Thread by @Rheumat_Aravind

🧵 MMF in 2025: Still the Lymphocyte Whisperer

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💊 Mycophenolate mofetil (MMF) remains a backbone immunosuppressant in lupus nephritis, ILD, and more.
But in 2025, its story has evolved — from better combos to smarter uses.
Let’s unpack the latest. 👇

@IhabFathiSulima @drkeithsiau @DrAkhilX #MedTwitter

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🔬 How it works
MMF blocks inosine monophosphate dehydrogenase (IMPDH) → shuts down guanosine synthesis.
This hits T & B cells hard (they rely on de novo purine synthesis).
🛑 Autoimmunity off, immunity preserved… mostly.

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🧠 What’s new mechanistically?
MMF not only suppresses lymphocytes but also tips the scale toward regulatory T cells (Tregs).
📉 CD4+, CD8+, B cells ↓
📈 Foxp3+ Tregs ↑
A quiet immune recalibration, not just brute-force suppression.

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📚 Updated Guidelines (ACR & KDIGO 2024–25)
✅ MMF now first-line in lupus nephritis (esp. Class III–V)
✅ Often combined with steroids + belimumab or voclosporin
✅ Pediatric SLE? MMF is no longer off-label — it’s endorsed.

🧠 Treat early. Combine smartly.

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🏥 Clinical Uses (beyond LN)
• Systemic sclerosis-ILD
• ANCA vasculitis (maintenance)
• Autoimmune hepatitis (select cases)
• Uveitis, myositis, Sjögren’s (off-label)
Versatile, especially when fertility or renal preservation matters.

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🧪 MMF vs AZA — 2025 Data
A recent RCT confirms it:
MMF > Azathioprine in preventing SLE flares during maintenance.
🛡️ Better disease control, same safety profile.
Evidence is stacking up.

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🚨 Side Effects to Watch
• GI: nausea, diarrhea
• Cytopenias
• Opportunistic infections (CMV, BK)
• Rare: hepatotoxicity

🔄 Switch to enteric-coated MPA if GI issues persist.
Stay alert, not afraid.

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👶 Pregnancy & Fertility
🚫 MMF is teratogenic — linked to miscarriage and malformations.
💡 Stop 6 weeks before conception.
✅ Use azathioprine or HCQ in pregnancy.
Fertility-sparing, but not pregnancy-safe.

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🧠 Monitoring Tips
No routine MPA levels. Focus on:
• CBC, LFTs, renal function
• Infection screening (CMV, TB, BK)
• Adherence
🧬 And don’t forget: no live vaccines during treatment.

🔄 Recheck before vaccines or surgery.

📈 Emerging Uses (2025)
• 🫁 Systemic sclerosis skin fibrosis — modest mRSS improvement in meta-analyses
• 🧠 AI-guided lupus nephritis pathology scoring now helps personalize MMF dosing
• 🧴 Liver transplant patients switching from CNIs to MMF show renal rescue!

🧬 It’s not just for lupus anymore.

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🧠 Pro Tips for 2025 Practice
• MMF + belimumab = synergy
• Splitting dose improves GI tolerance
• Expect immunoglobulin dip → watch for infections
• Counsel early on fertility & contraception

🎯 Use it wisely. It rewards experience.

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💡 MMF in 2025 is not just about suppression — it’s about precision, preservation, and personalization.

From lupus kidneys to scleroderma lungs, MMF continues to deliver.

#RheumTwitter #NEETPG