Before starting

Required

• Baseline
  • Pregnancy test · two tests 8-10 days apart in women of child bearing potential; exclude before initiating
  • Albumin
  • ALT or AST
  • Blood pressure
  • Full blood count
  • Height
  • Liver function tests
  • Serum creatinine (for creatinine clearance) or Calculated glomerular filtration rate
  • Vaccination status
  • Weight

Vaccination status

Consider vaccination against pneumococcus and influenza prior to starting treatment.

After started or dose changed

Required

• Every 2 weeks for minimum 6 weeks until dose stable; then 3 monthly
  • Albumin
  • ALT or AST
  • Full blood count
  • Serum creatinine (for creatinine clearance) or Calculated glomerular filtration rate

Ongoing once stable

Required

• At least every 12 weeks
  • Albumin
  • ALT or AST
  • Full blood count
  • Serum creatinine (for creatinine clearance) or Calculated glomerular filtration rate

Abnormal results

Respond to absolute levels

Consider stopping treatment and contacting a specialist any of the following develop:

Blood pressure

• BP greater than 140/90mmHg. Manage in accordance with hypertension guidelines.

Full blood count

• WCC less than 3.5 x 10⁹/L,
• Neutrophils less than 1.6 x 10⁹/L
• Unexplained eosinophilia greater than 0.5x 10 ⁹/L
• Platelets less than 140 x 10⁹/l
• Unexplained fall in serum albumin less than 30g/L
• MCV greater than 105f/L then check B12, folate, thyroid-stimulating hormone levels. If abnormal treat; if normal discuss with specialist team.

Liver function

• AST or ALT increase to greater than 100units/ml

Renal function

• Creatinine increase greater than 30% above baseline over 12 months
• Calculated GFR less than 60ml/min/1.73m² (repeat in 1 week, if still more than 30% from baseline, withhold and discuss with specialist team)

Investigate if urinary protein

If urinary protein is at 2+ or more, a mid-stream urine sample should be taken, and:

• if there is evidence of infection, this should be treated appropriately;
• if the urine sample is sterile (no infection present) and the urinary protein 2+ or more persists on two consecutive measurements, stop mycophenolate mofetil and discuss with specialist team.

Notes

Advice to patients

Advise patients to seek urgent medical attention if they develop symptoms such as:

• Skin or mucosal reaction (rash, pruritus, mouth or throat ulceration)
• Sore throat
• Fever
• Unexplained bruising or bleeding
• Nausea, vomiting, diarrhoea or weight loss
• Diffuse alopecia
• Breathlessness, infection or cough
• Peripheral neuropathy

Both male and female patients should be aware of the advice on conception and contraception

Bibliography

• Ledingham J, Gullick N, Irving K et al. BSR and BHPR Standards, Guidelines and Audit Working Group, BSR and BHPR guideline for the prescription and monitoring of non-biologic disease-modifying anti-rheumatic drugs, Rheumatology, Volume 56, Issue 6, June 2017, Pages 865–868 [cited June 2020]
• NICE Clinical Knowledge Summaries (CKS). DMARDs – mycophenolate. Updated Jul 2018 [cited 30/07/2020]
• Medicines and Healthcare products Regulatory Agency (MHRA). Mycophenolate mofetil, mycophenolic acid: updated contraception advice for male patients. Drug Safety Update volume 11 issue 7; February 2018: 2. [cited 30/07/2020].
• Joint Formulary Committee. British National Formulary (online) London: BMJ Group and Pharmaceutical Press [cited 30/04/2020]
• Roche Products Limited. Summary of Product Characteristics – Cellcept 500mg Film-Coated Tablets. Last revised 02/2020 [cited 30/07/2020]
• Specialist Pharmacy Service. Switching between liquid and tablet/capsule formulations – Which medicines require extra care? Published 17/07/2020