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Systemic Immunosuppressant — Bullous Diseases / Autoimmune Dermatoses Pregnancy: ABSOLUTE CONTRAINDICATION — teratogenic; mandatory Pregnancy Prevention Programme (EMA); two forms of contraception required

Mycophenolate Mofetil

Brand names: CellCept, Myfenax

Adult dose

Dose: 500 mg twice daily (starting dose); increase over 2–4 weeks to 1–1.5 g twice daily
Route: Oral
Frequency: Twice daily (with food to reduce GI side effects)
Max: 3 g/day (dermatological use); 1.5 g twice daily commonly used
Steroid-sparing immunosuppressant for pemphigus vulgaris, bullous pemphigoid, dermatomyositis, chronic actinic dermatitis, and severe atopic eczema. Inhibits inosine monophosphate dehydrogenase (IMPDH) — purine synthesis inhibitor selectively affecting lymphocytes. Slow onset 4–8 weeks.

Paediatric dose

Dose: Seek specialist opinion mg/kg
Route: Oral
Frequency: Twice daily
Max: Not established as standard — specialist paediatric dermatology use
Specialist paediatric dermatology use only — consider in severe refractory autoimmune dermatoses

Dose adjustments

Renal

No dose adjustment required in mild-moderate renal impairment; use with caution in severe impairment

Hepatic

Use with caution in severe hepatic impairment

Paediatric weight-based calculator

Specialist paediatric dermatology use only — consider in severe refractory autoimmune dermatoses

Clinical pearls

  • ABSOLUTE CONTRAINDICATION in pregnancy — causes 23% miscarriage rate and major congenital malformations (external ear/facial abnormalities — mycophenolate embryopathy); EMA mandates Pregnancy Prevention Programme
  • Pregnancy Prevention Programme mandatory: two forms of contraception; negative pregnancy test before starting and monthly during treatment
  • Superior GI tolerability with enteric-coated mycophenolate sodium (Myfortic) — consider switching if significant GI side effects
  • PCP prophylaxis (co-trimoxazole) often prescribed with mycophenolate in dermatology for high-dose or combination immunosuppression
  • Pemphigus vulgaris: mycophenolate + prednisolone is standard steroid-sparing regimen after initial disease control with systemic steroids ± rituximab
  • CMV monitoring: check CMV PCR if fever, cytopenias, or GI symptoms develop on mycophenolate

Contraindications

  • Pregnancy — ABSOLUTE CONTRAINDICATION (teratogenic — major malformations, miscarriage)
  • Breastfeeding
  • Hypersensitivity to mycophenolate or mycophenolic acid

Side effects

  • GI disturbance (diarrhoea, nausea — most common; switch to mycophenolate sodium EC for better GI tolerability)
  • Myelosuppression (leucopenia, neutropenia)
  • Increased infection risk (CMV, PCP, fungal)
  • Lymphoma (long-term — similar to azathioprine)
  • Progressive multifocal leukoencephalopathy (PML — rare)

Interactions

  • Antacids — reduce absorption; separate by 2 hours
  • Ciclosporin — reduces mycophenolate levels by inhibiting enterohepatic recirculation
  • Probenecid — increases mycophenolate levels
  • Live vaccines — contraindicated during treatment

Monitoring

  • FBC (weekly for 4 weeks, then every 2 weeks × 2 months, then monthly)
  • Renal function
  • LFTs
  • Pregnancy test (monthly — women of childbearing potential)
  • CMV PCR (if symptoms)

Reference: BNFc; BNF 90; BNFc; EMA Pregnancy Prevention Programme; BAD Pemphigus Guidelines; BAD Bullous Pemphigoid Guidelines 2012 (updated). Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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