180 The Eurasian Journal of Medicine
Mycophenolate Mofetil in the Treatment of Systemic Lupus
Sistemik Lupus Eritematozus Tedavisinde Mikofenolat Mofetil
1Ankara University, School of Medicine, Department of Clinical Immunology and Rheumatology, Ankara, Turkey.
Correspondence to: Ali Sahin, M.D., Ankara University, School of Medicine, Department of Clinical Immunology and Rheumatology, 06100, Sihhiye, An-
kara, Turkey. Phone: +90.312.5082234, Fax: +90.312.3097779, e-mail: firstname.lastname@example.org
Mycophenolate mofetil (MMF) is an immunosuppressive agent that
has been shown to be effective in transplant patients. It is also ef-
ficacious in the management of lupus nephritis and useful in the
treatment of autoimmune conditions because its mechanisms of
action target T- and B- lymphocytes, leading to suppression of the
cell-mediated immune response and antibody formation. MMF has
been used successfully to treat immune-mediated conditions like
myasthenia gravis, autoimmune hepatitis and immune cytopenias.
However, the conditions for its optimal use for non-renal manifesta-
tions (e.g., hematological, neuropsychiatric, myocardial, pulmonary
or cutaneous symptoms) in lupus patients are unclear. There have
yet to be any randomized, controlled trials to guide the optimal dose
and duration of MMF treatment in such situations. MMF is well tole-
rated and safe to use, although there are reports of serious adverse
effects including urticaria, myopathy, Epstein-Barr virus-associated B-
cell lymphoma, cytomegalovirus infection and disseminated varicella
zoster infection. Immunosuppressive treatment with MMF and sup-
portive care over the past few decades have led to improved clinical
outcomes in patients with severe lupus nephritis. A favorable long-
term prognosis can be ensured provided that effective treatment
is instituted early, before irreversible renal parenchymal damage oc-
curs. Another area of concern for patients is the increased cost of
long-term MMF use.
Mikofenolat mofetil (MMF) transplant hastalarında etkinliği göste-
rilmiş bir immünsüpresif ajandır. Lupus nefriti ve diğer otoimmün
hastalıkların tedavisinde; T ve B lenfositleri hedef alan etki mekaniz-
masına bağlı olarak, hücresel immün yanıtı ve antikor oluşumunu
baskılayarak, etkinliği gösterilmiştir. Myastenia gravis, otoimmün
hepatit, immün sitopeniler gibi otoimmün hastalıklarda başarıyla
kullanılmaktadır. Fakat, lupus hastalarında böbrek dışı tutulumlar-
da (hematolojik, nöropsikiyatrik, miyokardiyal, pulmoner, kütanöz
vb.) optimal kullanımı kesinlik kazanmamıştır. Bu durumlarda kul-
lanımında optimal doz ve süreye dair yol gösterici randomize kont-
rollü çalışma henüz bulunmamaktadır. MMF iyi tolere edilmekte ve
kullanımı güvenli olmasına rağmen; ürtiker, miyopati, Epstein-Barr
virüs ilişkili B-hücreli lenfoma, sitomegalovirüs enfeksiyonları ve dis-
semine varisella zoster gibi birtakım yan etkiler bildirilmiştir. Ciddi
lupus nefritli hastalarda MMF ile immünsüpresif tedavi ve destek
bakımı sayesinde son yıllarda klinik sonuçlarda iyileşme sağlanmıştır.
İrreversibl renal parankimal hasar oluşmadan önce etkin tedavinin
başlanması halinde uzun dönem prognoz daha iyi olabilir. MMF’in
uzun süreli kullanımında hastalar için önemli olan bir diğer noktada
Keywords: Systemic lupus erythematosus, Mycophenolate mofetil, Treat-
Anahtar Kelimeler: Sistemik lupus eritematozus, Mikofenolat mofetil,
181 EAJM: 41, December 2009
ycophenolate mofetil (MMF), a mycophenolic acid
(MPA) prodrug, depletes guanosine nucleotides through
the inhibition of inosine-5’-monophosphate dehydroge-
nase (IMPDH), acting preferentially on T- and B-lymphocytes .
IMPDH is the rate-limiting enzyme in the de novo synthesis of
guanosine nucleotides, and T- and B-lymphocytes depend on this
pathway more than other cell types. MPA is also a more potent
inhibitor of the type II isoform of IMPDH, which is expressed
in activated lymphocytes, than of the type I isoform of IMPDH,
which is expressed in most other cell types . Therefore, MPA
exerts a more potent cytostatic effect on lymphocytes than on
other cell types. This is the main mechanism by which MPA sup-
presses the cell-mediated immune response and antibody for-
mation. Additionally, MPA also inhibits the glycosylation and ex-
pression of adhesion molecules and hinders the recruitment of
lymphocytes and monocytes into sites of inflammation . The
production of nitric oxide (NO) by inducible NO synthase (iNOS)
is also decreased, without affecting the activity of constitutive
NO synthases. This effect is mediated by MPA through the deple-
tion of tetrahydrobiopterin, a cofactor of the inducible form of
iNOS. Through these mechanisms, MMF exerts anti-inflammatory
and immunosuppressive activities.
In contrast to calcineurin inhibitors, MMF is not nephrotoxic.
It does not induce the production of transforming growth factor
(TGF)-χ, a cytokine that is fibrogenic. Additionally, MMF has no
adverse effects on blood pressure, cholesterol levels or triglycer-
ide levels in recipients. It was also noted that MPA is not muta-
genic and inhibits the proliferation of human B-lymphocytes that
are transformed by Epstein-Barr virus. MPA also suppresses the
proliferation of human arterial smooth muscle cells. These two
properties of MPA may decrease the risk of lymphoma develop-
ment and proliferative arteriopathy in recipients of MMF . Analy-
ses of clinical trials show that MMF reduces the incidence of early
and late rejection, is protective against long-term deterioration of
renal function, and reduces late renal allograft loss independently
of acute rejection and without increasing the risk for malignan-
cies . Apart from renal transplants, MMF has also been found
to be useful in the management of pancreatic, hepatic and car-
diac transplants [5-9].
MMF is a suppressor of both T- and B-cell lymphocyte pro-
liferation and has been used successfully for the prevention of
acute and chronic rejection of renal allografts [10-13]. MMF has
a selective antiproliferative effect on lymphocytes and inhibits
antibody production by B-lymphocytes. MMF also induces de-
oxyguanosine nucleotide depletion and inhibits the transfer of
fucose and mannose to glycoproteins including glycoprotein ad-
hesion molecules. In view of the functions of adhesion molecules
(facilitating the attachment of leukocytes to endothelial cells,
playing a role in the initial interaction between leukocytes and
endothelial cells, and involvement in the interactions between
antigen-presenting cells and lymphocytes as well as effector lym-
phocytes and target cells), MMF should reduce the inflammatory
process in its early stages.
At higher concentrations, which may be reached in the clini-
cal setting, MMF has effects on cells that are unrelated to the
immune system. It has an antiproliferative effect on vascular
smooth muscle cells, even when pro-proliferative stimuli (e.g., an-
giotensin II and TGF-χ) are present. This effect is not shared by
other immunosuppressive drugs such as cyclosporine or tacroli-
mus. This antiproliferative effect on vascular smooth muscle cells
may be of relevance concerning the effect of MMF on chronic
allograft dysfunction. Because some glomerulopathies are associ-
ated with vascular lesions and microthrombus formation, which
resemble vascular rejection, MMF might be of use in advanced
stages of chronic glomerulopathies. Other documented chronic
activities of MMF include reduction of glomerular hypertrophy
and hyperfiltration, reduction of myofibroblast formation and col-
lagen III deposition and reduction of tubular cell proliferation and
interstitial fibrosis [10-14].
T- and B-lymphocytes are involved in the pathogenesis of
Fig. 1 _ Treatment algorithm for diffuse proliferative lupus nephritis. *:
Prior serious toxicities due to CYC, severe cytopenia, patient reluctance, etc.
#: Alternative treatments including MMF and cyclosporine, A: immunoad-
sorption, intravenous immunoglobulin, AZA: azathioprine, MP: methylpred-
nisolone, CYC: cyclophosphamide, MMF: mycophenolate mofetil .
182 EAJM: 41, December 2009
autoimmune conditions. Hence, interference with their function
or proliferation will be beneficial for the management of these
conditions. Suppression of the cell-mediated immune response
and antibody production are key elements in the successful treat-
ment of many immune-mediated conditions. Therefore, MMF has
a role to play in the management of such conditions. MMF has
been a useful drug in the treatment of recurrent glomerulone-
phritis in allografts and all forms of primary glomerulonephritides,
especially nephrotic syndrome, lupus nephritis and vasculitis.
Zandman-Goddard and Shoenfeld reviewed the evidence
for the contribution of MMF in autoimmunity in animal models
of systemic lupus erythematosus (SLE), mercury-induced auto-
immune glomerulonephritis, diabetes mellitus, experimental
autoimmune uveoretinitis and experimental allergic encephalitis
. Clinically, MMF has been used as a monotherapy or adjunct
therapy for myasthenia gravis [16-17], chronic immune demye-
linating polyneuropathy , chronic autoimmune hepatitis [19-
20], immune cytopenias [21-23], autoimmune inflammatory my-
opathy , psoriatic arthritis , non-lupus glomerulopathies
(IgA nephropathy, membranous nephropathy, focal segmental
glomerulosclerosis, membranoproliferative glomerulonephritis
or hepatitis C-associated glomerulonephritis) , autoimmune
HCV-associated hematological disorders , systemic vasculitis
 and inflammatory skin diseases (pemphigus vulgaris, pem-
phigus foliaceus and bullous pemphigoid) .
Treatment of Non-renal Manifestations of SLE:
A. Hematological Manifestations
Hematological manifestations are common among lupus pa-
tients [30-32], and immune leukopenia, thrombocytopenia and
hemolytic anemia are commonly encountered in the clinic. Most
of these lupus-related cytopenias respond well to higher doses
of corticosteroids or immunosuppressive drugs. Patients with re-
fractory immune cytopenias are uncommon, but very high doses
of corticosteroids and/or immunosuppressive agents are often
necessary to control the disease. Therapy-related complications
(for example, avascular necrosis associated with long-term high-
dose corticosteroids or recurrent infections associated with high-
dose cytotoxic drugs) have become significant issues that need
to be addressed. In 2003, Vasoo et al. reported the successful
use of MMF in the treatment of a lupus patient with refractory
thrombocytopenia . Prior treatment with high-dose cortico-
steroids, pulse methylprednisolone and intravenous immunoglo-
bulin therapy had failed. The patient’s platelet counts returned to
normal when MMF was instituted into the drug regimen. More
recently, Chang  described another successful outcome with
lupus-related refractory thrombocytopenia. Alba  and Mak
et al.  have reported the use of MMF to treat lupus patients
with hemolytic anemia refractory to conventional treatment and
observed good responses. In the rare occurrence of pure red-cell
aplasia in a lupus patient, a successful outcome was obtained
with the administration of cyclosporine and MMF . These
cases represent a small series of successfully treated patients, but
their promising outcomes give us an insight into the usefulness
of MMF as a second- or third-line therapy for lupus patients with
refractory immune cytopenias.
B. Neuropsychiatric Manifestations
Neuropsychiatric abnormalities, ranging from psychosis to
cognitive deficits, occur frequently in lupus patients with active
disease. Frequently, the severity of the neurological involvement
requires chronic administration of high doses of corticosteroids
and/or cytotoxic drugs, with their attendant complications. How-
ever, there are no randomized controlled trials assessing the ef-
ficacy of MMF in such lupus patients reported to date. Most of
the relevant literature consists of anectodal reports. Jose and
co-workers successfully treated and maintained a lupus patient
with psychotic manifestations with MMF . Another reported
success involved a case of cerebral vasculitis in a patient with
hereditary complete C4 deficiency and SLE. She was treated with
a combination of immunoadsorption and MMF . Additionally,
Mok et al. have reported their preliminary experience with MMF
in the treatment of a patient with a lupus-related myelopathy in
the spinal cord .
C. Myocardial and Pulmonary Manifestations
Pericarditis and serositis (e.g., pleurisy) occur in lupus pa-
tients and are usually treated adequately with corticosteroids.
However, more serious involvements, such as myocarditis with
pulmonary hemorrhage, are uncommon but can be fatal. Treat-
ment of severe lupus-related pulmonary hemorrhage is often dif-
ficult. Samad reported on the use of MMF to treat a patient
with childhood SLE with recurrent pulmonary hemorrhage .
Regarding another pulmonary disorder, Swigris and co-workers
performed a retrospective survey of 28 patients with connective
tissue-related interstitial lung disease, one of whom had SLE, and
found that MMF preserves lung function and is safe and well
tolerated . In animal studies, MMF has been shown to pre-
vent the development of experimental autoimmune myocarditis
. Hence, MMF may be useful in the management of lupus-
related myocarditis. In a review of 12 lupus-related hemophago-
cytic syndrome patients with high prevalance of pericarditis and/
or myocarditis. MMF was successfully used as an adjunct in the
long-term treatment regimens for two of the patients .
D. Cutaneous Manifestations
Cutaneous lesions are common manifestations in lupus pa-
tients, and discoid rashes often lead to scarring of the involved
skin. In 2001, Goyal reported the successful treatment of recalci-
trant palmoplantar lesions in two lupus patients , and a year
later, Schanz described the resolution of extensive and refractory
subacute cutaneous lupus erythematosus with MMF in another
two patients. These patients had unfortunately developed severe
complications while on high-dose corticosteroid therapy .
Mycophenolate Mofetil and SLE
183 EAJM: 41, December 2009
1. McMurray RW, Harisdangkul V. Mycopheno-
late mofetil: selective T cell inhibition. Am J
Med Sci 2002; 323: 94-6.
2. Allison AC, Eugui EM. Mycophenolate
mofetil and in mechanisms of action. Immu-
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Lang P , Pardon A, Audard V. Long-term ben-4.
Conflict interest statement The authors declare that they have no conflict of interest to the publication of this article.
Hanjani and Nousari expanded the use of MMF for the treat-
ment of four lupus patients with cutaneous lupus (lupus tumi-
dus, lupus panniculitis, discoid LE with perniosis and subacute LE)
. These reports collectively testify to the promise that MMF
holds for the treatment of lupus-related cutaneous manifesta-
tions. However, Pisoni recently reported poor results from the
use of MMF to treat refractory cutaneous lesions. Of the seven
patients with SLE and refractory skin involvement (including
acute cutaneous lupus, subacute cutaneous lupus, discoid lupus
erythematosus, vasculitis, urticarial rash and chilblain lupus), five
did not respond, one demonstrated only a partial response and
one showed an initial response, with subsequent relapse while
still on MMF . Hence, the usefulness of MMF in the manage-
ment of lupus with refractory cutaneous involvement is yet to be
E. Treatment Strategies
MMF seems to have promise as a second- or third-line agent
for the treatment of refractory non-renal lupus manifestations.
It is relatively well tolerated [49-51], safe to use and shows no
nephrotoxicity or adverse effects on blood pressure, cholesterol
levels or triglyceride levels. It is not associated with significant risk
of ovarian toxicity. Despite its clinical safety and relatively mild,
common side-effects, such as nausea, vomiting and diarrhea,
there are other concerns associated with MMF use. Urticaria
, myopathy , Epstein-Barr virus-associated B-cell lympho-
ma , cytomegalovirus (CMV) infections [55,56] and dissemi-
nated varicella zoster infections [57,58] have been reported.
Anectodal reports of the successful treatment of refractory
non-renal lupus manifestations cannot allow us to definitively
determine the optimal dose or duration of treatment. Hence,
the lack of randomized, double-blind controlled trials presents
a drawback in the effort to optimize the use of MMF in such
situations. In the renal setting, the Tricontinental Mycophenolate
Mofetil Renal Transplantation Study Group  determined that
a dosage of 2-3 g of MMF daily is efficacious and that the lower,
2-g daily dose regimen is associated with fewer side effects and
CMV infections. Another drawback to the wide use of MMF is
the high cost of the drug. Its cost can sometimes be prohibitive,
especially to those not covered by comprehensive medical insur-
ance and those residing in developing countries.
Lupus Nephritis Treatment
The management of severe proliferative lupus nephritis can
be divided into an initial induction phase followed by a prolonged
maintenance phase (Figure 1). Immunosuppressive treatment
during the two phases has the respective aims of achieving re-
mission and preventing relapse. Immunosuppressive medications,
tailored according to disease activity, remain the mainstay of
treatment for severe lupus nephritis. Commonly adopted treat-
ment regimens include combinations of corticosteroids and anti-
proliferative agents, such as cyclophosphamide, azathioprine or
The role of MMF in improving long-term outcomes of lupus
nephritis patients remains unknown. An ongoing, large-scale mul-
ticenter randomized controlled trial will determine the effective-
ness of MMF compared to intravenous cyclophosphamide during
the induction stage and MMF compared to azathioprine during
the maintenance phase. The optimal treatment regimen for lupus
nephritis varies according to several factors: class, activity and
chronicity indices and other prognostic factors (Tables 1, 2).
MMF has been widely used to prevent renal allograft rejec-
tion. Many case series and small controlled trials have suggested
the effectiveness of MMF in the treatment of lupus nephritis.
In early trials, cyclophosphamide (CYC) in combination with glu-
cocorticoids (GC) led to improved renal survival compared with
GC therapy alone and achieved lower rates of recurrence. Intra-
venous CYC became preferred over oral CYC due to perceived
lower levels of toxicity (i.e., increased risk of infection, ovarian
failure, reversible alopecia and bladder toxicity, particularly with
the use of pre-treatment hydration).
Subsequent studies have shown that a longer duration of
therapy during the maintenance phase improved remission rates
. A recent randomized, open-label, non-inferiority trial sup-
ports the notion that MMF is as effective as intravenous CYC in
inducing short-term remission of lupus nephritis with a better
safety profile . Regarding the management of lupus nephri-
tis, the role of MMF and its safety profile and cost-effectiveness
have been analyzed in several clinical trials by different groups
The issues of optimal dose, duration of treatment and cost-
effectiveness of MMF can only be adequately addressed with
randomized, controlled trials. Advances in immunosuppression
and supportive care over the past few decades have led to imp-
roved clinical outcomes in patients with severe lupus nephritis,
with increased efficacy and fewer complications. However, based
on anectodal reports, MMF is a useful addition to the armamen-
tarium available for treatment of lupus patients with refractory
non-renal manifestations. Another drawback to the wide use of
MMF is the high cost of the drug. Its cost can sometimes be pro-
hibitive, especially to those not covered by comprehensive medi-
cal insurance and those residing in developing countries.
184 EAJM: 41, December 2009
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