Rheumatology Advance Access originally published online on January 18, 2005
Rheumatology 2005 44(3):280-286; doi:10.1093/rheumatology/keh500
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Rheumatology Vol. 44 No. 3 © British Society for Rheumatology 2005; all rights reserved
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Leflunomide in rheumatoid arthritis: recommendations through a process of consensus
Department of Rheumatology, Ysbyty Gwynedd Hospital and University of Wales, Bangor, 1 Department of Rheumatology, St George's Hospital, 2 Department of Rheumatology, Guy's and St Thomas’ Hospital, 3 Department of Rheumatology, GKT School of Medicine, London, 4 Department of Rheumatology, Princess of Wales Hospital, Bridgend, 5 Department of Rheumatology, University Hospital Aintree, Liverpool, 6 Bognor Regis, West Sussex, 7 Department of Rheumatology, Huddersfield Royal Infirmary, Huddersfield, 8 Department of Rheumatology, Nottingham City Hospital, Nottingham, 9 Department of Rheumatology, Musgrave Park Hospital, Belfast, 10 Rheumatology Department, Haywood Hospital, Burslem, Stoke-on-Trent and 11 Department of Rheumatology, North Cheshire Hospital NHS Trust, Warrington, UK.
Correspondence to: P. Maddison, Department of Rheumatology, Ysbyty Gwynedd Hospital, Bangor LL57 2PW, UK. E-mail: peter.maddison{at}nww-tr.wales.nhs.uk
Objectives. To determine, by consensus, the optimal use of leflunomide in rheumatoid arthritis (RA), using a multidisciplinary panel of experts and performing meta-analyses of available data
Methods. A multidisciplinary panel of experts in RA was convened. Important questions, pertinent to the use of leflunomide in the treatment of RA, were defined by consensus at an initial meeting. Each question was allocated to subgroups of two or three members, who worked separately to prepare a balanced opinion, based on published literature, data from individual patients taking part in phase II and phase III clinical trials provided by Aventis, and data from a USA-based medical claims database (AETNA). The full group then reconvened to agree on an overall consensus statement. Recommendations concerning efficacy and tolerability versus comparator drugs and placebo were derived from two new meta-analyses.
Results. Leflunomide was at least as effective as sulphasalazine and methotrexate, and equally well tolerated on meta-analysis of trial data. Overall withdrawal rates for all adverse events were similar for all three drugs. Avoidance of the loading dose reduces ‘nuisance’ side-effects (e.g. nausea), but probably delays the onset of action. Adverse events could usually be managed by dose reduction and/or symptomatic therapy.
Conclusions. On the basis of efficacy, safety and cost, leflunomide should be considered in patients with RA who have failed first-line DMARD drug therapy. In refractory cases, leflunomide may be used in combination with, for example, methotrexate before biological agents. Therapy should be initiated by a specialist, but repeat prescribing in general practice on a shared care basis is acceptable using agreed protocols. Clear mechanisms are required to monitor toxicity, with good communication between the patient and rheumatologist to manage nuisance side-effects and avoid unnecessary discontinuation of leflunomide.
KEY WORDS: Leflunomide, Rheumatoid arthritis, DMARDs, Combination therapy, Adverse events
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