over the whole study period 2000–2007. Drugs for cardiovascular diseases, dyslipidemia, diabetes mellitus, hypothyroidism and obstructive pulmonary disease were more frequently purchased than in the sex- and age-adjusted population, with rate ratios ranging from 1.6 to 7.8. Over the years 2000–2007, almost all the patients with incident SLE in Finland started with a DMARD. Higher percentages of SLE patients were on medication for several common chronic diseases than in the population as a whole.

Mycophenolate in refractory and relapsing lupus nephritis

BACKGROUND

Mycophenolate (MF) is effective as induction and maintenance treatment in patients with lupus nephritis (LN). This study evaluates the efficacy and safety of MF in patients with refractory and relapsing LN.

METHODS

Data were retrospectively obtained for 85 patients (35 refractory and 50 relapsing) from 11 nephrology departments in Spain. The primary endpoints were the incidence and cumulative number of renal responses and relapses and their relationship with baseline clinical and analytical data. The secondary endpoint was the appearance of side effects.

RESULTS

The main clinical and analytical variables were similar both in refractory and relapsing LN. Most of the patients had received cyclophosphamide, and all of them switched to MF. 74 patients (87%) achieved a response (69% partial, 31% complete). Age at starting MF, gender, pathological classification, body mass index, blood pressure, baseline renal function, and proteinuria were not associated with achieving response. After stopping MF, 3 of 19 patients (15.7%) relapsed, all at 6 months of follow-up. No differences were found between clinical and analytical variables and number of relapses. Side effects were unremarkable, except for 1 patient, who died of thrombocytopenia and ovarian hemorrhage.

CONCLUSIONS

Switching to MF from other immunosuppressive treatments is effective and safe in refractory and relapsing LN.

[Established medications : new areas of application]

During the last 10 years several new medications from hemato-oncology and transplantation medicine have been transferred to rheumatology. Additionally, medications which are approved for rheumatoid arthritis were increasingly also studied and used for other systemic inflammatory rheumatic diseases. This is especially the case for rituximab and mycophenolate and to a lesser extent also for leflunomide, tumor necrosis factor (TNF) antagonists, tocilizumab and abatacept. Recently, rituximab was approved for severe granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA) after the publication of two prospective randomized trials in 2010. The situation concerning rituximab is much more problematic for systemic lupus erythematosus (SLE) where randomized placebo-controlled trials exist but unfortunately did not meet the primary endpoint requirements (too many highly effective additional forms of treatment in both arms and unsuitable endpoints), although data from registries suggest efficacy especially in cases resistant to treatment. In the case of mycophenolate (MPS) the problem with SLE is totally different. All prospective trials met the endpoints and in one trial MPS was even superior to azathioprine for treatment of lupus nephritis (LN) which led to the recommendation of MPS for induction and maintenance in LN by EULAR and EDTRA as well as more recently by the ACR. However, MPS still is not approved for SLE or LN. The present manuscript gives an overview of existing data for selected connective tissue diseases and vasculitides (for which at least larger retrospective case series or registry data exist) being treated with medications approved for other indications.

Efficacy of mycophenolate mofetil in adolescent patients with lupus nephritis: evidence from a two-phase, prospective randomized trial

The safety and efficacy of mycophenolate mofetil (MMF) were evaluated in adolescent patients with systemic lupus erythematosus and active or active/chronic class III–V lupus nephritis. During the 24-week induction phase, patients were randomized to oral MMF (target dose 3.0 g/day) or intravenous cyclophosphamide (IVC) (0.5–1.0 g/m2/month), plus prednisone. Response was defined as a decrease in 24-hour urine protein:creatinine ratio (P:Cr) to <3 in patients with baseline nephrotic range proteinuria, or by ≥50% if subnephrotic baseline proteinuria, and stabilization (±25%) or improvement in serum creatinine. In the 36-month maintenance phase, induction therapy responders were randomized 1:1 to MMF (1.0 g twice daily) or oral azathioprine (AZA) (2 mg/kg/day), plus prednisone. In the induction phase, 10 patients received MMF and 14 received IVC; 15 (62.5%) achieved treatment response (MMF, 7 (70%); IVC, 8/15 (57.1%); p = 0.53, odds ratio (95% confidence interval) 2.0 (0.2, 15.5)). There was a non-statistically significant difference in maintenance of response to MMF (7/8; 87.5%) versus AZA (3/8; 37.5%). Seven patients withdrew (MMF, 2; AZA, 5). During both phases, rates of serious adverse events were similar in both arms. During both phases treatment response with MMF was as effective as the comparator.

Pharmacokinetics and pharmacodynamics of mycophenolic acid and their relation to response to therapy of childhood-onset systemic lupus erythematosus

OBJECTIVES

Mycophenolic acid (MPA) is the active form of mycophenolate mofetil (MMF), which is currently used off-label as immunosuppressive therapy in childhood-onset SLE (cSLE). The objectives of this study were to (1) characterize the pharmacokinetics (MPA-PK) and pharmacodynamics (MPA-PD) of MPA and (2) explore the relationship between MPA-PK and cSLE disease activity.

METHODS

MPA-PK [area under the curve from 0-12 hours (AUC(0-12))] and MPA-PD [inosine-monophosphate dehydrogenase (IMPDH) activity] were evaluated in cSLE patients on stable MMF dosing. Change in SLE disease activity while on MMF therapy was measured using the British Isles Lupus Assessment Group (BILAG) index.

RESULTS

A total of 19 AUC(0-12) and 10 IMPDH activity profiles were included in the analysis. Large interpatient variability in MPA exposure (AUC(0-12)) was observed (mean ± SE: 32 ± 4.2 mg h/L; coefficient of variation: 57%). Maximum MPA serum concentrations coincided with maximum IMPDH inhibition. AUC(0-12) and weight-adjusted MMF dosing were only moderately correlated (r = 0.56, P = 0.01). An AUC(0-12) of ≥30 mg h/L was associated with decreased BILAG scores while on MMF therapy (P = 0.002).

CONCLUSION

Weight-adjusted MMF dosing alone does not reliably allow for the prediction of exposure to biologically active MPA in cSLE. Individualized dosing considering MPA-PK appears warranted as this allows for better estimation of immunologic suppression (IMPDH activity). Additional controlled studies are necessary to confirm that an MPA AUC(0-12) of at least 30 mg h/L is required for cSLE improvement.

Intravenous immunoglobulin in lupus panniculitis

Systemic lupus erythematosus (SLE) is a disease of unknown cause that may involve one or many organ or systems. Skin involvement is a major feature in this disease, and a wide variety of skin conditions may be present. Lupus erythematosus panniculitis (LEP) constitutes a rare form of cutaneous lupus characterized by recurrent nodular or plaque lesions that can vary from a benign and mild course to a more disfiguring disease. Initial therapy includes corticosteroids, antimalarials, and azathioprine and, in refractory cases, two antimalarials in association, mycophenolate mofetil, or other immunomodulators. Intravenous immuglobulin (IVIG) is used in many autoimmune disorders, like in SLE, although clinical trials have not yet taken place. In this report, we review skin manifestations of SLE and their treatment, IVIG, and finally a case of LEP successfully treated with IVIG when other therapy modalities failed.

The efficacy of low-dose mycophenolate mofetil for treatment of lupus nephritis in Taiwanese patients with systemic lupus erythematosus

Mycophenolate mofetil (MMF) has recently been introduced as an immunosuppressive agent for the treatment of glomerulonephritis with systemic lupus erythematosus (SLE) and the data have been encouraging. However, response to MMF treatment appears to differ ethnically. Therefore, we determined efficacy and safety of low-dose MMF for Taiwanese patients with lupus nephritis. We studied 36 lupus nephritis patients who were treated with MMF. The dose started at 0.5 g/day and we collected the data from patients who received up to 1 g/day MMF. Outcome measures were 24 h for proteinuria, serum creatinine, C3/C4 levels, and anti-dsDNA titers collected at the baseline and at 3-month treatment intervals. Daily urinary protein significantly decreased from 6.15 +/- 4.28 g to 2.69 +/- 2.36 g at the last visit (P < 0.01) in spite of the significant absence of changes in serum creatinine levels. The response rate was 65.7% including five (14.3%) cases of complete remission and 18 (51.4%) cases of partial remission. The concomitant oral prednisolone dose decreased significantly from 20.07 +/- 11.78 mg/day to 13.93 +/- 6.79 mg/day at 6 months (P < 0.01). The level of C3 increased significantly from 59.46 +/- 32.73 to 71.99 +/- 25.81 (P < 0.01) and the anti-dsDNA antibody titer decreased from 161.71 +/- 221.42 to 46.57 +/- 117.47 (P < 0.01). No severe adverse effects were observed in the study. Low-dose MMF (0.5 to 1 g/day) combined with glucocorticoids appears to be a safe and effective therapy for lupus nephritis in Taiwanese patients. Our results suggest that lupus nephritis in Oriental patients might respond to lower doses of MMF than Caucasians.

Mycophenolate in dermatology

Originally used to treat psoriasis nearly three decades ago, mycophenolic acid, reformulated as mycophenolate mofetil (MMF), has been rediscovered by the world of dermatology. As a relatively well-tolerated immunosuppressive used in organ transplant recipients, MMF has recently been reported to show promise for several dermatologic conditions, including psoriasis, pemphigus vulgaris, pyoderma gangrenosum, bullous lichen planus, and even connective tissue diseases such as lupus erythematosus and dermatomyositis. Although not intended to be exhaustive, this review discusses MMF with regard to its basic pharmacology, its side effects, and its reported efficacy in a variety of dermatologic indications. Relevant literature was retrieved by a Medline search combining the terms "mycophenolate" or "mycophenolic acid" and "skin" or "skin disease" or a number of specific conditions ("psoriasis", "dermatitis", "eczema", "pemphigoid", "pemphigus", "vasculitis", "pyoderma gangrenosum", "Crohn's disease", "graft-versus-host disease", "lichen planus"). As MMF has only been recently re-introduced for dermatologic application, the nature of much of the literature is admittedly that of case reports or case series. Nevertheless, the results are sufficiently promising to warrant further larger, control studies.

Mycophenolate mofetil is effective in reducing disease flares in systemic lupus erythematosus patients: a retrospective study

Mycophenolate mofetil (MMF) is effective in the treatment of patients with active systemic lupus erythematosus (SLE). We sought to evaluate its efficacy in reducing the number of disease flares in adults with SLE. For this retrospective study, all patients seen at our institution over a six year period, 1999–2005, with the diagnosis of SLE treated with MMD were identified. Data regarding lupus flare was obtained for patients at least one and up to two years prior to starting MMF. The number of flares prior to MMF therapy was compared to the number of lupus flares in the one to two year period after starting MMF. Clinical assessment was performed with the SELENA-SLEDAI instrument. Differences between groups were compared using the signed rank test. The rate of flares (flares per person-year), before and after the introduction of MMF were compared assuming the occurrence of flares followed a Poisson distribution. In the evaluable 67 patients, the mean time period of followup prior to starting MMF was 14.1 months (range 0.3–24), mean time period of follow-up after starting MMF was 14.8 months (range 1.5–24); and mean MMF dose was 1328 mg/day (range 250–3000). The mean flare rate was reduced from 8.9 to 5.3 per 10 personyears and the mean prednisone dose was reduced on average 7.3 mg/day after starting MMF therapy. MMF treatment significantly reduced the total number of lupus flares and prednisone requirements. Even with the reduction in mean daily prednisone dose, both the SLEDAI and physican global assessment also improved during MMF therapy.

An update on the use of mycophenolate mofetil in lupus nephritis and other primary glomerular diseases

Mycophenolate mofetil (MMF) has been used successfully as an immunosuppressive medication in transplantation for over a decade. Owing to its efficacy and relatively benign adverse effect profile, its use has been investigated in the treatment of several glomerular diseases, as we describe in this Review. Of these, MMF has most extensively been studied in lupus nephritis. Randomized controlled trials have documented the value of MMF in both induction and maintenance therapy for severe lupus nephritis in several different geographic and ethnic populations, and have defined its potential toxicity. In minimal-change disease, focal segmental glomerulosclerosis and membranous nephropathy, promising but limited data on MMF treatment exist from small retrospective and prospective studies. Ongoing, larger, prospective trials, such as the NIH trial in focal segmental glomerulosclerosis, might clarify the value of MMF in the treatment of this disease. The efficacy of MMF in IgA nephropathy remains unclear, despite several small, controlled trials. Conflicting results might reflect differences in the disease process, differences in MMF metabolism, or varying responses to the immunosuppressive agent in different populations. Only through large, collaborative, controlled trials will the true role of MMF be defined for each glomerular disease.

[Treatment of lupus nephritis]

Lupus nephritis is a relevant source of morbidity and mortality in patients with systemic lupus erythematosus. The standard therapy of remission induction in severe lupus nephritis is based on the use of monthly intravenous cyclophosphamide. Recent data have established that the maintenance of remission in lupus nephritis can be achieved with azathioprine or mycophenolate mofetil, with less adverse effects than quarterly intravenous cyclophosphamide. In recent years, a number of controlled randomized clinical trials have been published, opening new therapeutic options in the induction of remission in lupus nephritis, such as less aggressive regimens of intravenous cyclophosphamide or mycophenolate mofetil. Further studies are needed for establishing the optimal therapy of lupus nephritis patients.

Clinical observations of mycophenolate mofetil therapy in refractory primary nephrotic syndrome

Mycophenolate mofetil (MMF) is an effective immunosuppressive agent in renal transplantation, and preliminary studies suggest that it may also be effective in the treatment of lupus nephritis. This study investigated the efficacy and safety of MMF therapy in patients with refractory primary nephrotic syndrome in a prospective multicentre clinical observation. Nineteen refractory nephrotic patients with minimal change disease or mesangial proliferative glomerulonephritis were enrolled in this study. Combined MMF and prednisone therapy was used for 6 months with an initial MMF dose of 1.0-2.0 g/day and a prednisone dose of 20-60 mg/day; both drugs were tapered gradually. It was found that all patients achieved clinical remission and 11 of 19 responded within 4 weeks, and 12 of 19 patients entered complete clinical remission. The prednisone dose in those patients who were previously steroid dependent could be successfully tapered. During follow up, three patients experienced transient increasing of proteinuria associated with infections and recovered without an adjustment of therapy. One patient was withdrawn from the study because of a fall in haemoglobin levels; other adverse effects did not necessitate withdrawal. Follow-up renal biopsies in two patients found no alteration in renal pathology. Mycophenolate mofetil is an effective and well-tolerated immunosuppressive agent for patients with refractory nephrotic syndrome.

[Revision of the recommendations of the Commission on Pharmacotherapy of the German Society for Rheumatology. Comment on the use of mycophenolic acid for systemic lupus erythematosus]

According to the NIH scheme, the "evidence based medicine" standard in the treatment of severe proliferative lupus-nephritis is cyclophosphamide in combination with steroids. Undesired effects, therapy resistance, and deficient long-term effects underscore the necessity for the development of alternative therapies for the treatment of organ involvement. Mycophenolate mofetil (MMF) possesses the potential to decisively improve the therapeutic possibilities for systemic lupus erythematosus (SLE). On the basis of the available data, MMF represents an alternative to the current standard therapies for severe lupus-nephritises and shows less toxicity. MMF is also effective in patients with other manifestations refractory to conventional therapy. Questions remain unanswered on the optimal dosage and possible reduction in cases of remission. In addition, the duration of maintenance therapy is unclear. Therefore, large, prospective, randomized clinical studies in the treatment of lupus-nephritis with a sufficiently long follow-up phase are underway.

Mycophenolate mofetil for non-renal manifestations of systemic lupus erythematosus: a systematic review

OBJECTIVE

To summarize the evidence for the use of mycophenolate mofetil (MMF) in non-renal manifestations of systemic lupus erythematosus (SLE).

METHODS

Treatment trials in human SLE from 1990 to 2006 that have been published in the English literature were searched by Medline using the keywords 'lupus', 'mycophenolate', 'neuropsychiatric', 'neurological', 'hematological', 'dermatological', 'cutaneous', 'skin', 'hemolytic' and 'thrombocytopenia'. Laboratory studies were excluded.

RESULTS

Twenty relevant studies were summarized. All were case series or open-labelled trials. The main indications for MMF were refractory haematological and dermatological lupus. Data regarding MMF in neuropsychiatric SLE were scant. Favourable results were reported with haematological disease. Evidence regarding the efficacy of MMF in refractory lupus skin lesions was conflicting. The efficacy of MMF in neuropsychiatric lupus was only modest and could not be separated from that of concomitant therapies. In one uncontrolled study, MMF was reported to be effective in preventing clinical flares in patients with persistently active serological markers. MMF was well tolerated in these reports.

CONCLUSIONS

Limited evidence suggests that MMF may be effective in refractory haematological and dermatological manifestations of SLE. Because of the possibility of publication bias, the efficacy of MMF in these manifestations has to be confirmed with controlled trials. The efficacy of MMF in neuropsychiatric SLE is unproven and should be restricted to those patients who are refractory and intolerant to, or reluctant for, cyclophosphamide. Finally, the current level of evidence does not support treating serology alone in SLE by MMF.

Induction therapies for class IV lupus nephritis with non-inflammatory necrotizing vasculopathy: mycophenolate mofetil or intravenous cyclophosphamide

The presence of renal noninflammatory necrotizing vasculopathy (NNV) is often associated with a severe form of lupus nephritis (LN), which is unresponsive to standard therapy. We conducted a 6-month randomized, prospective, open-label trial comparing mycophenolate mofetil (MMF) (1.5-2.0 g/day) with monthly i.v. cyclophosphamide (CTX) (0.75-1.0 g/m2) as induction therapy for class IV LN with NNV. The primary and second end points were complete remission (CR) and partial remission (PR), respectively. Of 20 patients recruited, nine were randomly assigned to MMF and 11 to CTX. The baseline characteristics between groups were not significant. CR was achieved in four patients (44.4%) receiving MMF and in none of the patients receiving CTX (P = 0.026). PR was achieved in two patients (22.2%) in the MMF group and three patients (27.2%) in the CTX group. The total remission rate (CR + PR) in the MMF and CTX group was 66.6 and 27.2%, respectively (P = 0.17). MMF was more effective than i.v. CTX in reducing proteinuria and haematuria. Adverse events were significantly less frequent with MMF than with CTX (P = 0.028). MMF was superior to i.v. CTX in inducing CR of LN with NNV and had a more favourable safety profile.

Mycophenolate mofetil for induction therapy of lupus nephritis: a systematic review and meta-analysis

BACKGROUND AND OBJECTIVES

Although the accepted standard of care for induction of lupus nephritis has been cyclophosphamide, recent trials suggest that mycophenolate mofetil may be as or more effective and less toxic. A systematic review and meta-analysis were performed to determine the risk for failure to induce remission of lupus nephritis in patients who were treated with mycophenolate mofetil compared with cyclophosphamide.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Studies were identified by a search of electronic databases, bibliographies, and conference proceedings and by contacting experts. Randomized trials that compared mycophenolate mofetil with cyclophosphamide for induction therapy in adults with biopsy-proven lupus nephritis were eligible. The primary outcome was failure to induce a remission of nephritis as defined by the original studies (based on proteinuria, renal function, and urine sediment).

RESULTS

Four studies that included 268 patients and had homogeneous results across studies were identified. In a fixed-effects model, the pooled relative risk for failure to induce remission for mycophenolate mofetil compared with cyclophosphamide was 0.70. The relative risk for the composite outcome of death or end-stage renal disease for mycophenolate mofetil compared with cyclophosphamide was 0.44. Leukopenia and amenorrhea occurred more frequently in cyclophosphamide-treated patients.

CONCLUSIONS

Treatment of lupus nephritis with mycophenolate mofetil compared with cyclophosphamide reduces the risk for failure to induce remission during induction therapy and may reduce the risk for death or end-stage renal disease. Mycophenolate mofetil may be considered as a first-line induction therapy for the treatment of lupus nephritis in patients without severe renal dysfunction.

Mycophenolate sodium treatment in patients with primary Sjögren syndrome: a pilot trial

The aim of this study was to evaluate the efficacy and safety of mycophenolate sodium (MPS) in patients with primary Sjögren syndrome (pSS) refractory to other immunosuppressive agents. Eleven patients with pSS were treated with MPS up to 1,440 mg daily for an observation period of 6 months in this single-center, open-label pilot trial. At baseline, after 3 months, and after 6 months, we examined the clinical status, including glandular function tests, as well as different laboratory parameters associated with pSS. In addition, subjective parameters were determined on the basis of different questionnaires. Treatment with MPS was well tolerated in 8 of 11 patients. Due to vertigo or gastrointestinal discomfort, two patients did not complete the trial. One patient developed pneumonia 2 weeks after treatment and was withdrawn. In the remaining patients, MPS treatment resulted in subjective improvement of ocular dryness on a visual analogue scale and a reduced demand for artificial tear supplementations. However, no significant alterations of objective parameters for dryness of eyes and mouth were observed, although a substantial improvement of glandular functions occurred in two patients with short disease duration. In addition, treatment with MPS resulted in significant reduction of hypergammaglobulinemia and rheumatoid factors as well as an increase of complement levels and white blood cells. MPS promises to be an additional therapeutic option for patients with pSS, at least in those with shorter disease duration. Further investigations about the efficacy and safety of MPS in pSS have to be performed in larger numbers of patients.

Mycophenolate mofetil attenuates pulmonary arterial hypertension in rats

Pulmonary arterial hypertension (PAH) is characterized by abnormal proliferation of smooth muscle cells (SMCs), leading to occlusion of pulmonary arterioles, right ventricular (RV) hypertrophy, and death. We investigated whether mycophenolate mofetil (MMF), a potent immunosuppresssant, prevents the development of monocrotaline (MCT)-induced PAH in rats. MMF effectively decreased RV systolic pressure and RV hypertrophy, and reduced the medial thickness of pulmonary arteries. MMF significantly inhibited the number of proliferating cell nuclear antigen (PCNA)-positive cells, infiltration of macrophages, and expression of P-selectin and interleukin-6 on the endothelium of pulmonary arteries. The infiltration of T cells and mast cells was not affected by MMF. In vitro experiments revealed that mycophenolic acid (MPA), an active metabolite of MMF, dose-dependently inhibited proliferation of human pulmonary arterial SMCs. MMF attenuated the development of PAH through its anti-inflammatory and anti-proliferative properties. These findings provide new insight into the potential role of immunosuppressants in the treatment of PAH.

Therapeutic options for resistant lupus nephritis

OBJECTIVES

To summarize the therapeutic options for proliferative and membranous lupus nephritis that is resistant to conventional treatment.

METHODS

Treatment trials in human lupus nephritis from years 1985 to 2005 that have been published in the English literature were searched by Medline using the keywords "lupus," "nephritis," "glomerulonephritis," "renal," "refractory," "resistant," "recalcitrant," "cyclophosphamide," "mycophenolate," "cyclosporin," "tacrolimus," "leflunomide," "intravenous immunoglobulin," "apheresis," "plasmapheresis," "immunoadsorption," "marrow transplantation," "stem cell transplantation," "immunoablative," "rituximab," and "biologics." Laboratory, histological, and nonrenal lupus studies were excluded.

RESULTS

There is no universal definition of treatment resistance in lupus nephritis. Controlled trials in refractory lupus nephritis are largely unavailable. Open-labeled studies have reported success of newer immunosuppressive drugs, immunomodulatory therapies, and the biological agents such as mycophenolate mofetil (MMF), calcineurin inhibitors, leflunomide, intravenous immunoglobulin, immunoadsorption, and rituximab in the treatment of cyclophosphamide (CYC) resistant proliferative lupus nephritis. More aggressive CYC regimens have been used in lupus nephritis, but at the expense of more toxicities. For membranous lupus nephritis (MLN), a combination of corticosteroids with either azathioprine, chlorambucil, cyclosporin A, MMF, or CYC is initially effective in two-thirds of patients. More aggressive and costly regimens should be reserved for truly refractory disease with persistent nephrotic syndrome or declining renal function. Evidence regarding the efficacy of MMF in refractory MLN is conflicting and controlled trials are necessary to resolve the controversy.

CONCLUSIONS

The treatment of refractory lupus nephritis remains anecdotal. An international consensus in the renal response criteria should be developed and validated so that controlled trials can be performed to compare the efficacy of various treatment modalities.

Mycophenolate mofetil is effective in reducing lupus glomerulonephritis proteinuria

Mycophenolate mofetil (MMF) significantly reduces proteinuria in experimental model of human membranous nephropathy (Heymann nephritis). Twenty consecutive SLE patients with persistent isolated severe proteinuria and/or proteinuric flare were studied for 18 months of MMF therapy. All of them presented stable renal function and 12 had biopsy proven membranous glomerulonephritis (WHO class V). The starting daily dose for MMF was 1.5 g to a maximum of 3 g. Patients were divided into: partial response, >or=50% decrease of baseline proteinuria; complete response, normal proteinuria levels (less than 0.3 g/24 h); flare, increase of at least 50% of the mean baseline proteinuria. All 20 SLE patients (100%) presented a 50% reduction of baseline proteinuria which was achieved in 8.2+/-3.3 months of MMF therapy, at a mean daily dose of 2.3+/-0.5 g. A significant decrease in 24-h protein excretion was observed compared to entry (3.47+/-1.26 vs. 1.33+/-0.67 g, P<0.0001) as well as a correspondent increase of serum albumin (3.2+/-0.4 vs. 3.7+/-0.4 mg/dl, P=0.02) and reduction of prednisone dose (33.7+/-20.0 to 18.6+/-14.1 mg/day, P=0.01). Complete response was observed in 11 SLE patients (55%) in 12.2+/-3.0 months of therapy with a significant decrease in proteinuria (P<0.0001), prednisone dose (P<0.0001) and an increase of serum albumin (P=0.003). Interestingly, initial proteinuria or serum albumin levels did not identify patients with complete response and those with partial response at the end of the study (P=0.543 and 0.657, respectively). Our pilot prospective study suggests that MMF appears to be effective in reducing severe persistent proteinuria in lupus glomerulonephritis, even in patients unresponsive to other immunosuppressive treatments.

Newer therapeutic approaches for systemic lupus erythematosus: immunosuppressive agents

There has been unprecedented growth in new therapeutic approaches for the treatment of systemic lupus erythematosus (SLE). These approaches include re-evaluation of the doses and duration of therapy with traditional agents, including intravenous cyclophosphamide and azathioprine. Drugs that were developed for other uses are being applied to specific SLE manifestations, and have spurred larger scale trials for overall disease activity. In addition, several new agents show promise in clinical trials; many have safer toxicity profiles than do traditional therapies. Some of these agents have multiple immunomodulatory effects, whereas others interfere with a specific immunologic process in one of the pathogenetic pathways of SLE activity.

Membrane initiated steroid signaling (MISS): computational, in vitro and in vivo evidence for a plasma membrane protein initially involved in genomic steroid hormone effects

Steroid hormones are indispensable for control of vital processes, development, reproduction and modulation of behavior. Lack or complete dysfunction of glucocorticoid (GC) signaling, in particular, have lethal consequences. Even a minor change in the level of circulating cortisol can be of physiological and clinical significance. Analysis of the action mechanisms of GC is therefore of major importance, especially since natural and synthetic GC are widely used in the therapy of GC-responsive diseases. According to the classical genomic concept of steroid hormone action, the effects of GC are mediated by specific nuclear receptors (GR). Recent findings provide evidence for the existence of additional, plasma membrane (PM) located steroid receptors, which are thought to be responsible for rapid, non-genomic responses. We present evidence for a PM-residing protein, termed "steroid hormone recognition and effector complex" (SHREC), which plays a pivotal role in the complex network of PM-related non-genomic responses leading to GR-mediated genomic effects. This conclusion was drawn from studies using different in vitro and in vivo models of a GC-target: (1) highly purified fractions of osmotically active PM-vesicles isolated from rat and human hepatocytes, (2) a computational model of SHREC generated by the "automated receptor modeling" (ARM) method, (3) rat liver cell lines transfected with a GC-responsive reporter gene construct and (4) young women orally administered with selected steroids. We conclude that SHREC and the GR participate in the same signaling chain, SHREC<-->steroid interaction is the initial step and an interdependent part of the complete GC signal propagation, thus called "membrane initiated steroid signaling" (MISS).

Systematic review and meta-analysis of randomised trials and cohort studies of mycophenolate mofetil in lupus nephritis

Mycophenolate mofetil (MMF) is an immunosuppressant drug being used for induction and maintenance of remission of lupus nephritis in systemic lupus erythematosus. Evidence about its use was sought from full publications and abstracts of randomised trials and cohort studies by using a variety of search strategies. Efficacy and adverse event outcomes were sought. Five randomised trials enrolled patients with World Health Organization (WHO) class III, IV, or V (mostly IV) lupus nephritis, predominantly comparing MMF (1 to 3 g daily) with cyclophosphamide and steroid. Complete response and complete or partial response was significantly more frequent with MMF than with cyclophosphamide, with numbers needed to treat of 8 (95% confidence interval 4.3 to 60) to induce one additional complete or partial response, with wide confidence intervals. Death was reported less frequently with MMF (0.7%, 1 death in 152 patients) than with cyclophosphamide (7.8%, 12 deaths in 154 patients), with a number needed to treat to prevent (NNTp) one death of 14 (8 to 48). Hospital admission was also lower with MMF (1.7% versus 15%; NNTp 7.4 [4.8 to 16]). Serious infections, leucopaenia, amenorrhoea, and hair loss were all significantly less frequent with MMF than with cyclophosphamide, but diarrhoea was significantly more common with MMF. Ten of 18 cohort studies enrolled only patients with lupus nephritis (author-defined or WHO class III to V). Seven of these 10 reported that complete or partial response with MMF (mostly 1 or 2 g daily) with steroid occurred in 121/151 (80%) and that treatment failure or no response occurred in 30/151 (20%). Adverse events were generally similar in cohort studies with and without only patients with lupus nephritis. In all 18 cohorts, gastrointestinal adverse events (diarrhoea, nausea, vomiting) occurred in 30%, infection in 23%, and serious infection in 4.3%. Adverse event discontinuations occurred in 14% and lack of efficacy occurred in 10%. There was a single death with MMF, a mortality rate over the course of 1 year of approximately 0.2%. The results form a basis on which to plan future studies and provide a guide for the use of MMF in lupus nephritis until results of larger studies are available. At least one such study is under way.

Mycophenolate mofetil or intravenous cyclophosphamide for lupus nephritis

BACKGROUND

Since anecdotal series and small, prospective, controlled trials suggest that mycophenolate mofetil may be effective for treating lupus nephritis, larger trials are desirable.

METHODS

We conducted a 24-week randomized, open-label, noninferiority trial comparing oral mycophenolate mofetil (initial dose, 1000 mg per day, increased to 3000 mg per day) with monthly intravenous cyclophosphamide (0.5 g per square meter of body-surface area, increased to 1.0 g per square meter) as induction therapy for active lupus nephritis. A change to the alternative regimen was allowed at 12 weeks in patients who did not have an early response. The study protocol specified adjunctive care and the use and tapering of corticosteroids. The primary end point was complete remission at 24 weeks (normalization of abnormal renal measurements and maintenance of baseline normal measurements). A secondary end point was partial remission at 24 weeks.

RESULTS

Of 140 patients recruited, 71 were randomly assigned to receive mycophenolate mofetil and 69 were randomly assigned to receive cyclophosphamide. At 12 weeks, 56 patients receiving mycophenolate mofetil and 42 receiving cyclophosphamide had satisfactory early responses. In the intention-to-treat analysis, 16 of the 71 patients (22.5 percent) receiving mycophenolate mofetil and 4 of the 69 patients receiving cyclophosphamide (5.8 percent) had complete remission, for an absolute difference of 16.7 percentage points (95 percent confidence interval, 5.6 to 27.9 percentage points; P=0.005), meeting the prespecified criteria for noninferiority and demonstrating the superiority of mycophenolate mofetil to cyclophosphamide. Partial remission occurred in 21 of the 71 patients (29.6 percent) and 17 of the 69 patients (24.6 percent), respectively (P=0.51). Three patients assigned to cyclophosphamide died, two during protocol therapy. Fewer severe infections and hospitalizations but more diarrhea occurred among those receiving mycophenolate.

CONCLUSIONS

In this 24-week trial, mycophenolate mofetil was more effective than intravenous cyclophosphamide in inducing remission of lupus nephritis and had a more favorable safety profile.

Use of Mycophenolate Mofetil in Autoimmune and Renal Diseases

Progress in understanding the pathogenesis and treatment of rheumatologic and glomerular diseases such as systemic lupus erythematosus and particularly lupus nephritis has been closely linked with the development of newer immunosuppressive agents. With improved patient survival following the institution of cyclophosphamide and corticosteroid therapy, longer-term management issues came to the forefront, especially how to decrease adverse effects of the immunosuppressive regimen. Many of the immunosuppressive regimens used in lupus patients were first established as efficacious and safe through their use in solid organ transplantation. Mycophenolate mofetil (MMF) is now widely used in the field of transplantation. Following anecdotal reports describing benefits of MMF in lupus and lupus nephritis patients, small studies and finally large randomized, controlled trials have established the use of MMF in these patients, particularly those with lupus nephritis. MMF use in other rheumatologic and renal diseases has been evaluated in only smaller studies and very few randomized controlled trials. Nevertheless, many studies currently are ongoing with this immunosuppressive agent. This article will review the published data and the experience of two major New York medical centers with the use of MMF in autoimmune and renal diseases.

Treatment for lupus nephritis: a revisit

The optimal treatment of severe lupus nephritis remains unclear. Regimens consisting of steroid and cyclophosphamide (CYC) appear to be most effective. Infection and gonadal toxicity is a major concern of CYC use in patients of reproductive age. In addition, failure to respond or refractory to CYC treatment may lead to the development of end-stage renal disease. Mycophenolate mofetil (MMF) is a new immunosuppressive agent that selectively inhibits activated lymphocytes and renal mesangial cells. Data from experimental lupus nephritis and controlled studies, albeit small and lacking statistical power, have revealed that MMF is as effective in lupus patients as CYC in the induction of renal remission or as maintenance therapy to reduce renal flare in the short term. The significantly less ovarian toxicity and infection when compared to CYC are particularly attractive for the consideration of MMF in lupus nephritis. The potential of other new therapeutic agents is discussed together with the need for patient recruitment in future trials of lupus nephritis to address the importance of ethnicity as well as histological grading.

Mycophenolate mofetil in lupus nephritis

There is an increasing body of literature suggesting the efficacy and tolerability of mycophenolate mofetil (MMF) for the treatment of lupus nephritis. The rationale for its use is based upon its successful profile as an immunosuppressive agent for prevention of allograft rejection, as well as studies in murine models of lupus which have reported improved renal function and animal survival compared to placebo. This report reviews the data regarding MMF therapy in murine lupus models, and describes the initial anecdotal experience with MMF in human lupus, especially in patients with glomerulonephritis who were unresponsive to corticosteroids and cyclophosphamide, or who had unacceptable toxicity on this standard of care regimen. The results of several nonblinded, controlled clinical trials are also described, in which MMF was compared to intravenous or oral cyclophosphamide in patients with lupus nephritis. MMF was found to be well tolerated, with most studies showing fewer infections than that associated with cyclophosphamide. Efficacy of MMF was at least equivalent to cyclophosphamide, and therefore appears to provide an alternative as a standard of care for induction and maintenance treatment of lupus nephritis.

Newer Therapeutic Approaches for Systemic Lupus Erythematosus

In recent years, advances in the treatment of systemic lupus erythematosus (SLE) refractory to conventional therapy have been suggested in anecdotal series and some clinical trials. A number of promising agents have been studied only in murine models of SLE, and clinical trials are awaited. Rigorously conducted clinical trials must be completed to advance these studies to the point that new therapies for SLE will be approved.

The Use of Systemic Immune Moderators in Dermatology: An Update

In addition to corticosteroids, dermatologists have access to an array of immunomodulatory therapies. Azathioprine, cyclophosphamide, methotrexate, cyclosporine, and mycophenolate mofetil are the systemic immunosuppressive agents most commonly used by dermatologists. In addition, new developments in biotechnology have spurred the development of immunobiologic agents that are able to target the immunologic process of many inflammatory disorders at specific points along the inflammatory cascade. Alefacept, efalizumab, etanercept, and infliximab are the immunobiologic agents that are currently the most well known and most commonly used by dermatologists. This article reviews the pharmacology, mechanism of action, side effects, and clinical applications of these therapies.