Rheumatoid arthritis

Leflunomide prescribing inconsistent with guidelines: survey

Rheumatologists have a flexible approach to leflunomide prescribing which is often inconsistent with treatment recommendations, a survey of Australian Rheumatology Association members has suggested.

Adelaide pharmacist Dr Ashley Hopkins and colleagues found that, among 66 respondents, only two said they used a loading dose of 100 mg daily for two to three days followed by 10 mg/day, as recommended when the drug was first marketed in 2000.

Half started at 20 mg/day, and the remainder at 10 mg/day. About 70% had used alternate daily dosing in some patients.

“In a patient initiating leflunomide, more than 75% of responders indicated that they would ‘almost always’ or ‘frequently’ monitor full blood examination, blood pressure, liver function, renal function and hepatitis B and C serology in high-risk patients,” Dr Hopkins wrote in Clinical Rheumatology.

The same proportion would continue to monitor blood counts, liver function and creatinine clearance estimate during the first 6 months of treatment, as recommended.

About 40% said they would almost always or frequently perform a chest X-ray because of the risk of interstitial lung disease with leflunomide, but only 8% said they would arrange pulmonary function testing.

While the majority said they would stop the drug immediately in response to increases in liver enzymes, only 20% would follow the recommendation for cholestyramine washout.

Washout is advised in the event of serious toxicity, also including pneumonitis and widespread rash, because the active metabolite of leflunomide has a half-life of about two weeks and may otherwise persist in plasma for up to two years.

Dr Hopkins said leflunomide was the last non-biological DMARD introduced in Australia. Its use had declined following relaxation of restrictions on biologic prescribing that previously required trialling of at least two conventional DMARDs.

“If leflunomide response could be optimised and toxicities avoided, leflunomide use may increase again, which may lead to less reliance on biological agents,” he said.

The data on leflunomide was captured as part of a larger survey of rheumatologists’ attitudes to treat-to-target concepts, DMARD initiation strategies, and views on the relative efficacy and toxicity on non-biologic DMARDs.

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