<div>Dear Mr. Cremers,</div><div>Enclosed please find our manuscript “Oral antibiotics lower
mycophenolate mofetil drug exposure by interfering with the
enterohepatic recirculation: a case series”. We consider this
manuscript particularly suitable for the <i>British Journal of
Clinical Pharmacology</i> as we report on three solid organ transplant
patients in which mycophenolic acid trough concentrations severely
decreased after oral antibiotic co-administration. We believe this
effect is due to interference with the enterohepatic recirculation by
some antibiotics. To the best of our knowledge, we are the first to
report such an effect for oral vancomycin.</div><div>We believe it is important to draw the attention of clinicians and
researchers to this interaction. The enterohepatic recirculation may
account for up to 60% of the mycophenolate acid (MPA) exposure and
bacterial infections are common in patients using immunosuppressants
such as mycophenolate mofetil (MMF). Interference with the enterohepatic
recirculation by antibiotics may thus have a significant impact on MPA
exposure and result in potentially ineffective immunosuppression leading
to allograft rejection. Therefore, we suggest routine screening for the
combination of mycophenolate mofetil and antibiotics interfering with
the enterohepatic recirculation, preferably using clinical decision
support systems.</div><div>This manuscript represents original material, has not been previously
published and has not been submitted for publication elsewhere.</div><div>I hope you will consider this case report for publication in your
journal.</div><div>Yours sincerely, also on behalf of all co-authors,</div><div>Midas Mulder, PharmD</div><div>Department of Hospital Pharmacy, Room Nc-212</div><div>ErasmusMC University Medical Center</div><div>PO box 2040, 3000CA, Rotterdam</div><div>The Netherlands</div><div>Email:
m.b.mulder@erasmusmc.nl</div>