Table 2.

Current recommendation on TDM of MMF in transplantation (45)a

Initial dosingCsA-based regimen: start MMF at 1.5 g twice daily, and then adjust dosage on the basis of TDM
Tacrolimus-based regimen: start MMF at 1 g twice daily
Frequency of monitoring and dose adjustmentDays 3 and 7 and once during days 10 to 14 after transplantation
    Week 3 or 4 (optional)
    Occasions of substantial changes in immunosuppressant regimen
    Occasions that require evaluation of clinical events, such as drug-related toxicity or rejection
Assay considerationsEither HPLC or EMIT is acceptable for monitoring
MPA target concentrations using EMIT are higher (as a result of cross-reactivity with AcMPAG)
Target concentrations (HPLC)MPA AUC
    30 to 60 mg·h/L in the first 30 d after transplantation
MPA C0
    CsA-based regimen: ≥1.3 mg/L
    tacrolimus-based regimen: ≥1.9 mg/L
Special populations
    calcineurin inhibitor-sparing regimen
    a higher end of MPA target concentrations range is required
    altered protein binding: free drug MPA concentration can be higherb
    renal impairment
    high bilirubin
Dosage adjustmentcEmbedded Image
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  • a Data are summary of reference (45). AcMPAG, MPA-acyl-glucuronide.

  • b Because of extensive protein binding of MPA, free drug MPA concentration can be higher, although the total MPA concentration is within the target range. Therefore, under circumstances of altered protein binding, total MPA levels are difficult to assess.

  • c This recommendation is under assumption of dosage linearity in MPA pharmacokinetics, which may not exist in all cases.