Ask the Experts - Mycophenolate vs Azathioprine?
Ask the Experts - Mycophenolate vs Azathioprine?
It is well known that mycophenolate mofetil (MMF) is highly superior to azathioprine in renal transplantation. However, cost is a limiting factor in places where there is not public support for transplantation. I would like to know if it is safe to use MMF for 6-12 months after transplantation and then switch to azathioprine in patients who can not afford long-term MMF therapy.
Ricardo S. Arze, MD
There are few data about MMF withdrawal in stable renal transplant recipients. Kaplan and colleagues reported a small series of stable kidney transplant recipients who were withdrawn from MMF at 1 year. Two of 45 patients developed rejection after withdrawal of MMF. Of 45 patients used as a case control, 1 patient developed rejection episode that may have been precipitated by lowering of the prednisone dose. However, the same investigators examined the utility of the use of MMF and long-term outcome in the United States Renal Data System database. Their data showed that recipients who were receiving MMF after transplant had less long-term chronic allograft failure.
There is evidence of a significant incidence of subclinical rejection in renal transplant recipients which may lead to chronic allograft nephropathy. In addition, long-term calcineurin toxicity is also a long-term clinical issue. The long-term use of MMF may allow late calcineurin-sparing or discontinuation without increasing the risk of rejection.
The key issues with withdrawal of any drug are adequate immunosuppression doses and calcineurin inhibitor and corticosteroid levels. In addition, the type of transplant (live donor vs cadaveric) and the age of the patient need to be factored in when considering withdrawal of any drug posttransplantation
It is well known that mycophenolate mofetil (MMF) is highly superior to azathioprine in renal transplantation. However, cost is a limiting factor in places where there is not public support for transplantation. I would like to know if it is safe to use MMF for 6-12 months after transplantation and then switch to azathioprine in patients who can not afford long-term MMF therapy.
Ricardo S. Arze, MD
There are few data about MMF withdrawal in stable renal transplant recipients. Kaplan and colleagues reported a small series of stable kidney transplant recipients who were withdrawn from MMF at 1 year. Two of 45 patients developed rejection after withdrawal of MMF. Of 45 patients used as a case control, 1 patient developed rejection episode that may have been precipitated by lowering of the prednisone dose. However, the same investigators examined the utility of the use of MMF and long-term outcome in the United States Renal Data System database. Their data showed that recipients who were receiving MMF after transplant had less long-term chronic allograft failure.
There is evidence of a significant incidence of subclinical rejection in renal transplant recipients which may lead to chronic allograft nephropathy. In addition, long-term calcineurin toxicity is also a long-term clinical issue. The long-term use of MMF may allow late calcineurin-sparing or discontinuation without increasing the risk of rejection.
The key issues with withdrawal of any drug are adequate immunosuppression doses and calcineurin inhibitor and corticosteroid levels. In addition, the type of transplant (live donor vs cadaveric) and the age of the patient need to be factored in when considering withdrawal of any drug posttransplantation
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