Mycophenolate Mofetil is indicated in combination with ciclosporin and corticosteroids for the prophylaxis of acute transplant rejection in patients receiving allogeneic renal, cardiac or hepatic transplants.

Treatment with Mycophenolate Mofetil should be initiated and maintained by appropriately qualified transplant specialists.

 

Use in renal transplant:

 

Adults: oral Mycophenolate Mofetilshould be initiated within 72 hours following transplantation. The recommended dose in renal transplant patients is 1 g administered   twice

 

daily (2 g daily dose).

 

Children and adolescents (aged 2 to 18 years): the recommended dose of mycophenolate mofetil is 600 mg/m2 administered orally twice daily (up to a maximum of 2 g  daily).

Mycophenolate mofetil 500 mg tablets should only be prescribed to patients with a body surface area greater than 1.5 m2, at a dose of 1 g twice daily (2 g daily dose). As some  adverse 

reactions occur with greater frequency in this age group (see section 4.8) compared with adults, temporary dose reduction or interruption may be required; these will need to take into account relevant clinical factors including severity of  reaction.

 

Children (< 2 years): there are limited safety and efficacy data in children below the age of 2 years. These are insufficient to make dosage recommendations and therefore use in this age group is not recommended.

 

 

Use in cardiac transplant:

 

Adults: oral Mycophenolate Mofetilshould be initiated within 5 days following transplantation. The recommended dose in cardiac transplant patients is 1.5 g administered twice daily (3 g daily dose).

 

Children: no data are available for pediatric cardiac transplant  patients.

 

 

Use in hepatic transplant:

 

Adults: Intravenous Mycophenolate should be administered for the first 4 days following hepatic transplant, with oral Mycophenolate Mofetilinitiated as soon after this as it can be tolerated. The recommended oral dose in hepatic transplant patients is 1.5 g administered twice daily (3 g daily dose).

 

Children: no data are available for pediatric hepatic transplant  patients.

 

                                          : the recommended dose of 1 g administered twice a day  for renal transplant patients and 1.5 g twice a day for cardiac or hepatic transplant patients is appropriate for the elderly.

 

Use in renal impairment: in renal transplant patients with severe chronic renal impairment (glomerular filtration rate < 25 ml/min/1.73 m2), outside the immediate post-transplant period, doses greater than 1 g administered twice a day should be avoided. These patients should also be carefully observed.

No dose adjustments are needed in patients experiencing delayed renal graft function post- operatively (see section 5.2). No data are available for cardiac or hepatic transplant patients with severe chronic renal impairment.

 

Use in severe hepatic impairment: no dose adjustments are needed for renal transplant patients with severe hepatic parenchymal disease. No data are available for cardiac transplant patients with severe hepatic parenchymal disease.

 

Treatment during rejection episodes: MPA (mycophenolic acid) is the active metabolite of mycophenolate mofetil. Renal transplant rejection does not lead to changes in MPA pharmacokinetics; dosage reduction or interruption of Mycophenolate Mofetilis not required. There is no basis for Mycophenolate Mofetildose adjustment following cardiac transplant rejection. No pharmacokinetic data are available during hepatic transplant  rejection.

Hypersensitivity reactions to mycophenolate mofetil have been observed (see section 4.8). Therefore, Mycophenolate Mofetilis contraindicated in patients with a hypersensitivity to mycophenolate mofetil or mycophenolic acid. Mycophenolate Mofetilis contraindicated in women who are breastfeeding (see section 4.6). For information on use in pregnancy and contraceptive requirements see section 4.6.

products, including mycophenolate, are at increased risk of developing lymphomas and other malignancies, particularly of the skin (see section 4.8). The risk appears to be related to the intensity and duration of immunosuppression rather than to the use of any specific agent. As general advice to minimize the risk for skin cancer, exposure to sunlight and UV light should be limited by wearing protective clothing and using a sunscreen with a high protection  factor.

 

Patients receiving mycophenolate should be instructed to report immediately any evidence of infection, unexpected bruising, bleeding or any other manifestation of bone marrow depression.

 

Patients treated with immunosuppressants, including mycophenolate mofetil, are at increased risk for opportunistic infections (bacterial, fungal, viral and protozoal), fatal infections and sepsis (see section 4.8). Among the opportunistic infections are BK virus associated nephropathy and JC virus associated progressive multifocal leukoencephalopathy  (PML).

These infections are often related to a high total immunosuppressive burden and may lead to serious or fatal conditions that physicians should consider in the differential diagnosis in immunosuppressed  patients with deteriorating renal function or neurological symptoms.

 

Patients receiving mycophenolate should be monitored for neutropenia, which may be related to mycophenolate itself, concomitant medications, viral infections, or some combination of these causes. Patients taking mycophenolate should have complete blood counts  weekly  during the first month, twice monthly for the second and third months of treatment, then monthly through the first year. If neutropenia develops (absolute neutrophil count < 1.3 x 103/µl) it may be appropriate to interrupt or discontinue  mycophenolate.

 

Cases of pure red cell aplasia (PRCA) have been reported in patients treated with mycophenolate mofetil in combination with other immunosuppressants. The mechanism for mycophenolate  mofetil induced PRCA is unknown. PRCA may resolve with dose reduction  or cessation of mycophenolate therapy. Changes to mycophenolate therapy should only be undertaken under appropriate supervision in transplant recipients in order to minimise the risk of graft rejection (see section 4.8).

 

Patients should be advised that during treatment with mycophenolate vaccinations may be less effective, and the use of live attenuated vaccines should be avoided (see section  4.5).

Influenza vaccination may be of value. Prescribers should refer to national guidelines for influenza vaccination.

 

Because mycophenolate has been associated with an increased incidence of digestive system adverse events, including infrequent cases of gastrointestinal tract ulceration, haemorrhage and perforation, mycophenolate should be administered with caution in patients with active serious digestive system disease.

 

Mycophenolate is an IMPDH (inosine monophosphate dehydrogenase) inhibitor. On theoretical grounds, therefore, it should be avoided in patients with rare hereditary deficiency of hypoxanthine-guanine phosphoribosyl-transferase (HGPRT) such as Lesch-Nyhan and Kelley-Seegmiller syndrome.

 

It is recommended that mycophenolate not be administered concomitantly with azathioprine because such concomitant administration has not been  studied.

 

In view of the significant reduction in the AUC of MPA by colestyramine, caution should be used in the concomitant administration of mycophenolate with medicinal products that interfere with enterohepatic recirculation because of the potential to reduce the efficacy of mycophenolate.

 

The risk: benefit of mycophenolate mofetil in combination with tacrolimus or sirolimus has not been established (see also section 4.5).

Interaction studies have only been performed in adults.

 

Aciclovir: higher aciclovir plasma concentrations were observed when mycophenolate mofetil was administered with aciclovir in comparison to the administration of aciclovir alone.   The  changes in MPAG (the phenolic glucuronide of MPA) pharmacokinetics (MPAG increased by 8%) were minimal and are not considered clinically significant. Because MPAG plasma concentrations are increased in the presence of renal impairment, as are aciclovir concentrations, the potential exists for mycophenolate mofetil and aciclovir, or its   prodrugs,

e.g. valaciclovir, to compete for tubular secretion and further increases in concentrations of both substances may occur.

 

Antacids with magnesium and aluminium hydroxides: absorption of mycophenolate mofetil was decreased when administered with antacids.

 

Proton pump inhibitors: concomitant use of mycophenolate mofetil and proton pump inhibitors may significantly reduce MPA plasma  concentrations.

 

Colestyramine: following single dose administration of 1.5 g of mycophenolate mofetil to normal healthy subjects pre-treated with 4 g TID (three times a day) of colestyramine for 4 days, there was a 40% reduction in the AUC of MPA (see section 4.4, and section  5.2).

Caution should be used during concomitant administration because of the potential to reduce efficacy of mycophenolate mofetil.

 

Medicinal products that interfere with enterohepatic circulation: caution should be used with medicinal products that interfere with enterohepatic circulation because of their potential to reduce the efficacy of mycophenolate mofetil.

 

Ciclosporin A: ciclosporin A (CsA) pharmacokinetics are unaffected by mycophenolate  mofetil. In contrast, if concomitant ciclosporin treatment is stopped, an increase in MPA AUC of around 30% should be expected.

 

Ganciclovir: based on the results of a single dose administration study of recommended doses   of oral mycophenolate and IV ganciclovir and the known effects of renal impairment on the pharmacokinetics of mycophenolate (see section 4.2) and ganciclovir, it is anticipated that co- administration of these agents (which compete for mechanisms of renal tubular secretion) will result in increases in MPAG and ganciclovir concentration. No substantial alteration of MPA pharmacokinetics is anticipated and mycophenolate dose adjustment is not required. In patients with renal impairment in which mycophenolate and ganciclovir or its prodrugs, e.g. valganciclovir, are co-administered the dose recommendations for ganciclovir should be observed and patients monitored carefully.

 

Oral contraceptives: the pharmacokinetics and pharmacodynamics of oral contraceptives were unaffected by coadministration of mycophenolate (see also section  5.2).

 

Rifampicin: in patients not also taking ciclosporin, concomitant administration of mycophenolate mofetil and rifampicin resulted in a decrease in MPA exposure (AUC0-12h)   of 18% to 70%. It is recommended to monitor MPA exposure levels and to adjust mycophenolate mofetil doses accordingly to maintain clinical efficacy when rifampicin is administered concomitantly.

 

Sirolimus: in renal transplant patients, concomitant administration of mycophenolate mofetil and CsA resulted in reduced MPA exposures by 30-50% compared with patients receiving the combination of sirolimus and similar doses of mycophenolate mofetil (see also section   4.4).

 

Sevelamer: decrease in MPA Cmax and AUC0-12 by 30% and 25%, respectively, were observed when mycophenolate mofetil was concomitantly administered with sevelamer without any clinical consequences (i.e. graft rejection). It is recommended, however, to administer mycophenolate mofetil at least one hour before or three hours after sevelamer intake to minimise the impact on the absorption of MPA. There is no data on mycophenolate mofetil with phosphate binders other than sevelamer.

 

Trimethoprim/sulfamethoxazole:  no effect on the bioavailability of MPA was observed.

 

Norfloxacin and metronidazole: in healthy volunteers, no significant interaction was observed when mycophenolate mofetil was concomitantly administered with norfloxacin and metronidazole separately. However, norfloxacin and metronidazole combined reduced the MPA exposure by approximately 30% following a single dose of mycophenolate  mofetil.

 

Ciprofloxacin and amoxicillin plus clavulanic acid: Reductions in pre-dose (trough) MPA concentrations of about 50% have been reported in renal transplant recipients in the days immediately following commencement of oral ciprofloxacin or  amoxicillin  plus  clavulanic  acid. This effect tended to diminish with continued  antibiotic  use and to cease  within  a few  days of their discontinuation. The change in predose level  may  not  accurately  represent  changes in overall MPA exposure. Therefore, a change in the dose of mycophenolate mofetil should not normally be necessary in the absence of clinical evidence of graft dysfunction. However, close clinical monitoring should be performed during  the combination  and shortly  after antibiotic treatment.

 

Tacrolimus: in hepatic transplant patients initiated on mycophenolate mofetil and tacrolimus, the AUC and Cmax of MPA, the active metabolite of mycophenolate mofetil, were not significantly affected by coadministration  with tacrolimus. In contrast, there was an increase  of approximately 20% in tacrolimus AUC when multiple doses of mycophenolate mofetil (1.5  g BID) were administered to patients taking tacrolimus. However, in renal transplant patients, tacrolimus concentration did not appear to be altered by mycophenolate mofetil (see also section 4.4).

 

Telmisartan

Concomitant administration of telmisartan and Lamucon resulted in an approximately 30% decrease of MPA concentrations. Telmisartan changes MPA's elimination by enhancing PPAR gamma (peroxisome proliferator-activated receptor gamma) expression, which in turn results in an enhanced UGT1A9 expression and activity. When comparing rates of transplant rejection, rates of graft loss or adverse event profiles between Lamucon patients with and without concomitant telmisartan medication, no clinical consequences of the pharmacokinetic drug-drug interaction were seen.

 

Other interactions: co-administration of probenecid with mycophenolate mofetil in  monkeys raises plasma AUC of MPAG by 3-fold. Thus, other substances known to undergo  renal  tubular secretion may compete with MPAG and thereby raise plasma concentrations of MPAG or the other substance undergoing tubular  secretion.

 

Live vaccines: live vaccines should not be given to patients with an impaired immune response. The antibody response to other vaccines may be diminished (see also section  4.4).

 

(Pregnancy  Category D)

 

It is recommended that mycophenolate therapy should not be initiated until a negative pregnancy test has been obtained. Effective contraception must be used before beginning mycophenolate therapy, during therapy, and for six weeks following discontinuation of  therapy (see section 4.5). Patients should be instructed to consult their physician immediately should pregnancy occur.

 

The use of mycophenolate is not recommended during pregnancy and should be reserved for cases where no more suitable alternative treatment is available. Mycophenolate  should be  used in pregnant women only if the potential benefit outweighs the potential risk to the foetus. There is limited data from the use of mycophenolate in pregnant women. However, congenital malformations including ear malformations, i.e. abnormally formed or absent external/middle ear, have been reported in children of patients exposed to mycophenolate in combination with other immunosuppressants during pregnancy. Cases of spontaneous abortions have been reported in patients exposed to mycophenolate mofetil. Studies in animals have shown reproductive toxicity (see section 5.3).

 

Mycophenolate mofetil has been shown to be excreted in the milk of lactating rats. It is not known whether this substance is excreted in human milk. Because of the potential for serious adverse reactions to mycophenolate mofetil in breast-fed infants, mycophenolate is contraindicated in nursing mothers (see section  4.3).

 

No studies on the effects on the ability to drive and use machines have been performed. The pharmacodynamic profile and the reported adverse reactions indicate that an effect is unlikely.

The following undesirable effects cover adverse reactions from clinical  trials:

The principal adverse reactions  associated  with  the administration  of mycophenolate  mofetil in combination with ciclosporin and corticosteroids include diarrhoea, leucopenia, sepsis and vomiting and there is evidence of a higher frequency of certain types of infections (see section 4.4).

Malignancies:

Patients receiving immunosuppressive regimens involving combinations of medicinal  products, including mycophenolate mofetil, are at increased risk of developing lymphomas   and other malignancies, particularly of the skin (see section 4.4). Lymphoproliferative disease or lymphoma developed in 0.6% of patients receiving mycophenolate mofetil (2 g or 3 g   daily) in combination with other immunosuppressants in controlled clinical trials of renal (2 g data), cardiac and hepatic transplant patients followed for at least 1 year. Non-melanoma skin carcinomas occurred in 3.6% of patients; other types of malignancy occurred in 1.1% of patients. Three-year safety data in renal and cardiac transplant patients did not reveal any unexpected changes in incidence of malignancy compared to the 1-year data. Hepatic transplant patients were followed for at least 1 year, but less than 3  years.

 

Opportunistic infections:

All transplant patients are at increased risk of opportunistic infections; the risk increased with total immunosuppressive load (see section 4.4). The most common opportunistic infections in patients receiving mycophenolate mofetil (2 g or 3 g daily) with other immunosuppressants in controlled clinical trials of renal (2 g data), cardiac and hepatic transplant patients  followed

for at least 1 year were candida mucocutaneous, CMV viraemia/syndrome and Herpes simplex. The proportion of patients with CMV viraemia/syndrome  was 13.5%.

 

Children and adolescents (aged 2 to 18 years):

The type and frequency of adverse reactions in a clinical study, which recruited 92 paediatric patients aged 2 to 18 years who were given 600 mg/m2 mycophenolate mofetil orally twice daily, were generally similar to those observed in adult patients given 1 g mycophenolate mofetil twice daily. However, the following treatment-related adverse events were more frequent in the paediatric population, particularly in children under 6 years of age, when compared to adults:diarrhoea, sepsis, leucopenia, anaemia and  infection.

 

                                            :

 

immunosuppression. Elderly patients receiving mycophenolate mofetil as part of a  combination immunosuppressive regimen, may be at increased risk of certain infections (including cytomegalovirus tissue invasive disease) and possibly gastrointestinal haemorrhage and pulmonary oedema, compared to younger individuals.

 

Other adverse  reactions:

 

and in ≥1/100 to <1/10 of patients treated with mycophenolate mofetil in the controlled clinical trials of renal (2 g data), cardiac and hepatic transplant patients are listed in the following table.

Adverse Reactions, Probably or Possibly Related to Mycophenolate Mofetil, Reported in Patients Treated with mycophenolate mofetil in Renal, Cardiac and Hepatic Clinical Trials when Used in Combination  with Ciclosporin  and Corticosteroids

 

Within the system organ classes, undesirable effects are listed under heading of frequency, using the following categories:

Very common (≥1/10) Common (≥1/100 to <1/10) Uncommon (≥1/1,000 to <1/100) Rare (≥1/10,000 to <1/1,000)

Very rare (<1/10,000), not known (cannot be estimated from the available  data)

Within each frequency grouping, undesirable effects are presented in order of decreasing seriousness.

 

System organ class		Adverse drug reactions
Infections and infestations                       Neoplasms benign, malignant and unspecified (incl cysts and polyps)     Blood and lymphatic system disorders       Metabolism and nutrition	Very common	Sepsis, gastrointestinal candidiasis, urinary tract infection, herpes simplex, herpes zoster
	Common               Very common	Pneumonia, influenza, respiratory tract infection, respiratory moniliasis, gastrointestinal infection, candidiasis, gastroenteritis, infection, bronchitis, pharyngitis, sinusitis, fungal skin infection, skin candida, vaginal candidiasis, rhinitis   -
	Common   Very common	Skin cancer, benign neoplasm of skin Leucopenia, thrombocytopenia, anaemia
	Common   Very	Pancytopenia, leucocytosis   -

 

 

disorders	common
Psychiatric disorders	Common           Very common	Acidosis, hyperkalaemia, hypokalaemia, hyperglycaemia, hypomagnesaemia, hypocalcaemia, hypercholesterolaemia, hyperlipidaemia, hypophosphataemia, hyperuricaemia, gout, anorexia   -
Nervous system disorders	Common     Very common	Agitation, confusional state, depression, anxiety, thinking abnormal, insomnia   -
Cardiac disorders	Common         Very common	Convulsion, hypertonia, tremor, somnolence, myasthenic syndrome, dizziness, headache, paraesthesia, dysgeusia   -
Vascular disorders	Common   Very common	Tachycardia   -
Respiratory, thoracic and	Common   Very common	Hypotension, hypertension, vasodilatation   -
mediastinal disorders
Gastrointestinal disorders	Common   Very	Pleural effusion, dyspnoea, cough   Vomiting, abdominal pain, diarrhoea,

 

 

Hepatobiliary disorders         Skin and subcutaneous tissue disorders       Musculoskeletal and connective tissue disorders       Renal and urinary disorders         General disorders and administration site conditions         Investigations	common	nausea
	Common           Very common	Gastrointestinal haemorrhage, peritonitis, ileus, colitis, gastric ulcer, duodenal ulcer, gastritis, oesophagitis, stomatitis, constipation, dyspepsia, flatulence, eructation   -
	Common   Very common	Hepatitis, jaundice, hyperbilirubinaemia   -
	Common   Very common	Skin hypertrophy, rash, acne, alopecia,   -
	Common   Very common	Arthralgia   -
	Common   Very common	Renal impairment   -
	Common     Very common	Oedema, pyrexia, chills, pain, malaise, asthenia,   -
	Common	Hepatic enzyme increased, blood creatinine increased, blood lactate

 

 

dehydrogenase increased, blood urea increased, blood alkaline phosphatase increased, weight decreased

Note: 501 (2 g mycophenolate mofetil daily), 289 (3 g mycophenolate mofetil daily) and 277 (2 g IV / 3 g oral mycophenolate mofetil daily) patients were treated in Phase III studies for the prevention of rejection in renal, cardiac and hepatic transplantation, respectively.

 

The following undesirable effects cover adverse reactions from post-marketing experience: The types of adverse reactions reported during post-marketing with mycophenolate mofetil are similar to those seen in the controlled renal, cardiac and hepatic transplant  studies.

Additional adverse reactions reported during post-marketing are described below with the frequencies reported within brackets if known.

 

Gastrointestinal: gingival hyperplasia (≥1/100 to <1/10), colitis including cytomegalovirus colitis (≥1/100 to <1/10), pancreatitis(≥1/100  to <1/10), and intestinal villous atrophy.

 

Disorders related to immunosuppression: serious life-threatening infections including meningitis, endocarditis, tuberculosis and atypical mycobacterial infection. Cases of BK virus associated nephropathy, as well as cases of JC virus associated progressive multifocal leucoencephalopathy (PML), have been reported in patients treated with immunosuppressants, including mycophenolate mofetil.

Agranulocytosis (≥1/1000 to <1/100) and neutropenia have been reported; therefore, regular monitoring of patients taking mycophenolate mofetil is advised (see section 4.4). There have been reports of aplastic anaemia and bone marrow depression in patients treated with mycophenolate mofetil, some of which have been  fatal.

 

Blood and lymphatic system disorder:

Cases of pure red cell aplasia (PRCA) have been reported in patients treated with mycophenolate mofetil (see section 4.4).

Isolated cases of abnormal neutrophil morphology, including the acquired Pelger-Huet anomaly, have been observed in patients treated with mycophenolate mofetil. These changes are not associated with impaired neutrophil function. These changes may suggest a ‘left shift’ in the maturity of neutrophils in haematological investigations, which may be mistakenly interpreted as a sign of infection in immunosuppressed patients such as those that receive mycophenolate mofetil.

 

Hypersensitivity: Hypersensitivity reactions, including angioneurotic oedema and anaphylactic reaction have been reported.

 

Congenital disorders: see further details in section  4.6.

 

Respiratory, thoracic and mediastinal  disorders:

 

There have been isolated reports of interstitial lung disease and pulmonary fibrosis in patients treated with mycophenolate mofetil in combination with other immunosuppressants, some of which have been fatal.

 

To reports any side  effect(s):

 

 

•             Saudi Arabia:

The National Pharmacovigilance and Drug Safety Centre (NPC) Fax: +966-11-205-7662

Call NPC at +966-11-2038222,  Exts 2317-2356-2353-2354-2334-2340.

Toll free phone: 8002490000 E-mail: npc.drug@sfda.gov.sa Website: www.sfda.gov.sa/npc

 

 

o      Other GCC States:

 

Please contact the relevant competent  authority.

Reports of overdoses with mycophenolate mofetil have been received from clinical trials and during post-marketing experience. In many of these cases, no adverse events were reported. In those overdose cases in which adverse events were reported, the events fall within the known safety profile of the medicinal product.

 

It is expected that an overdose of mycophenolate mofetil could possibly result in oversuppression of the immune system and increase susceptibility to infections and bone marrow suppression (see section 4.4). If neutropenia develops, dosing with Mycophenolate Mofetilshould be interrupted or the dose reduced (see section  4.4).

 

Haemodialysis would not be expected to remove clinically significant amounts of MPA or MPAG. Bile acid sequestrants, such as colestyramine, can remove MPA by decreasing the enterohepatic re-circulation of the drug (see section  5.2).

Mechanism of action:

 

Pharmacotherapeutic group: immunosuppressants, selective immunosuppressants, ATC code: L04AA06

 

Mycophenolate mofetil is the 2-morpholinoethyl ester of MPA. MPA is a potent, selective, uncompetitive and reversible inhibitor of inosine monophosphate dehydrogenase,  and

 

therefore inhibits the de novo pathway of guanosine nucleotide synthesis without incorporation into DNA.

Because T- and B-lymphocytes are critically dependent for their proliferation on de novo synthesis of purines whereas other cell types can utilise salvage pathways, MPA has more potent cytostatic effects on lymphocytes than on other cells.

 

Absorption:

 

Following oral administration, mycophenolate mofetil undergoes rapid and extensive absorption and complete presystemic metabolism to the active metabolite, MPA. As evidenced by suppression of acute rejection following renal transplantation, the immunosuppressant activity of mycophenolate is correlated with MPA concentration. The mean bioavailability of oral mycophenolate mofetil, based on MPA AUC, is 94% relative to IV mycophenolate mofetil. Food had no effect on the extent of absorption (MPA AUC)   of mycophenolate mofetil when administered at doses of 1.5 g BID to renal transplant patients. However, MPA Cmax was decreased by 40% in the presence of  food.

Mycophenolate mofetil is not measurable systemically in plasma following oral administration.

 

Distribution

 

As a result of enterohepatic recirculation, secondary increases in plasma MPA concentration are usually observed at approximately 6 – 12 hours post-dose. A reduction in the AUC of MPA of approximately 40% is associated with the co-administration of colestyramine (4 g TID), indicating that there is a significant amount of enterohepatic  recirculation.

 

MPA at clinically relevant concentrations, is 97% bound to plasma albumin. Biotransformation

MPA is metabolised principally by glucuronyl transferase to form the phenolic glucuronide of MPA (MPAG), which is not pharmacologically  active.

 

 

Elimination

 

A negligible amount of substance is excreted as MPA (< 1% of dose) in the urine. Orally administered radiolabelled mycophenolate mofetil results in complete recovery of the administered dose; with 93% of the administered dose recovered in the urine and 6%  recovered in the faeces. Most (about 87%) of the administered dose is excreted in the urine as MPAG.

 

At clinically encountered concentrations,  MPA and MPAG are not removed by  haemodialysis. However, at high MPAG plasma concentrations (> 100 µg/ml), small amounts of MPAG are removed.

 

In the early post-transplant period (< 40 days post-transplant), renal, cardiac and hepatic transplant patients had mean MPA AUCs approximately 30% lower and Cmax approximately 40% lower compared to the late post-transplant period (3 – 6 months   post-transplant).

 

Renal impairment:

In a single dose study (6 subjects/group), mean plasma MPA AUC observed in subjects with severe chronic renal impairment (glomerular filtration rate <25 ml/min/1.73 m2) were 28 –   75% higher relative to the means observed in normal healthy subjects or subjects with lesser degrees of renal impairment. However, the mean single dose MPAG AUC was 3 –   6-fold

higher in subjects with severe renal impairment than in subjects with mild renal impairment or normal healthy subjects, consistent with the known renal elimination of MPAG. Multiple  dosing of mycophenolate mofetil in patients with severe chronic renal impairment has not   been studied. No data are available for cardiac or hepatic transplant patients with severe   chronic renal impairment.

 

Delayed renal graft function:

In patients with delayed renal graft function post-transplant, mean MPA AUC (0–12h)   was

 

comparable to that seen in post-transplant patients without delayed graft function. Mean   plasma MPAG AUC (0-12h) was 2 – 3-fold higher than in post-transplant patients without delayed graft function. There may be a transient increase in the free fraction and  concentration 

of plasma MPA in patients with delayed renal graft function. Dose adjustment of mycophenolate does not appear to be necessary.

 

Hepatic impairment:

In volunteers with alcoholic cirrhosis, hepatic MPA glucuronidation processes were relatively unaffected by hepatic parenchymal disease. Effects of hepatic disease on this process probably depend on the particular disease. However, hepatic disease with predominantly  biliary

damage, such as primary biliary cirrhosis, may show a different  effect.

 

Children and adolescents (aged 2 to 18 years):

Pharmacokinetic parameters were evaluated in 49 paediatric renal transplant patients given 600 mg/m2 mycophenolate mofetil orally twice daily. This dose achieved MPA AUC values similar to those seen in adult renal transplant patients receiving mycophenolate at a dose  of

1  g BID in the early and late posttransplant period. MPA AUC values across age groups were similar in the early and late posttransplant  period.

 

 Elderly  pati ents  (≥  65  years) :

Pharmacokinetic behavior of mycophenolate mofetil in the elderly has not been formally evaluated.

 

Oral contraceptives:

The pharmacokinetics of oral contraceptives were unaffected by coadministration of mycophenolate (see also section 4.5). A study of the coadministration of mycophenolate (1 g bid) and combined oral contraceptives containing ethinylestradiol (0.02 mg to 0.04 mg) and levonorgestrel (0.05 mg to 0.15 mg), desogestrel (0.15 mg) or gestodene (0.05 mg to 0.10 mg) conducted in 18 non-transplant women (not taking other immunosuppressants) over 3 consecutive menstrual cycles showed no clinically relevant influence of mycophenolate on the ovulation suppressing action of the oral contraceptives. Serum levels of LH, FSH and progesterone were not significantly affected.

In experimental models, mycophenolate mofetil was not tumourigenic. The highest dose   tested in the animal carcinogenicity studies resulted in approximately 2 – 3 times the systemic exposure (AUC or Cmax) observed in renal transplant patients at the recommended clinical   dose of 2 g/day and 1.3 – 2 times the systemic exposure (AUC or Cmax) observed in cardiac transplant patients at the recommended clinical dose of 3  g/day.

 

Two genotoxicity assays (in vitro mouse lymphoma assay and in vivo mouse bone marrow micronucleus test) showed a potential of mycophenolate mofetil to cause chromosomal aberrations. These effects can be related to the pharmacodynamic  mode of action, i.e.

inhibition of nucleotide synthesis in sensitive cells. Other in vitro tests for detection of gene mutation did not demonstrate genotoxic activity.

 

Mycophenolate mofetil had no effect on fertility of male rats at oral doses up to 20 mg/kg/day. The systemic exposure at this dose represents 2 to 3 times the clinical exposure at the recommended clinical dose of 2 g/day in renal transplant patients and 1.3 – 2 times   the

clinical exposure at the recommended clinical dose of 3 g/day in cardiac transplant patients. In  a female fertility and reproduction study conducted in rats, oral doses of 4.5 mg/kg/day caused malformations (including anophthalmia, agnathia, and hydrocephaly) in the first generation offspring in the absence of maternal toxicity. The systemic exposure at this dose was approximately 0.5 times the clinical exposure at the recommended clinical dose of 2 g/day for renal transplant patients and approximately 0.3 times the clinical exposure at the   recommended clinical dose of 3 g/day for cardiac transplant patients. No effects on fertility or reproductive parameters were evident in the dams or in the subsequent  generation.

 

In teratology studies in rats and rabbits, foetal resorptions and malformations occurred in rats   at 6 mg/kg/day (including anophthalmia, agnathia, and hydrocephaly) and in rabbits at 90 mg/kg/day (including cardiovascular and renal anomalies, such as ectopia cordis and ectopic kidneys, and diaphragmatic and umbilical hernia), in the absence of maternal toxicity. The systemic exposure at these levels is approximately equivalent to or less than 0.5 times the clinical exposure at the recommended clinical dose of 2 g/day for renal transplant patients and approximately 0.3 times the clinical exposure at the recommended clinical dose of 3 g/day for cardiac transplant patients.

 

Refer to section 4.6 .

 

The haematopoietic and lymphoid systems were the primary organs affected in toxicology studies conducted with mycophenolate mofetil in the rat, mouse, dog and monkey. These effects occurred at systemic exposure levels that are equivalent to or less than the clinical exposure at the recommended dose of 2 g/day for renal transplant recipients. Gastrointestinal effects were observed in the dog at systemic exposure levels equivalent to or less than the clinical exposure at the recommended doses. Gastrointestinal and renal effects consistent with dehydration were also observed in the monkey at the highest dose (systemic exposure levels equivalent to or greater than clinical exposure). The nonclinical toxicity profile of mycophenolate  mofetil appears to be consistent with adverse events observed in human  clinical trials which now provide safety data of more relevance to the patient population (see section 4.8).

Core content:

Cellulose microcrystalline

 

Povidone Talc

Magnesium stearate Croscarmellose sodium

 

Coating content: Hypromellose Hydroxypropylcellulose Titanium dioxide (E171) Macrogol( 400);

Iron Oxide Black (E172) Iron Oxide Red (E172)

Not applicable

2 years

Do not store above 30 C. Keep the blister in the outer carton in order to protect from light. This medicinal product does not require any special storage  conditions

PVC/PE/PVdC/Al blister

Pack sizes: 50, 150 and 250 film-coated  tablets.

 

Not all pack sizes may be marketed.

Because mycophenolate mofetil has demonstrated teratogenic effects in rats and rabbits, tablets should not be crushed.

Any unused product or waste material should be disposed of in accordance with local requirements.