Mycophenolate Mofetil (MMF) Dose

*Note: After Month 12, use “Add Event” and select “MMF after Month 12” if participant has continued MMF or a substitute post the Month 12 reporting period.

Timeline requirements for this form are as follows:
Assessment timeframe: Week 3, Week 4, Week 5, Week 6, Week 7, Week 8, Week 9. Week 10, Week 11, Week 12, Week 13, Month 4, Month 5, Month 6, Month 7, Month 8, Month 9, Month 10, Month 11, Month 12.
Submission timeframe:

Date of physician’s MMF dose report __________
Enter the date of the Mycophenolate Mofetil dose report. If substitute for MMF was given, enter the date of dose report for substitution. Enter the date in the DD/MMM/YYYY format.

Was MMF (CellCept, Myfortic) administered
Indicate if MMF was administered since the previously reported reporting period.

• Yes
• No
  

If no, was a substitution administered
If no is selected, indicate if a substitution was administered instead of MMF

• Yes
• No
  

If yes, indicate substitution administered __________
If “Yes” is selected, provide the name of the medication.

Provide reason for substitution __________
Provide a reason why MMF was discontinued and a new medication was started in the text box.

Dose given _______ mg/day
Enter the dose of MMF in mg/day. If a substitute for MMF was given, enter dose of substitution. Enter the dose in “NNNNN” format. This format allows for five digits without a decimal.

N/A, MMF discontinued ☐
If MMF or the substitute was discontinued and no other substitute was administered, check this box.

Enter date of last dose __________ mg/day
Enter the last dose of MMF in mg/day. If a substitute for MMF was given, enter the last dose of substitution. Enter the dose in “NNNNN” format. This format allows for five digits without a decimal.

Were MMF doses tapered to discontinuation
Indicate if MMF or substitute was discontinued.

• Yes
• No
• Not applicable, ongoing
  

If No, indicate why MMF has not been or will not be discontinued
If “No” was selected, indicate a reason why MMF or substitute has not or will not be discontinued.

• MMF dose reduction still in progress
• Chimerism level too low for discontinuation
• Evidence of kidney rejection reported
• Other
  

Specify Other__________

If “Other” was indicated, specify the reason in the text box.

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