Mycophenolate mofetil is noninferior to cyclophosphamide for inducing remission among patients with antineutrophil cytoplasmic antibody-associated vasculitis, randomized trial data show.

Discontinuation of mycophenolate mofetil for at least 10 days is associated with an improved antibody response to COVID-19 vaccination among people with rheumatic diseases, research suggests.

The study, published in The Lancet Rheumatology , included 158 participants treated with cyclophosphamide or placebo in SLS I and 142 participants who were given cyclophosphamide or mycophenolate mofetil in SLS II.

The EMA recommends that voclosporin should be used in combination with mycophenolate mofetil for treating active class III, IV, or V lupus nephritis in adults.

Noemie Jourde-Chiche (Aix-Marseille Université, France) and co-authors report in the Annals of the Rheumatic Diseases that the 2-year relapse rate was 27.3% in 44 patients who were randomly assigned to taper and discontinue maintenance immunosuppressive therapy with azathioprine or mycophenolate mofetil over a 3-month period after 2‒3 years of treatment.

In patients treated with mycophenolate mofetil–corticosteroid combination therapy, administration of a third vaccine dose significantly increased seroconversion rates from 52.6% after the second dose to 89.5% after the third dose.

Antibody nonresponse, receipt of the Bharat Biotech Covaxin vaccine, and mycophenolate mofetil use were all significantly associated with breakthrough infection risk on univariate analysis.

The study included 21 patients on immunosuppressive maintenance therapy regimens involving combinations of steroids, azathioprine, mycophenolate mofetil, and rituximab, who received two doses of the BNT162b2 vaccine between March and May 2021, with a third dose given a median 103 days after the second.

Rovin remarked that the combination of voclosporin and mycophenolate mofetil was “effective in patients of diverse racial and ethnic backgrounds” in a subgroup analysis of the AURORA trial.

And among those who were subsequently hospitalized, 10 (46%) were taking CD20 inhibitors and seven (32%) were on anti-metabolites, specifically mycophenolate.

They explain that background therapy in both groups comprised mycophenolate mofetil 1 g twice daily plus intravenous methylprednisolone 0.25–0.5 g/day for 2 days followed by rapidly tapering oral prednisone with a starting dose of 20–25 mg/day.

The phase 3 double-blind study is a 2-year extension of the previously reported AURORA 1 study , comparing the calcineurin inhibitor voclosporin 23.7 mg twice a day with placebo as an add on to mycophenolate mofetil 2.0 g/day and low-dose steroid treatment.

They found that higher levels of total serum IgG and naïve B cells at baseline were associated with better seropositivity rates at day 42, while treatment with methotrexate or mycophenolate mofetil was associated with a “drastically reduced” antibody response.

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The researchers note that DMARDs used prior to hospitalization included rituximab in four patients and mycophenolate mofetil or mycophenolic acid in two.

They say that pooled seroconversion rates were “excellent” (>90%) in people taking tumor necrosis factor (TNF) inhibitors, interleukin inhibitors, and anti-integrin therapies, but “slightly lower” (70–90%) with other drugs including mycophenolate mofetil, methotrexate, hydroxychloroquine, and Janus kinase (JAK) inhibitors.

In accordance with the higher degree of disease severity, patients with early-onset pSS were prescribed prednisone/methylprednisolone (38.89 vs 21.55%) or mycophenolate mofetil (13.89 vs 0.34%) significantly more often than those in the later-onset group.

In an exploratory multivariate analysis, they found that older people (≥60 years) in the RMD group, as well as those taking prednisone, methotrexate, mycophenolate mofetil, tumor necrosis factor inhibitors, abatacept, or rituximab, had a reduced likelihood of seroconversion.

The 37 patients who did not mount an IgG response included 24 of the 47 rituximab-treated patients, three of the eight abatacept-treated patients, and two of the 11 taking mycophenolate mofetil monotherapy.

Mycophenolate mofetil or intravenous cyclophosphamide is suggested as induction therapy for lupus nephritis classes III and IV.