Mycophenolate. What, When, How and Why

Introduction

Welcome to the Bova UK podcast, where we discuss veterinary diseases from diagnosis through to management. These podcasts are designed for registered veterinary surgeons and veterinary nurses. However, if you’re listening as a pet owner, we strongly advise that you consult with your local veterinary surgeon if you have any concerns about your animal

---

Meet the Expert

Emma

Welcome, Darren. It’s great to have you on today’s podcast. As a brief introduction, Darren Kelly is a specialist in internal medicine, currently practising at a referral hospital in Hampshire, and he’s also part of the team at Veterinary Specialists Online. To begin with, could you tell us what Veterinary Specialists Online offers?

Dr Darren Kelly

Thanks, Emma, and thank you for having me. Veterinary Specialists Online—or VSO—is a service providing remote specialist support to first-opinion vets via video or phone consultations with pet owners. Afterward, we provide a comprehensive report with guidance on diagnosis, investigation, and treatment.

In addition, we support both vets and clients in cases where in-person referrals aren’t feasible. Moreover, our team spans various disciplines including internal medicine, oncology, cardiology, behaviour, and more. Notably, we also offer a vet-to-vet advice service.

Emma

That sounds incredibly helpful, especially in light of current pressures on referral services.

---

Part 1: Introduction to Mycophenolate

Emma

Today, we’re focusing on managing immune-mediated diseases—specifically, the use of mycophenolate. Why did you choose to highlight this drug?

Dr Darren Kelly

Mycophenolate is an immunosuppressive agent that’s less frequently used than others like ciclosporin or azathioprine. Nonetheless, it has some clear advantages. Therefore, I want to help vets become more comfortable with its use, mechanisms, and effects.

---

Part 2: Mechanism and Clinical Application

Emma

So, how does mycophenolate work?

Dr Darren Kelly

Mycophenolate mofetil is a prodrug converted in the liver to mycophenolic acid. Importantly, it inhibits inosine monophosphate dehydrogenase, which is essential for DNA synthesis in B and T lymphocytes. Consequently, it reduces immune cell proliferation.

Originally, it was developed as an alternative to azathioprine, with similar efficacy but fewer serious side effects.

Emma

Which immune-mediated diseases do you treat with it?

Dr Darren Kelly

It’s used in IMHA, IMTP, MUE, and also for conditions like immune-mediated polyarthritis and myasthenia gravis. Furthermore, it’s a first-line option for immune complex glomerulonephritis.

---

Part 3: Dosage and Formulation

Emma

What dose do you typically recommend?

Dr Darren Kelly

The standard dose is 10–12 mg/kg twice daily. While once-daily dosing is possible, I prefer splitting it to reduce side effects. Also, I administer it with food for better compliance.

Emma

Does formulation matter in smaller patients?

Dr Darren Kelly

Yes, definitely. Human products are large and can’t be split. Hence, for smaller patients or cats, a reformulated version from a manufacturer like Bova is essential.

---

Part 4: Duration and Monitoring

Emma

How long do you use mycophenolate in IMHA or IMTP?

Dr Darren Kelly

Typically, I treat for four to six months, initially combining it with steroids. Ideally, I taper steroids within 8–10 weeks, then continue mycophenolate alone.

Emma

Do you recommend gastroprotectants?

Dr Darren Kelly

Not routinely. In fact, recent evidence suggests PPIs may cause more harm than good in some cases. Thus, I reserve them for specific indications.

Emma

What about blood monitoring?

Dr Darren Kelly

Mycophenolate doesn’t usually cause bone marrow suppression or liver issues. Therefore, I only monitor based on the underlying disease, not just the drug.

---

Part 5: Side Effects and Interactions

Emma

What side effects do you see most commonly?

Dr Darren Kelly

Gastrointestinal upset, mainly diarrhoea—seen in about 10–15% of dogs. Generally, I continue treatment if mild. However, for more severe cases, I might add probiotics or short-term metronidazole.

Emma

Are there any drug combinations to avoid?

Dr Darren Kelly

Yes—avoid pairing it with azathioprine. They act on similar pathways and combining them isn’t beneficial. On the other hand, it can be used alongside ciclosporin if needed.

---

Part 6: Choosing the Right Treatment

Emma

How do you decide which immunosuppressant to use?

Dr Darren Kelly

Overall, it depends on familiarity, tolerability, and cost. I prefer mycophenolate for IMHA and IMTP. Meanwhile, I favour leflunomide for immune-mediated polyarthritis.

Emma

Can mycophenolate be used alone?

Dr Darren Kelly

It’s not typical, but it may work as a sole agent in some IMTP cases. Nonetheless, steroids are usually necessary at the start for quicker control.

---

Closing Remarks

Emma

Darren, thank you for the valuable insights—it’s been a really informative session.

Dr Darren Kelly

Thank you. It’s been a pleasure to share this with your audience.

---

Outro

This podcast is intended for registered veterinary professionals. If you are a pet owner, please consult your vet directly with any concerns about your animal.