title: Leflunomide in rheumatoid arthritis: recommendations through a process of consensus.
abstract: OBJECTIVE
  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.
authors.affiliation: Department of Rheumatology, Ysbyty Gwynedd Hospital, University of Wales, Bangor LL57 2PW, UK. peter.maddison@nww-tr.wales.nhs.uk
authors.forename: P
authors.initials: P
authors.lastname: Maddison
authors.forename: P
authors.initials: P
authors.lastname: Kiely
authors.forename: B
authors.initials: B
authors.lastname: Kirkham
authors.forename: T
authors.initials: T
authors.lastname: Lawson
authors.forename: R
authors.initials: R
authors.lastname: Moots
authors.forename: D
authors.initials: D
authors.lastname: Proudfoot
authors.forename: R
authors.initials: R
authors.lastname: Reece
authors.forename: D
authors.initials: D
authors.lastname: Scott
authors.forename: R
authors.initials: R
authors.lastname: Sword
authors.forename: A
authors.initials: A
authors.lastname: Taggart
authors.forename: C
authors.initials: C
authors.lastname: Thwaites
authors.forename: E
authors.initials: E
authors.lastname: Williams
mesh_terms: D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D001172:Arthritis, Rheumatoid / Q000188:drug therapy*; D004359:Drug Therapy, Combination; D004361:Drug Tolerance; D006801:Humans; D007166:Immunosuppressive Agents / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D007555:Isoxazoles / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D000077339:Leflunomide; D010349:Patient Compliance; D011369:Professional-Patient Relations
chemical_list: D000894:Anti-Inflammatory Agents, Non-Steroidal; D007166:Immunosuppressive Agents; D007555:Isoxazoles; D000077339:Leflunomide