tacrolimus and Oral-Ulcer

A case of mycophenolate mofetil (MMF)-induced oral ulceration in a kidney transplant recipient is reported.. A 54-year-old man who had received a kidney transplant 7 months previously reported to our outpatient clinic with severe oral ulcers with odynophagia and was admitted to the hospital. His maintenance immunosuppressive agents at the time of admission consisted of tacrolimus and mycophenolate. The patient had stable renal function, with all laboratory values within normal ranges. After various alternative etiologies were ruled out, drug-induced oral ulceration was suspected, and the patient's tacrolimus dose was empirically reduced, resulting in reduction of the trough concentration from 10 ng/mL to 3.3 ng/mL without improvement of the ulceration. Mycophenolate-induced oral ulceration was suspected, and MMF was discontinued. Within 5 days of discontinuation, there was a remarkable improvement in both the size and severity of the ulceration, and the patient was discharged from the hospital. During the next clinic visit (a total of 12 days after MMF was discontinued), the patient's mouth and esophageal ulcers had completely healed. Six weeks after complete resolution of the ulcer, MMF at a dosage of 250 mg twice daily was initiated; the dosage was subsequently increased to 500 mg twice daily without a recurrence of ulceration.. A 54-year-old man developed oral ulceration after 7 months of MMF therapy. Discontinuation of therapy resulted in prompt resolution of the patient's ulcers, with no recurrence of ulceration at a lower MMF dose. This is the first case report indicating that mycophenolate-induced ulceration may be dose dependent.

Topics: Dose-Response Relationship, Drug; Humans; Immunosuppressive Agents; Kidney Transplantation; Male; Middle Aged; Mycophenolic Acid; Oral Ulcer; Tacrolimus

Topics: Administration, Topical; Humans; Immunosuppressive Agents; Lichen Planus, Oral; Oral Ulcer; Tacrolimus; Treatment Outcome

Myelodysplastic syndrome (MDS) in children is often associated with chromosomal anomalies and trisomy 8 is a characteristic karyotypic feature in up to 20% of the cases. Behçet disease is a rare multisystem inflammatory disorder characterized by recurrent mouth and genital ulcers. MDS with trisomy 8 has been observed in adult patients with Behçet syndrome with some cases developing prior to the clinical manifestations of the latter. We present a female with a similar association and explain the importance of identifying the coexisting conditions. The immunological abnormalities, which may be observed in MDS and their possible mechanisms, are also discussed.

Topics: Adolescent; Anemia, Refractory; Behcet Syndrome; Chromosomes, Human, Pair 8; Female; Humans; Immunologic Deficiency Syndromes; Immunosuppressive Agents; Karyotyping; Oral Ulcer; Tacrolimus; Thalidomide; Trisomy

Mycophenolate Mofetil (MMF) is an immunosuppressive drug usually used in kidney transplants to prevent rejection. It has various adverse effects such as leucopenia, anemia, diarrhea but Mouth ulcers are rarely reported.. We present a case report of MMF-induced mouth ulcers in an African patient.. A 41-year-old African-male patient has painful oral ulcers which developed 5 months after kidney transplantation. The immunosuppressive maintenance regimen comprised Steroids, Tacrolimus and MMF.. These ulcers were firstly related to a fungic or viral infection so the patient was prescribed Fluconazole and Aciclovir without any improvement. Then, Tacrolimus blood level was checked and it was in a therapeutic range. Finally, we decide to stop MMF and the ulcers healed quickly.. Oral ulcers are frequently seen complications in immunosuppressant patient but are rarely described with MMF. These ulcers can become large and very painful and degrade patient's life quality. So when infections causes are excluded, we have to keep in mind that these ulcers can be a drug adverse effect.

Topics: Adult; Drug-Related Side Effects and Adverse Reactions; Humans; Immunosuppressive Agents; Kidney Transplantation; Male; Mycophenolic Acid; Oral Ulcer; Steroids; Tacrolimus; Transplant Recipients

Ulcerative lichen planus (ULP) is a rare variant of lichen planus that is characterized by chronic, painful, and disabling ulcerations. Ulcerative lichen planus has been known to be resistant to many treatments, and therapeutic interventions often involve use of aggressive immunosuppressive medications without satisfactory remission of symptoms. We present the case of a 56-year-old man with an 8-year history of painful ulcerations on the right plantar foot as well as a large ulceration of the left lateral tongue. Biopsy confirmed a suspected diagnosis of plantar ULP. The patient developed marked clinical improvement of the cutaneous and oral mucosal lesions with oral and topical steroids, topical tacrolimus, and oral doxycycline after only 4 weeks of treatment. It is important for dermatologists to be aware of the potential diagnosis of plantar ULP, especially in the evaluation of chronic treatment-resistant ulcers that often have been previously misdiagnosed. We introduce this novel therapeutic regimen as a rapidly effective and relatively safe alternative to conventional immunosuppressive agents for long-term management of plantar ULP.

Topics: Biopsy; Doxycycline; Drug Therapy, Combination; Follow-Up Studies; Foot Ulcer; Glucocorticoids; Humans; Immunosuppressive Agents; Lichen Planus; Male; Middle Aged; Oral Ulcer; Tacrolimus; Treatment Outcome

Topics: Actinomycosis; Antilymphocyte Serum; Humans; Immunosuppression Therapy; Kidney Transplantation; Male; Middle Aged; Mycophenolic Acid; Oral Ulcer; Tacrolimus; Transplantation, Homologous

Immunosuppressive drugs and other medications may predispose patients to oral diseases. Data on oral mucosal health in recipients of liver transplantation (LT) are limited. We, therefore, recruited 84 LT recipients (64 with chronic liver disease and 20 with acute liver failure) for clinical oral examinations in a cross-sectional, case-control study. Their oral health had been clinically examined before transplantation. The prevalence of oral mucosal lesions (OMLs) was assessed in groups with different etiologies of liver disease and in groups with different immunosuppressive medications, and these groups were compared to controls selected from a nationwide survey in Finland (n = 252). Risk factors for OMLs were evaluated with logistic regression. OMLs were more frequent in LT recipients versus controls (43% versus 15%, P < 0.001), and the use of steroids raised the prevalence to 53%. Drug-induced gingival overgrowth was the single most common type of lesion, and its prevalence was significantly higher for patients using cyclosporine A (CSA; 29%) versus patients using tacrolimus (TAC; 5%, P = 0.007); the prevalence was even higher with the simultaneous use of calcium channel blockers and CSA (47%) or TAC (8%, P = 0.002). Lesions with malignant potential such as drug-induced lichenoid reactions, oral lichen planus-like lesions, leukoplakias, and ulcers occurred in 13% of the patients with chronic liver disease and in 6% of the controls. Every third patient with chronic liver disease had reduced salivary flow, and more than half of all patients were positive for Candida; this risk was higher with steroids. In conclusion, the high frequency of OMLs among LT recipients can be explained not only by immunosuppressive drugs but also by other medications. Because dry mouth affects oral health and OMLs may have the potential for malignant transformation, annual oral examinations are indicated.

Topics: Adult; Aged; Calcium Channel Blockers; Case-Control Studies; Cross-Sectional Studies; Cyclosporine; End Stage Liver Disease; Female; Gingival Diseases; Humans; Immunosuppressive Agents; Leukoplakia; Lichen Planus; Liver Failure, Acute; Liver Transplantation; Logistic Models; Male; Middle Aged; Mouth Mucosa; Oral Ulcer; Prevalence; Risk Factors; Tacrolimus

Medication-induced ulcerative stomatitis can be a complication of immunosuppressive therapy in a post-transplant patient. A 54-year-old African-American female patient presented with significant, recalcitrant oral ulcers 5 months after renal transplant as a result of mucosal toxicity and severe leucopenia caused by her immunosuppressive maintenance regimen of tacrolimus (US Pharmacopeia, Rockville, MD) and mycophenolate mofetil (Santa Cruz Biotechnology, Santa Cruz, CA). The patient was also prescribed fluconazole as an antifungal, which likely contributed to the patient's increase in tacrolimus blood levels. Altering the medication dosages ultimately reduced blood tacrolimus levels, allowing for resolution of her oral ulcers. This report indicates that medication-induced oral ulcerations are a potential sequela of post-transplant immunosuppressive therapy.

Topics: Female; Graft Rejection; Humans; Immunosuppressive Agents; Kidney Transplantation; Middle Aged; Mycophenolic Acid; Oral Ulcer; Tacrolimus

To evaluate the efficacy and safety of conversion from calcineurin inhibitors to sirolimus among liver transplant recipients with calcineurin inhibitor-induced complications.. After receiving liver transplants, 25 patients with calcineurin inhibitor-induced complications (22 renal dysfunction and 3 new-onset diabetes mellitus) were converted from sirolimus to tacrolimus. The serum creatinine, sirolimus trough level, liver function, acute rejection episodes, and drug-related adverse effects were monitored.. The patients were followed for 12 to 50 months (median, 25 months). The renal function of the 22 patients with renal dysfunction improved after sirolimus conversion. The serum creatinine levels were significantly lower at 3 months after conversion versus before conversion (113.2 ± 21.8 μmol/L vs 163.2 ± 45.3 μmol/L; P < .05). At the end of the follow-up, the average serum creatinine level was 101.9 ± 23.4 μmol/L among the 20 living recipients. Diabetes also was under control in 3 diabetic recipients after the conversion. Four patients experienced episodes of acute rejection, and intravenous steroid bolus therapy was administered in 2 of them. No graft was lost because of acute rejection. The adverse effects of sirolimus included hyperlipidemia (7/25), anemia (8/25), and mouth ulcers (9/25). All these adverse effects were relieved after a short-term symptomatic therapy, and no patient was withdrawn from the conversion trial.. Sirolimus monotherapy is effective and safe in liver transplant recipients. Conversion to sirolimus was associated with a sustained improvement in renal function and diabetes mellitus without an increased incidence of acute rejection episodes.

Topics: Acute Disease; Anemia; Calcineurin Inhibitors; Creatinine; Diabetes Mellitus, Type 2; Follow-Up Studies; Graft Rejection; Humans; Hyperlipidemias; Immunosuppressive Agents; Liver Transplantation; Male; Middle Aged; Oral Ulcer; Retrospective Studies; Sirolimus; Tacrolimus

Topics: Adult; Enzyme Inhibitors; Female; Humans; Immunosuppressive Agents; Mycophenolic Acid; Oral Ulcer; Pancreas Transplantation; Sirolimus; Tacrolimus; Tongue Diseases

Topics: Acute Disease; Adult; Behcet Syndrome; Diarrhea; Glomerulonephritis, IGA; Humans; Immunosuppressive Agents; Kidney Diseases; Kidney Transplantation; Male; Oral Ulcer; Recurrence; Tacrolimus

Topics: Child, Preschool; Graft Rejection; Heart Transplantation; Humans; Immunosuppressive Agents; Male; Oral Ulcer; Stomatitis, Aphthous; Tacrolimus; Treatment Outcome

Topics: Aged, 80 and over; Calcineurin Inhibitors; Female; Humans; Immunosuppressive Agents; Lichen Planus, Oral; Oral Ulcer; Recurrence; Tacrolimus; Time Factors

Calcineurin inhibitors have dramatically improved the outcomes of pediatric liver transplantation. However, calcineurin inhibitor use is associated with a 50% reduction in glomerular filtration rate in the first year post-transplant. Nephrotoxicity can be difficult to manage, especially in the pediatric population. We hypothesized that the addition of an mTOR inhibitor with decreased calcineurin inhibitor levels might improve or prevent renal insufficiency and improve control of rejection. A retrospective chart review was performed on the patients treated with sirolimus who had undergone an orthotopic liver transplant between January 2000 and February 2003. Thirty-eight patients were identified. Mean age was 8.6 yr. Fourteen patients were male and 24 were female. Mean weight was 30.3 kg. The most common indications for starting sirolimus were rejection (42%) and renal impairment (29%). Seventy-three percent of patients begun on sirolimus remain on the medication. Those with renal impairment (11 patients) showed improvement in their creatinine levels from a mean baseline of 1.3 to 0.8 mg/dL. Their calculated creatinine clearance (Schwartz formula) improved from 63.7 to 84.8 mL/min (p = 0.03). Patients started on sirolimus for rejection showed significant improvement in hepatocellular enzymes despite a reduction in the tacrolimus level from 12.2 to 7.5 ng/mL. The mean alanine aminotransferase level improved from 221 to 100 units/L (p = 0.02), and the mean aspartate aminotransferase improved from 121 to 99 units/L (p = 0.59). Addition of sirolimus to a tacrolimus-based regimen with lower target tacrolimus levels improved liver function in patients with rejection. Addition of sirolimus significantly improved renal function as shown by creatinine level and calculated creatinine clearance in those children with renal impairment. The effect of combined immunosuppressant treatment with tacrolimus and sirolimus on long-term renal function needs to be evaluated.

Topics: Adolescent; Adult; Child; Child, Preschool; Creatinine; Drug Therapy, Combination; Female; Hepatitis; Humans; Immunosuppressive Agents; Infant; Liver Transplantation; Male; Neutropenia; Oral Ulcer; Postoperative Care; Retrospective Studies; Sirolimus; Tacrolimus; Treatment Outcome

Oral ulcers have may possible causes, including immunosuppression and drug therapy. Severe cases of oral ulceration merit special consideration because the ulcers may become large enough to alter the quality of life of the patient. The present case involves a male patient who in 1994 received an orthotopic liver transplantation because of alcoholic cirrhosis. The initial immunosuppressive regimen was induced with tacrolimus (4 mg/d) and prednisone (20 mg/d). Ten months after orthotopic liver transplantation, the patient complained of multiple recurrent oral ulcers, dysphagia, and severe oral pain, which did not respond to any of the treatments over a 3-year period. Approximately 3(1/4) years after these unresponsive ulcers appeared, the reduction of the oral dosage of tacrolimus resulted in the total remission of the ulcers. A retrospective analysis demonstrated that appearance of the ulcers coincided with a dose of 9 mg/d of tacrolimus (whole blood levels of 12 ng/mL); the ulcers did not disappear until the dose was reduced to 4 mg/d (whole blood level of 6.6 ng/mL).

Topics: Administration, Oral; Deglutition Disorders; Follow-Up Studies; Humans; Immunosuppressive Agents; Liver Cirrhosis, Alcoholic; Liver Transplantation; Male; Middle Aged; Oral Ulcer; Recurrence; Retrospective Studies; Tacrolimus; Treatment Outcome

Topics: Adult; Drug Therapy, Combination; Graft vs Host Disease; Hematopoietic Stem Cell Transplantation; Humans; Hyperbilirubinemia; Immunosuppressive Agents; Infection Control; Leukemia, Monocytic, Acute; Male; Mycophenolic Acid; Oral Ulcer; Prednisone; PUVA Therapy; Tacrolimus; Transplantation, Homologous; Xerostomia

The buccal side effects of immunodepressors are well defined with cyclosporine and certain antimitotic agents. We report a case of buccal ulcerations in a patient treated with a new immunosuppressive macrolide: tacrolimus (Prograf).. A 53 year-old woman presenting a severe cardio-myopathy, underwent heart transplantation in May 1997. Tacrolimus was introduced in October 1997 after 3 episodes of acute reject. Eight months after tacrolimus, painful apthoid buccal ulcerations appeared. Biopsy of the buccal mucosa and other biological examinations revealed no particular etiology. Since tacrolimus could not be stopped, treatment with thalidomide was initiated. It was suspended on two occasions due to adverse events. The buccal ulcerations relapsed rapidly. The intrinsic imputability of tacrolimus in the occurrence of these lesions was noted "l2" ("plausible").. Several arguments suggest that these buccal ulcerations may result from the toxicity of tacrolimus: 1) absence of past history of apthae; 2) anatomo-clinical aspect of the lesion differing from that of common apthae, but similar to the ulcerations observed with nicorandil; 3) delay in occurrence of analogous ulcerations compared with that observed with methotrexate or nicorandil; 4) absence of another etiology; 5) relapse of ulcerations on two occasions after suspension of thalidomide, whilst tacrolimus was continued.

Topics: Biopsy; Female; Graft Rejection; Heart Transplantation; Humans; Immunosuppressive Agents; Middle Aged; Mouth Mucosa; Oral Ulcer; Stomatitis, Aphthous; Tacrolimus