Conversion from Mycophenolate Mofetil to Enteric-coated Mycophenolate Sodium ( myfortic ®) in a Patient with Graft-versus-host Disease

The patient was 58 years old in September 2002 when he was diagnosed with chronic myeloid leukaemia (CML). He was first treated using IFNa, to which aracytine was soon added. By February 2003, hyperleukocytosis with myelocytosis was still present so the interferon was replaced by imatinib. The patient’s condition continued to deteriorate, and the haematopoietic cell count started to increase in August 2003. In September 2003, the patient underwent allogeneic haematopoietic stem cell transplantation with peripheral stem cells from a human leukocyte antigen-matched brother after a busulfan-based non-myeloablative conditioning regimen. Graftversus-host disease (GVHD) prophylaxis consisted of cyclosporine 3mg/kg per day and short-course methotrexate. Subsequent changes in the immunosuppressive regimen are summarised in table I. On day 15 posttransplant, a differential count clearly indicated recrudescence of the CML, with a total white blood cell count of 65 000 10/l, including 70% myeloid cells. In response to this, cyclosporine was discontinued because there was no evidence of GVHD, and treatment with imatinib (400mg/day) and low-dose busulfan (2mg/day by mouth) was started. A complete cytogenetic and molecular remission was observed unexpectedly within 2 months. On day 19, grade II cutaneous GVHD developed, with no gastrointestinal symptoms. The patient was given methylprednisolone followed by anti-IL-2 antibody therapy (Leucotac) for 4 days. The symptoms failed to improve by day 46, however, and treatment with mycophenolate mofetil (MMF) was started at a dose of 1000mg twice a day. The patient quickly developed severe diarrhoea two to three times a day responsible for a body weight loss of 5% within one week, and 18 days after the introduction of MMF (i.e. on day 64) it was withdrawn and replaced with enteric-coated mycophenolate sodium (EC-MPS; myfortic) at a dose of 720mg twice a day. The gastrointestinal symptoms quickly resolved after conversion from MMF to EC-MPS and the GVHD steadily waned. In January 2004, 4 months posttransplantation, the GVHD flared up again so the corticosteroid dose was increased to 80mg/day, and tacrolimus 2mg twice a day was started. In the face of persistent GVHD, this regimen of EC-MPS 720mg twice a day, prednisolone 80mg/day and tacrolimus 2mg twice a day was maintained until March 2004 when the patient developed acute kidney failure and tacrolimus was discontinued. As the GVHD appeared to be under control, the corticosteroid dose was tapered downwards, starting in May 2004. The patient is still alive in good condition and in complete molecular remission from his CML. CASE REPORT Drugs 2006; 66 Suppl. 2: 29–31 0012-6667/06/0002-0029/$44.95/0