Medications and Their Complications

Introduction to Medication Complications

• Progressive multifocal leukoencephalopathy (PML) is a rare but potentially fatal opportunistic infection caused by JC virus reactivation, particularly in patients with renal impairment, and requires monitoring protocols 1
• Patients on mycophenolate therapy should be educated to report neurological symptoms promptly, including headache, dizziness, numbness, tingling, and weakness, to facilitate early detection of neurologic complications 1

Management of Medication Side Effects

• For peripheral neuropathy, prompt consideration of discontinuing therapy should be taken to mitigate the risk of neurologic complications 1
• The risk of neurologic complications, including PML, must be weighed against the benefits of mycophenolate therapy in preventing organ rejection or controlling autoimmune disease, and included in monitoring protocols 1

Treatment of Systemic Lupus Erythematosus (SLE)

• The American College of Rheumatology recommends mycophenolate mofetil (MMF) for treatment of lupus nephritis, as both induction and maintenance therapy 2, 3
• MMF is used to treat SLE and its manifestations, including lupus nephritis, as noted by the American College of Rheumatology 3, 2
• Evaluate for signs of SLE disease activity using clinical signs and laboratory tests (anti-dsDNA, complement levels) 3

Monitoring and Managing Adverse Effects

• Monitor for weight loss, gastrointestinal side effects, and enteropathy, as MMF can cause these conditions, leading to malabsorption and weight loss, according to the American College of Rheumatology and Gastroenterology societies 4, 5
• Consider switching to enteric-coated mycophenolate sodium formulation for GI side effects, and check MPA levels and consider dose reduction for severe diarrhea, as recommended by the American Gastroenterological Association 1, 6
• MMF can cause leukopenia, anemia, thrombocytopenia, and neutropenia, highlighting the need for regular CBC monitoring (weekly for the first month, twice monthly for the second and third months, monthly for the remainder of the first year, and every 1-3 months thereafter), as recommended by the American Society of Hematology and the American Society of Clinical Oncology 1, 6, 7
• MMF can cause systemic hypertension, peripheral edema, tachycardia, hypercholesterolemia, electrolyte disturbances, and hyperglycemia, indicating the need for regular monitoring of these parameters, as suggested by the American College of Cardiology 1
• MMF can cause headache, tremor, insomnia, dizziness, anxiety, somnolence, and confusion, as well as blurred vision, cataracts, and other ophthalmological conditions, highlighting the need for regular neurological and ophthalmological assessments, as recommended by the American Academy of Neurology and the American Academy of Ophthalmology 1
• MMF can cause urinary tract infections, hematuria, tubular necrosis, and respiratory infections, indicating the need for regular monitoring of renal and respiratory function, as suggested by the American Society of Nephrology and the American Thoracic Society 1

Special Considerations

• MMF has a FDA black box warning for use during pregnancy due to teratogenic and embryocidal effects, increased risk of miscarriage, and higher risk of birth defects, and is also associated with an increased risk of lymphoma, skin cancers, and other malignancies with prolonged use, as noted by the FDA and the National Cancer Institute 1, 7
• Activated charcoal, aluminum/magnesium antacids, cholestyramine, and iron can inhibit MMF absorption, and coadministration with certain medications should be avoided, as noted by the American Society of Health-System Pharmacists 1, 6
• Liver function tests (at least monthly) and MPA blood levels (if GI intolerance develops) are recommended, according to the American Society of Clinical Oncology 1, 6