CHICAGO — Mycophenolate mofetil may be eclipsing cyclophosphamide as the standard-of-care induction therapy for lupus nephritis, Jill P. Buyon, M.D., reported at a symposium sponsored by the American College of Rheumatology.
Although the role of mycophenolate mofetil (MMF) in maintenance therapy still needs to be defined, the immunosuppressive agent has generated a lot of excitement, she said.
“In patients who don't have rapidly escalating renal insufficiency and whose creatinines are less than 2, there is little question at this point in time that I would suggest MMF over IV Cytoxan [cyclophosphamide],” she said. “I think it's better tolerated.”
She cited results from the largest open-label, controlled study, led by Ellen M. Ginzler, M.D., of the State University of New York Downstate Medical Center, Brooklyn. In that investigation, Dr. Ginzler and colleagues randomly assigned 140 patients with class III, VI, or V lupus nephritis to MMF, starting at 1 g/day and escalating to 3 g, as tolerated, or to intravenous cyclophosphamide, dosed according to National Institutes of Health protocols. The treatment period was 24 weeks.
In all, 16 of the 71 patients initially assigned to the MMF group achieved complete remission of their nephritis, defined as normal serum creatinine level, inactive urine sediment, and proteinuria less than or equal to 500 mg/24 hours. By comparison, 4 of the 69 patients initially assigned to the cyclophosphamide group achieved this primary end point (Arthritis Rheum. 2003;48[9 suppl.]:S647[abstract 1690]).
MMF was well tolerated and appeared better accepted by participants than cyclophosphamide.
“This study has really changed the way I manage patients,” said Dr. Buyon, of the Hospital for Joint Diseases and professor of medicine at New York University. “I certainly call this to my patients' attention, and many, many patients prefer using MMF.”
Dr. Buyon starts patients on MMF 500 mg twice daily, titrating to a target dose of 3 g/day. Some patients may not be able to achieve the target dose because of GI intolerance.
All patients started on MMF also receive prednisone at approximately 60 mg daily, which is reduced over the course of 2-3 months to between 5 mg/day and 10 mg/day.
Dr. Buyon added that she also switches patients induced with cyclophosphamide to MMF if they are doing well at 6 months.