CASE REPORT Mycophenolate mofetil 585 Am J Health-Syst Pharm—Vol 68 Apr 1, 2011 C A S E R E P O R T Oral ulcers associated with mycophenolate mofetil use in a renal transplant recipient RENEE R. WENG, CLARENCE E. FOSTER III, LANNY L. HSIEH, AND PUJA R. PATEL Purpose. A case study of mycophenolate mofetil-induced oral ulcers in a renal trans- plant patient is reported. Summary. A 23-year-old Hispanic man who received a renal transplant from a liv- ing relative secondary to end-stage renal disease due to focal segmental glomeru- losclerosis arrived at an outpatient clinic with gum swelling and pain. He had been on a maintenance immunosuppressive regimen consisting of cyclosporine 150 mg twice daily, mycophenolate mofetil 1 g twice daily, and prednisone 12.5 mg daily for approximately four months. Rou- tine laboratory tests revealed an elevated serum creatinine concentration (2.2 mg/ dL) and a decreased white blood cell count (2.3 × 10 3 /μL). All other laboratory test values were within normal limits. Initially, cyclosporine-induced gingival hyperplasia was suspected. However, despite reduc- tion of the cyclosporine dosage, the gum pain and swelling did not improve, and the patient began to complain of odynophagia and worsening of symptoms. On physical examination, scattered ulcerations on the RENEE R. WENG, PHARM.D., is Transplant Pharmacist Specialist, Department of Pharmacy Practice, Division of Renal and Pancreas Transplantation; CLARENCE E. FOSTER III, M.D., is Associate Clinical Professor and Chief, Division of Renal and Pancreas Transplantation; and LANNY L. HSIEH, M.D., is Assistant Professor and Hospitalist, Department of Medicine, University of California Irvine (UCI) Medical Center, Orange. PUJA R. PATEL, PHARM.D., is Postgraduate Year 1 Pharmacy Practice Resident, Northshore University Health System, Evanston, IL; at the time of writing she was a pharmacy stu- dent, UCI Medical Center. Address correspondence to Dr. Weng at the Division of Renal and Pancreas Transplantation, University of California Irvine Medical Center, 333 City Boulevard West, Suite 1205, Orange, CA 92868 (rweng@uci.edu). The authors have declared no potential conflicts of interest. Copyright © 2011, American Society of Health-System Pharma- cists, Inc. All rights reserved. 1079-2082/11/0401-0585$06.00. DOI 10.2146/ajhp100276 gums and lips were noted. The diagnosis of oral ulcerations secondary to myco- phenolate mofetil therapy was suspected when other etiologies, such as hemato- logic disorders, malignancies, and viral in- fections, were eliminated. Mycophenolate mofetil was discontinued. One week later, the patient’s ulcers had regressed and odynophagia improved, as did his renal function and leukopenia. Mycophenolate mofetil was not restarted, and the patient reported complete resolution of symp- toms six weeks after discontinuation of mycophenolate mofetil. Conclusion. After five months of therapy, a 23-year-old renal transplant recipient developed mycophenolate mofetil toxicity manifested as oral ulcers. Discontinuation of therapy resulted in rapid resolution of oral ulcers. Index terms: Cyclosporine; Immunosup- pressive agents; Kidney failure; Mycophen- olate mofetil; Oral ulcer; Prednisone; Toxic- ity; Transplantation Am J Health-Syst Pharm. 2011; 68:585-8 K idney transplantation is an im- portant therapeutic option for patients with end-stage renal disease (ESRD), offering a chance of an improved quality of life and im- proved long-term survival. 1-3 How- ever, kidney transplantation requires patients to remain on lifelong im- munosuppressive therapy to prevent allograft rejection. 1 Recent advances in immunosuppressive therapy have resulted in improved graft and pa- tient survival rates, as well as lower rates of transplant rejection. 4 The goal of immunosuppres- sive therapy is to prevent allograft rejection while minimizing drug- related adverse effects, opportunistic infections, and transplant-related malignancies. A multidrug regi- men is often used, as it allows for a synergistic effect and a reduction of drug toxicity. At most transplanta- tion centers, a three-drug regimen consisting of a calcineurin inhibitor, an antiproliferative agent, and a cor- ticosteroid such as prednisone is the standard of care. 4 Regimens may vary from center to center based on needs, experience, and cost and are often individualized based on risk of rejec- tion and graft loss. Data suggest that long-term outcomes are superior in patients who receive a kidney from a living donor versus a deceased donor; therefore, many transplant centers have different immunosuppressive regimens for living donor and de-