title: Leflunomide and rheumatoid arthritis: a systematic review of effectiveness, safety and cost implications.
abstract: OBJECTIVE
  To assess the effectiveness, safety and cost implications of leflunomide treatment for rheumatoid arthritis.
  
  
  METHODS
  Systematic review.
  
  
  METHODS
  Four trials retrieved from Medline, Embase, the Cochrane Library, Econlit, HMIC (Dhdata), HMIC (Helmis), HMIC (King's Fund Database) and Best Evidence3.
  
  
  METHODS
  Efficacy measures (including tender joint counts, swollen joint counts, assessment of functioning, Health Assessment Questionnaire, Modified Health Assessment Questionnaire, pain (visual analogue scale), Erythrocyte Sedimentation Rate, C-reactive Protein), radiological progression and treatment adverse events.
  
  
  RESULTS
  Leflunomide therapy was demonstrated to be significantly superior to placebo in relation to the efficacy outcome measures and it slowed the radiological progression of patients' disease in three studies. Treatment success and duration of sustained response were also significantly superior than on placebo, as were quality of life measures. Leflunomide treatment was comparable to sulphasalazine and methotrexate with respect to efficacy, radiological progression and quality of life measures. The most common adverse effects leading to withdrawal from leflunomide treatment were gastrointestinal symptoms (diarrhoea and nausea), allergic reactions (rash and pruritus), alopecia, dyspepsia, hypertension and elevated transaminase levels. Weight loss and dizziness have also been reported for leflunomide therapy. Leflunomide is more expensive than most DMARDs, costing about pound400 a year more than sulphasalazine.
  
  
  CONCLUSIONS
  Despite the small number of published articles relating to leflunomide treatment, the evidence suggests that leflunomide is similar in efficacy to both sulphasalazine and methotrexate, although with a differential pattern of side-effects. There is a need for further research to assess the long-term outcomes of leflunomide treatment.
authors.affiliation: Wessex Institute for Health Research and Development, University of Southampton, Southampton, U.K. paulj@soton.ac.uk
authors.forename: P J
authors.initials: PJ
authors.lastname: Hewitson
authors.forename: S
authors.initials: S
authors.lastname: Debroe
authors.forename: A
authors.initials: A
authors.lastname: McBride
authors.forename: R
authors.initials: R
authors.lastname: Milne
mesh_terms: D000368:Aged; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000009:adverse effects / Q000191:economics* / Q000627:therapeutic use*; D001172:Arthritis, Rheumatoid / Q000188:drug therapy* / Q000191:economics / Q000473:pathology; D002986:Clinical Trials as Topic; D003362:Cost-Benefit Analysis; D018450:Disease Progression; D016527:Drug Costs; D006801:Humans; D007555:Isoxazoles / Q000009:adverse effects / Q000191:economics* / Q000627:therapeutic use*; D000077339:Leflunomide; D010146:Pain; D016896:Treatment Outcome
chemical_list: D000894:Anti-Inflammatory Agents, Non-Steroidal; D007555:Isoxazoles; D000077339:Leflunomide