What is your approach towards initial regimen and tapering of mycophenolate in scleroderma?

I start low and go slow to avoid diarrhea and abdominal upset. I give the patient 250 mg tablets and tell them to increase as tolerated to 1000 mg PO BID. I write Cellcept 1000 mg PO BID to the pharmacy to avoid questions. I seldom increase beyond 1000 mg PO BID because it seems like pushing the dose higher than 2g per day increases the risk for infections and GI side effects. If ILD is present, I start the patient on PJP prophylaxis to help avoid confusion if a new infiltrate appears. I keep patients on Cellcept for ~5 years then I taper it slowly. Two years is too short, we published that, but no one knows how long to treat. I follow the same approach for skin except I do not start PJP prophylaxis.

My goal is to get the patient to tolerate it first, and then uptitrate to a goal dose of 2-3 g/d. 3 g if permissible for the first year (for both progressive cutaneous and/or ILD) and then reduce after gaining improvement or significant stability to 2g daily for maintenance for at least 3-4 years. There are no guidelines on how long is too long. Disease activity is likely to be highest in the 1st 5y and that’s my rationale for treatment duration. 

I start at 500 mg BID for 2 weeks and increase to 1g BID thereafter if well tolerated. And to 3g over the next 2-4 weeks.

3 g was the target dose in SLS-II study and is in SLS-III in progress. But, I agree with Dr. @Dr. First Last that tolerance can vary a lot, especially with active preexisting GI issues. So at a minimum, trying to achieve 2 g daily is key.