[CIS PIDD] [cis-pidd] MMF - VZV vaccine - Low level Immune suppression ?

[Ravishankar.Sargur at sth.nhs.uk]

Dear all, 

Our rheumatologists have twigged that the guidelines on VZV vaccine does not capture the dose the MMF ( defining low dose immune suppression). 

Both the US and UK guidelines define AZA < 3mg/kg / day as low dose immune suppression.  There is no data on dose equivalence between MMF and AZA.  Mechanistically - MMF is more active against activated T cells. 
If one looks at comparison of adverse events ( HZ occurrence and other infections) between AZA and MMF in the  Renal, hepatic, cardiac TX - they are comparable, but the studies have used AZA of upto 2 mg/kg. MMF 1 g BD is probably equivalent to  AZA  =2mg/kg. 

My view ( in the absence of data on dose equivalence, erring on the side of caution) is 1g BD as a cut-off for low level immunosuppression.  

I would appreciate your thoughts and comments ?  - whether up to 3 g / day MMF is acceptable for administration of  VZV vaccine. 

BW

Ravi 


"Low-level immunosuppression includes treatment with prednisone <2 mg/kg with a maximum of ≤20 mg/day; methotrexate ≤0.4 mg/kg/week; azathioprine ≤3 mg/kg/day; or 6-mercaptopurine ≤1.5 mg/kg/day. 
High-level immunosuppression regimens include treatment with doses higher than those listed for low-dose immunosuppression and biologic agents such as tumor necrosis factor antagonists or rituximab." ( ACIP (US) and Green Book (UK)).  http://cid.oxfordjournals.org/content/early/2013/11/26/cid.cit684/T6.expansion.html 



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