Treatments

Mycophenolate mofetil

Mycophenolate mofetil (MMF) is one of the second-line immunosuppressive agents used in the treatment of non-infectious uveitis. 

The medication lowers the inflammation in the body and reduces the immune system activity by the inhibition of the function of T and B lymphocytes (one of the body’s main types of immune cells constituting the immune system).

MMF is usually prescribed in the following situations:
  • When the dose of prednisolone to maintain the quiescence of uveitis is unacceptable because high (>7.5mg/day maintenance) 

  • When recurrent high doses of steroids are needed for relapsing disease 

  • When the use of immunosuppressive therapy is needed at presentation due to severity of uveitis
  • When a steroid-sparing agent is needed due to prednisolone side effects 


MMF is usually started in a dose of 500mg twice a day, and increase if tolerated after 1-2 weeks, to reach the typical therapeutic dose of 1000mg twice a day.

Higher dose can be prescribed accordingly to achieve the best result. For it to work well, the medication should be taken regularly. Patients should not be discouraged if the results are not immediate, because the drug takes several weeks to become effective. 

A reasonably long period of therapy (2 years) is usually required as maintenance therapy in most cases. However, MMF does not help everyone who takes it and in some patients the condition might not improve.

Side effects

The use of MMF can be associated with side effects. Not everyone will develop side effects from the use of the medication and presence of side effects varies from person to person. Potential side effects include:

  • Gastrointestinal symptoms (abdominal pain, nausea, diarrhoea, vomiting)
  • Urogenital issues (blood in urine with change in colour, urinary tract infection) 

  • Leukopenia and thrombocytopenia (reduction in the level of certain blood cells) - patients should be warned to report immediately any signs of infections and inexplicable bruising or bleeding
  • Renal or liver impairment
  • Hyperglycaemia (high blood sugar)
  • Agitation, anxiety, depression
  • Insomnia (not being able to sleep)
  • Headache and dizziness
  • Skin cancer - avoid exposure to UV and strong sunlight, use sun block, long sleeves, etc.
  • Hair loss

contraindicate

If patients experience side effects after taking MMF, they should report them immediately to the doctor. Most side effects should improve when reducing the dosage or eventually stopping the medication. 

Certain medical conditions contraindicate the use of MMF, including:

  • Pregnancy and women of childbearing potential who are not using highly effective contraception and who have not had pregnancy testing (see below)
  • Breastfeeding
  • Localised or systemic infection

Other conditions

Other conditions required cautions in the administration of the drug. The doctor needs to be informed in case of:
  • Active serious gastro-intestinal disease 

  • Pre-existing bone marrow disorder and/or cytopaenia (reduction in the number of blood cells) - patients should be warned to report immediately any new symptoms suggestive of infections, or bruising and bleeding

  • Patients should not donate blood during therapy or for at least 6 weeks following discontinuation of MMF. Men should not donate semen during therapy or for 90 days following discontinuation of MMF
Patients should inform the doctor about any medications they have been taken, due to potential risk of MMF interaction with other drugs, and about allergy to medications. Patients should avoid antacids containing magnesium and or aluminium or iron supplements.

Pregnancy

MMF can cause birth defects and miscarriages.
  • Due to potential risk to the foetus, women who might be pregnant, are breastfeeding or looking to start a family should not take MMF.
  • Women with childbearing potential should use two reliable forms of contraception simultaneously before starting MMF, during therapy, and for six weeks after stopping therapy.
  • Women of childbearing potential should have a pregnancy test 8 – 10 days before starting the drug, followed by a second test immediately before treatment starts. Pregnancy tests should be repeated if gap in contraception. 

  • For male patients taking MMF it is recommended that either the male patient or his female partner use reliable contraception during MMF treatment and for at least 90 days after stopping treatment.


Viral infections and vaccinations

As MMF reduce the ability of the immune system to fight infections, patients on treatment are more likely to catch infections of the skin, mouth, stomach, intestines, lungs and urinary tract. Patients should report symptoms of infections to the doctor.

Patients should avoid live vaccines while on MMF, including yellow fever, rubella and MMR. It is safe to have the flu vaccination and Pneumovax as they are not live vaccines.

Monitoring

Patients are regularly checked while on treatment.

Before starting the therapy an initial blood test is carried out

  • To rule out infections such as HIV, HBV and HCV 

  • To check blood pressure, body weight, cholesterol and blood sugar
  • to check blood cells (FBC), kidney function (U&E) and liver function (LFT) 

While on treatment, blood monitoring, including FBC, U&E and LFT is performed every 2 weeks for 6 weeks, then monthly for 3 months and then at least every 12 weeks. 


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