Prenatal Exposure to Mycophenolate Mofetil: An Updated Estimate

Klieger-Grossmann, Chagit; Chitayat, David; Lavign, Sharon; Kao, Kelly; Garcia‐Bournissen, Facundo; Quinn, Declan; Luo, Vicky; Sermer, Mathew; Riordan, Sara; Laskin, Carl A.; Matok, Ilan; Gorodischer, Rafael; Chambers, Christina D.; Levi, Amalia; Koren, Gideon

doi:10.1016/s1701-2163(16)34622-9

Cited by 54 publications

(39 citation statements)

References 16 publications

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“…Th e potential for impaired wound healing with everolimus and sirolimus must be considered if cesarean section is performed (193)(194)(195)(196). It is clear that mycophenolic acid should not be used during pregnancy owing to risk of congenital malformations and embryo-fetal toxicity (197)(198)(199)(200).…”

Section: Primary Biliary Cirrhosismentioning

confidence: 99%

ACG Clinical Guideline: Liver Disease and Pregnancy

Tran

Ahn

Reau

2016

American Journal of Gastroenterology

236

257

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Consultation for liver disease in pregnant women is a common and oftentimes vexing clinical consultation for the gastroenterologist. The challenge lies in the need to consider the safety of both the expectant mother and the unborn fetus in the clinical management decisions. This practice guideline provides an evidence-based approach to common diagnostic and treatment challenges of liver disease in pregnant women. Am J Gastroenterol 2016; 111:176-194; doi: 10.1038/ajg.2015 Initial evaluation of pregnant patientA pregnant patient presenting with abnormal liver tests should undergo standard workup as with any non-pregnant individual (strong recommendation, very low level of evidence). Imaging in pregnancyUltrasound is safe and the preferred imaging modality used in assessment of abnormal liver tests suggestive of biliary tract disease (strong recommendation, low level of evidence).Magnetic resonance imaging without gadolinium can be used in the second and third trimester (conditional recommendation, low level of evidence).Computed tomography scans carry a risk of teratogenesis and childhood hematologic malignancies but may be used judiciously with minimized radiation protocols (2-5 rads; conditional recommendation, very low level of evidence). Endoscopy in pregnancyEndoscopy is safe in pregnancy but should be deferred until the second trimester if possible (strong recommendation, low level of evidence).Meperidine and propofol can be used for endoscopic sedation (strong recommendation, moderate level of evidence). Management of biliary disease in pregnancyERCP can be performed when indicated for pregnant women presenting with biliary disease that strongly necessitates intervention such as biliary pancreatitis, symptomatic choledocholithiasis, and/or cholangitis. Minimizing fetal exposure to fl uoroscopy is imperative (strong recommendation, low level of evidence).Symptomatic cholecystitis should be managed with early surgical intervention with laparoscopic cholecystectomy (strong recommendation, low level of evidence). Liver masses in pregnancyAsymptomatic hemangioma and focal nodular hyperplasia do not need routine imaging or surveillance during pregnancy (strong recommendation, very low level evidence).Hepatic adenomas should be monitored with ultrasound during pregnancy for growth. Patients with large adenomas (>5 cm) should be referred for resection prior to pregnancy (strong recommendation, low level of evidence). Hepatitis B in pregnancyActive-passive immunoprophylaxis with hepatitis B immunoglobulin and the HBV vaccination series should be administered to all infants born to HBV-infected mothers to prevent perinatal transmission (strong recommendation, low level of evidence).Women chronically infected with HBV and high viral load (>10 6 log copies/ml (200,000 IU/ml) and higher) should be offered antiviral medication with tenofovir or telbivudine in the third trimester to reduce perinatal transmission of HBV (strong recommendation, low level of evidence).C-section should not be performed electively in HBV-pos...

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Section: Primary Biliary Cirrhosismentioning

confidence: 99%

ACG Clinical Guideline: Liver Disease and Pregnancy

Tran

Ahn

Reau

2016

American Journal of Gastroenterology

236

257

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“…Although it is typically known as an anti-rejection drug for kidney transplants, mycophenolate is now often used in the treatment of cutaneous graft-versus-host disease [3]. It accomplishes immunosuppression through the inhibition of the de novo purine synthesis pathway in B and T lymphocytes and the stifling of their proliferation [3,87].…”

Section: Mycophenolatementioning

confidence: 99%

“…The teratogenicity of mycophenolate (pregnancy category D) has become a key issue because of its increased use in female lupus patients of child-bearing age [3,87]. Although it is known to be associated with fetal loss, a number of congenital anomalies have been noted in the offspring of mycophenolate patients such as microtia or anotia and orofacial clefts [87,90,91].…”

Section: Mycophenolatementioning

confidence: 99%

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Screening and Vaccinations in Patients Requiring Systemic Immunosuppression: An Update for Dermatologists

Goyal

Merola

2015

Am J Clin Dermatol

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Immunomodulatory agents are becoming an increasingly important tool in the dermatologist's armamentarium against autoimmune and auto-inflammatory conditions. This review addresses the guidelines for vaccination and screening studies prior to the initiation of immunomodulatory agents. Included are discussions of vaccination schedules, hepatitis vaccination and screening, tuberculosis screening, and specific screening recommendations for antimalarials, azathioprine, cyclosporine, methotrexate, mycophenolate mofetil, tumor necrosis factor-α inhibitors, and newer medications like apremilast and tofacitinib.

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“…Purine antagonist [93] Anti-proliferative effects [94] Increases T cell apoptosis [94] Decreases iNOS [95] Reduces adhesion molecules [94] Impairs fibroblasts [112] Azathioprine intolerance [100] Refractory disease [101] Frontline therapy [99] Expensive [108] Leukopenia [22] Congenital malformations [121] Side effects, 3-34% [22] Uncertain steroid sparing [22] Ineffective in cholangitis [106] Budesonide High hepatic clearance [123,127] Anti-proliferative effects [135] Reduces chemokines [136] Increases T cell apoptosis [134] Frontline therapy [132] Mild disease [22] Not salvage therapy [139] Low systemic availability [22] Cirrhotic intolerances [138] Uncertain durability [140] Unclear histologic effect [132] Prednisone intolerance [139] Tacrolimus Cyclosporine…”

Section: Mycophenolate Mofetilmentioning

confidence: 99%

Nonstandard Drugs and Feasible New Interventions for Autoimmune Hepatitis: Part I

Czaja¹

2012

IADT

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Nonstandard drugs that target critical pathogenic pathways or immune regulatory mechanisms constitute the next generation of treatments for autoimmune hepatitis. Mycophenolate mofetil impairs the proliferation of lymphocytes, decreases autoantibody production, and induces apoptosis of activated immunocytes. Patients treated for azathioprine intolerance improve more frequently than patients treated for refractory liver disease (54% versus 10%), and mycophenolate mofetil is emerging as a rescue therapy for this population. Complete corticosteroid withdrawal is possible in 40% of patients treated with mycophenolate mofetil, and the frequency of side effects ranges from 3-34%. Budesonide in combination with azathioprine has normalized liver tests more frequently (47% versus 18%) and with fewer side effects (28% versus 53%) than standard therapy after 6 months. Budesonide is emerging as a frontline treatment in non-cirrhotic patients with uncomplicated disease or contraindications to conventional corticosteroids. Cyclosporine and tacrolimus are effective salvage agents for steroid-refractory disease, but side effects have been common and occasionally serious. The 6- thioguanine nucleotides and rapamycin are feasible treatments for autoimmune hepatitis, but 6-thioguanine has major obstacles to overcome, especially the risk of liver toxicity or nodular regenerative hyperplasia. The nonstandard drug therapies emerging for autoimmune hepatitis reflect the need to supplement or supplant current treatment regimens. None has been licensed for use in autoimmune hepatitis, and their applications have been based on results from small singlecenter experiences.

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Prenatal Exposure to Mycophenolate Mofetil: An Updated Estimate

Cited by 54 publications

References 16 publications

ACG Clinical Guideline: Liver Disease and Pregnancy

ACG Clinical Guideline: Liver Disease and Pregnancy

Screening and Vaccinations in Patients Requiring Systemic Immunosuppression: An Update for Dermatologists

Nonstandard Drugs and Feasible New Interventions for Autoimmune Hepatitis: Part I

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