Mycophenolate mofetil for lupus nephritis: an update

Abstract

Renal disease in systemic lupus erythematosus carries significant morbidity and mortality. Intensive immunosuppression to dampen kidney inflammation timely and maintenance therapy to prevent renal flares is necessary to reduce the long-term risk of renal failure. Mycophenolate mofetil (MMF) has emerged to be the first-line treatment of lupus nephritis for its better safety profile compared with cyclophosphamide. In controlled trials, MMF is non-inferior to cyclophosphamide for induction therapy but is superior to azathioprine as maintenance therapy. Although biologics have shown promise in refractory lupus nephritis, combining MMF with a number of novel biological agents does not enhance the therapeutic efficacy. Recently, low-dose combination of MMF and tacrolimus has been shown to be more efficacious than intravenous pulse cyclophosphamide in inducing remission of lupus nephritis in Chinese patients. Therapeutic monitoring of the serum mycophenolic acid level to enhance the efficacy of MMF in lupus nephritis is being explored.

Keywords:

• biologics
• efficacy
• glomerulonephritis
• lupus
• mycophenolic acid

Financial & competing interests disclosure

The author has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Mycophenolate mofetil (MMF) has become the first-line immunosuppressive agent for induction therapy of lupus nephritis in most localities.

• MMF is not inferior to its more toxic alternative, cyclophosphamide, as induction therapy of lupus nephritis but appears to be more effective than azathioprine in reducing renal flares as maintenance therapy.

• MMF induction/maintenance seems to be safe and effective in the long-term treatment of lupus nephritis.

• Low-dose combination of MMF and tacrolimus is potentially useful for induction therapy of high-risk patients with lupus nephritis, including those with refractory disease.

• Combination of MMF with the novel biological agents is unrevealing so far, but results of ongoing studies in lupus nephritis are eagerly awaited.

• Monitoring of the mycophenolic acid level for MMF dosage titration has potential in enhancing the efficacy of the regimen in lupus nephritis.