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Yan B, Tie X, Wang L, Qiao X, Su X. Enteric-coated Mycophenolate Sodium plus hydroxychloroquine therApy versus hydroxychloroquine for the Remission of Proteinuria in IgA Nephropathy (EMSAR-IgAN trial): study protocol for a randomised trial. BMJ Open 2025; 15:e098688. [PMID: 40288788 PMCID: PMC12035470 DOI: 10.1136/bmjopen-2024-098688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2024] [Accepted: 04/17/2025] [Indexed: 04/29/2025] Open
Abstract
INTRODUCTION The management of immunoglobulin A (IgA) nephropathy remains a topic of debate. Hydroxychloroquine and mycophenolate mofetil (MMF) are two immunosuppressive agents that have recently garnered increased attention among patients with IgA nephropathy in China. Several studies have shown the comparable efficacy between MMF and enteric-coated mycophenolate sodium (EC-MPS), with lower adverse event rates for EC-MPS. The present study aims to evaluate the efficacy and safety of EC-MPS combined with hydroxychloroquine as an immunosuppressive regimen for patients with high-risk progressive IgA nephropathy, despite receiving routine supportive treatment. METHODS AND ANALYSIS This study is a multicentre, prospective, randomised controlled, open-label, blinded endpoint trial. 96 patients diagnosed with IgA nephropathy and persistent proteinuria from 12 general hospitals in Shanxi Province of China will be recruited and randomly assigned to receive either EC-MPS plus hydroxychloroquine or hydroxychloroquine alone in a 1:1 ratio. We will compare the efficacy and safety of hydroxychloroquine combined with or without oral EC-MPS (720-1080 mg/day for 6 months, and tapered to 360-540 mg/day for another 6 months) on a background of supportive care. All enrolled patients will receive standard basic treatment to achieve optimum blood pressure and the maximum tolerated dose of ACE inhibitors or angiotensin receptor blockers. The primary outcome is the change in 24-hour urine protein at 6 months relative to baseline. Participants will be subject to regular follow-up for a duration of 12 months. ETHICS AND DISSEMINATION This study has received ethical approval from the Ethics Committee of Shanxi Medical University Second Hospital (No. 2024YX-481). A duly signed and dated informed consent form must be obtained from each participant or his/her legal guardian prior to any operational procedures related to the trial. The result of this study will be presented and published at international conferences and in scientific journals. TRIAL REGISTRATION NUMBER ChiCTR2400093530.
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Affiliation(s)
- Bingjuan Yan
- Department of Nephrology, Second Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
- Shanxi Kidney Disease Institute, Taiyuan, Shanxi, China
- Kidney Research Center of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Xuan Tie
- Department of Nephrology, Second Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
- Shanxi Kidney Disease Institute, Taiyuan, Shanxi, China
- Kidney Research Center of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Lihua Wang
- Department of Nephrology, Second Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
- Shanxi Kidney Disease Institute, Taiyuan, Shanxi, China
- Kidney Research Center of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Xi Qiao
- Department of Nephrology, Second Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
- Shanxi Kidney Disease Institute, Taiyuan, Shanxi, China
- Kidney Research Center of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Xiaole Su
- Department of Nephrology, Second Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
- Shanxi Kidney Disease Institute, Taiyuan, Shanxi, China
- Kidney Research Center of Shanxi Medical University, Taiyuan, Shanxi, China
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Kaye AD, Shah SS, Johnson CD, De Witt AS, Thomassen AS, Daniel CP, Ahmadzadeh S, Tirumala S, Bembenick KN, Kaye AM, Shekoohi S. Tacrolimus- and Mycophenolate-Mediated Toxicity: Clinical Considerations and Options in Management of Post-Transplant Patients. Curr Issues Mol Biol 2024; 47:2. [PMID: 39852117 PMCID: PMC11763814 DOI: 10.3390/cimb47010002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2024] [Revised: 12/17/2024] [Accepted: 12/18/2024] [Indexed: 01/26/2025] Open
Abstract
Tacrolimus and mycophenolate are important immunosuppressive agents used to prevent organ rejection in post-transplant patients. While highly effective, their use is associated with significant toxicity, requiring careful management. Tacrolimus, a calcineurin inhibitor, is linked to nephrotoxicity, neurotoxicity, metabolic disturbances such as diabetes mellitus and dyslipidemia, and cardiovascular complications such as hypertension and arrhythmias. Mycophenolate, a reversible inhibitor of inosine monophosphate dehydrogenase, frequently causes gastrointestinal disturbances, including diarrhea and colitis, as well as hematologic side effects like anemia and leukopenia, which increase infection risk. Therapeutic drug monitoring (TDM) and pharmacogenomics have emerged as essential strategies for mitigating these toxicities. TDM ensures tacrolimus trough levels are maintained within a therapeutic range, minimizing the risks of nephrotoxicity and rejection. Pharmacogenomic insights, such as CYP3A5 polymorphisms, allow for personalized tacrolimus dosing based on individual metabolic profiles. For mycophenolate, monitoring inosine monophosphate dehydrogenase activity provides a pharmacodynamic approach to dose optimization, reducing gastrointestinal and hematologic toxicities. Emerging tools, including dried blood spot sampling and pharmacokinetic modeling, offer innovative methods to simplify monitoring and enhance precision in outpatient settings. Despite their utility, the toxicity profiles of these drugs, including those of early immunosuppressants such as cyclosporine and azathioprine, necessitate further consideration of alternative immunosuppressants like sirolimus, everolimus, and belatacept. Although promising, these newer agents require careful patient selection and further research. Future directions in immunosuppressive therapy include integrating individual pharmacogenetic data to refine dosing, minimize side effects, and improve long-term graft outcomes. This narrative review underscores the importance of personalized medicine and advanced monitoring in optimizing post-transplant care.
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Affiliation(s)
- Alan D. Kaye
- Departments of Anesthesiology and Pharmacology, Toxicology, and Neurosciences, Louisiana State University Health Sciences Center Shreveport, Shreveport, LA 71103, USA
| | - Shivam S. Shah
- School of Medicine, Louisiana State University Health Sciences Center at Shreveport, Shreveport, LA 71103, USA; (S.S.S.); (C.D.J.); (C.P.D.)
| | - Coplen D. Johnson
- School of Medicine, Louisiana State University Health Sciences Center at Shreveport, Shreveport, LA 71103, USA; (S.S.S.); (C.D.J.); (C.P.D.)
| | - Adalyn S. De Witt
- School of Medicine, Indiana University, 340 W 10th St., Indianapolis, IN 46202, USA
| | - Austin S. Thomassen
- School of Medicine, Louisiana State University Health Sciences Center at Shreveport, Shreveport, LA 71103, USA; (S.S.S.); (C.D.J.); (C.P.D.)
| | - Charles P. Daniel
- School of Medicine, Louisiana State University Health Sciences Center at Shreveport, Shreveport, LA 71103, USA; (S.S.S.); (C.D.J.); (C.P.D.)
| | - Shahab Ahmadzadeh
- Department of Anesthesiology, Louisiana State University Health Sciences Center Shreveport, Shreveport, LA 71103, USA
| | - Sridhar Tirumala
- Department of Anesthesiology, Louisiana State University Health Sciences Center Shreveport, Shreveport, LA 71103, USA
| | - Kristin Nicole Bembenick
- Department of Anesthesiology, Louisiana State University Health Sciences Center Shreveport, Shreveport, LA 71103, USA
| | - Adam M. Kaye
- Department of Pharmacy Practice, Thomas J. Long School of Pharmacy, University of the Pacific, 751 Brookside Road, Stockton, CA 95207, USA
| | - Sahar Shekoohi
- Department of Anesthesiology, Louisiana State University Health Sciences Center Shreveport, Shreveport, LA 71103, USA
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Li S, Yao S, Tie X, Shi X, Feng R, Su X, Wang L. Enteric-coated Mycophenolate Sodium therApy versus cyclophosphamide for induction of Remission in Microscopic PolyAngiitis (EMSAR-MPA trial): study protocol for a randomised controlled trial. BMJ Open 2024; 14:e074662. [PMID: 38471694 PMCID: PMC10936518 DOI: 10.1136/bmjopen-2023-074662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 02/22/2024] [Indexed: 03/14/2024] Open
Abstract
INTRODUCTION Several studies have demonstrated that mycophenolate mofetil (MMF) may be an excellent alternative to cyclophosphamide (CYC) or rituximab for the induction of remission in non-life-threatening anti-neutrophil cytoplasmic antibodies associated vasculitis because of its strong immunosuppressive potency and low toxicity profile. Enteric-coated mycophenolate sodium (EC-MPS) was introduced to reduce gastrointestinal adverse reactions of MMF. This study will evaluate the efficacy and safety of EC-MPS combined with glucocorticoid in patients with active and non-life-threatening microscopic polyangiitis (MPA). METHODS AND ANALYSIS This study is a multicentre, open-label, randomised controlled, non-inferiority trial. A total of 110 patients with active and non-life-threatening MPA from 11 hospitals in Shanxi Province of China will be recruited and randomised in a 1:1 ratio to receive either EC-MPS or CYC. All patients will receive the same glucocorticoid plan. We will compare oral EC-MPS (720-1440 mg/day) with intravenous pulsed CYC (7.5-15 mg/kg) administered for 3-6 months. All patients will be switched from their assigned treatment (EC-MPS or CYC) to oral azathioprine (2 mg/kg/day) after remission has been achieved, between 3 and 6 months. Azathioprine will be continued until the study ends at 18 months. The primary end point of efficacy is the remission rate at 6 months. Follow-up will continue for 18 months in order to detect an influence of induction regimen on subsequent relapse rates. ETHICS AND DISSEMINATION This study has received approval from the Ethics Committee of the Second Hospital of Shanxi Medical University (2022YX-026). All participants are required to provide written informed consent and no study-related procedures will be performed until consent is obtained. The results of this trial will be published in peer-reviewed journals and presented at conferences. TRIAL REGISTRATION NUMBER ChiCTR2200063823.
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Affiliation(s)
- Sijia Li
- Division of Nephrology, Shanxi Medical University Second Hospital, Shanxi Kidney Disease Institute, Taiyuan, Shanxi, People's Republic of China
| | - Shulei Yao
- Division of Nephrology, Shanxi Medical University Second Hospital, Shanxi Kidney Disease Institute, Taiyuan, Shanxi, People's Republic of China
| | - Xuan Tie
- Division of Nephrology, Shanxi Medical University Second Hospital, Shanxi Kidney Disease Institute, Taiyuan, Shanxi, People's Republic of China
| | - Xiaojing Shi
- Division of Nephrology, Shanxi Medical University Second Hospital, Shanxi Kidney Disease Institute, Taiyuan, Shanxi, People's Republic of China
| | - Rongrong Feng
- Division of Nephrology, Shanxi Medical University Second Hospital, Shanxi Kidney Disease Institute, Taiyuan, Shanxi, People's Republic of China
| | - Xiaole Su
- Division of Nephrology, Shanxi Medical University Second Hospital, Shanxi Kidney Disease Institute, Taiyuan, Shanxi, People's Republic of China
| | - Lihua Wang
- Division of Nephrology, Shanxi Medical University Second Hospital, Shanxi Kidney Disease Institute, Taiyuan, Shanxi, People's Republic of China
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Xu G, Wang Z, Yan T, Li J, Zhou X. Bioequivalue of two mycophenolate sodium enteric-coated tablets and the drug monitoring based on limited sampling strategy: A single-center, randomized, open-label, three-period, reference-replicated, crossover study. Transpl Immunol 2023; 81:101923. [PMID: 37652363 DOI: 10.1016/j.trim.2023.101923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 08/18/2023] [Accepted: 08/27/2023] [Indexed: 09/02/2023]
Abstract
OBJECTIVE A mycophenolate sodium enteric-coated tablet has shown a satisfying anti-rejection effect in patients receiving solid organ transplantation. The current study evaluated the bioequivalence between the test (Ruiyirong®) vs. reference (Myfortic®) formulations by exploring equations for predicting their area under the concentration-time curve (AUC) using a limited sampling strategy in healthy subjects. METHODS Forty-eight healthy Chinese subjects were randomized into three administration sequences (test-reference-reference, reference-reference-test, and reference-test-reference) to receive the Ruiyirong or Myfortic treatment on days 1, 8, and 15. RESULTS The 90% confidential interval (CI) of the geometric mean ratios (test/reference) of maximum plasma concentration (Cmax), the AUC from time 0 to the last timepoint (AUC0-t), and the AUC from 0 to infinity (AUC0-∞) was 92.90%-110.57%, 96.91%- 101.80%, and 96.71%-101.84%, respectively. All these values fell into the bioequivalence criteria of 80.00%-125.00% (based on the criteria of the Food and Drug Administration). The adverse events were 10.4% in Ruiyirong test group and 14.6% in Myfortic reference group. Eight equations for estimating the AUC of the Ruiyirong test and Myfortic reference formulations were evaluated; most of them worked well with the R-value >0.8. Among the four chosen equations, the intragroup verification exhibited a high agreement with the R-value ranging from 0.857 to 0.971 and with the low predictive error (PE > 5% with absolute PE > 15%). Meanwhile, the intergroup verification indicated a high inter-agreement with the R-value ranging from 0.896 to 0.974 (all P < 0.001). CONCLUSION The Ruiyirong test vs. Myfortic reference formulations meet the bioequivalent criteria and are well tolerated. The further linear regression analysis explores eight equations predicting the AUC value and the chosen four equations for the Ruiyirong test and Mayfortic reference formulations are interchangeable.
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Affiliation(s)
- Guangxun Xu
- Hepato-Pancreato-Biliary Center, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing 102218, China
| | - Zhendi Wang
- Department of Urology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Key Laboratory of Organ Transplantation, Ministry of Education, NHC, Chinese Academy of Medical Sciences, Wuhan 430030, China
| | - Tianzhong Yan
- Department of Urology, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Henan University People's Hospital, Zhengzhou 450003, China
| | - Jinyu Li
- Department of Urology Surgery, 909 Hospital, Joint logistic Support Force of PLA (Southeast Hospital, Xiamen University), Zhangzhou 363000, China
| | - Xiaofeng Zhou
- Department of Urology, China-Japan Friendship Hospital, Beijing 100029, China.
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