Pharmacokinetics and tolerance of mycophenolate mofetil in renal transplant children

Abstract 

Mycophenolate mofetil (MMF) is a prodrug that is hydrolyzed to the active immunosuppressant mycophenolic acid (MPA). The drug is now widely prescribed for adult renal transplant recipients and its use has been extended to pediatric patients, although pharmacological data in this age group are limited. Nine pediatric renal transplant recipients received MMF with corticosteroids and either cyclosporine or tacrolimus a median of 55 months (range 7.5–124 months) months after transplantation. The pharmacokinetic parameters of MPA and MPA glucuronide (MPAG) were determined at steady state by high-performance liquid chromatography after administration of MMF at the oral dose of 494±142 mg/m² twice daily. MPA was rapidly absorbed, with a peak concentration at 1.4 h. The mean plasma concentration of MPA at steady state was 4.7±1.3 µg/ml. The areas under the plasma concentration-time curves (AUCs) over 12 h (between two administrations) were 57.0±15.3 µg.h/ml for MPA and 1,515±722 µg.h/ml for MPAG, and the apparent oral clearance was 11.7±7.0 and 0.5±0.4 l/h for MPA and MPAG, respectively. Assuming that the pharmacokinetics of MPA was dose dependent, the mean concentration at steady state and the AUC for MPA were calculated for the recommended dosage schedule of 600 mg/m² every 12 h and were 6.3±2.7 µg/ml and 75.2±32.9 µg.h/ml, respectively. The tolerance of MMF was studied prospectively with a follow-up of 1.1±0.2 years. Gastrointestinal disorders requiring dosage reduction or discontinuation of therapy, observed in five of nine patients, occurred at an incidence higher than expected from adult data. Our results suggest that the dose of 600 mg/m² every 12 h extrapolated from adult data for use in pediatric patients would be associated with plasma levels and AUCs higher than expected and may be associated with a higher incidence of side-effects, primarily gastrointestinal.