Evidence-based Treatment of a Patient with Rheumatoid Arthritis with Leflunomide_Chinese Journal of Evidence-Based Medicine

Authors：

TIAN Panwen ,  WU Hongmei , WANG Danlin

Department of Geriatrics, West China Hospital, Sichuan University, Chengdu 610041, China;

Corresponding author：

WU Hongmei, Email: drwhm@163.com

Keywords：

Arthritis; Rheumatoid; Leflunomide; Methotrexate; Treatment

DOI：

10.7507/1672-2531.20080014

Video：

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Objective　 To investigate the effectiveness, safety and cost-effectiveness of leflunomide for rheumatoid arthritis, and formulate an evidence-based treatment plan for a patient with rheumatoid arthritis.
Methods　 We searched the ACP Journal Club, The Cochrane Library (Issue 2, 2007) and MEDLINE (1990 to 2007), and critically appraised the available evidence.
Results　 The available Level A (high quality) evidence showed that the efficacy and adverse events of leflunomide were comparable to those of methotrexate. The total cost of treating patients with leflunomide was significantly higher when compared to methotrexate. The combination of leflunomide and methotrexate in patients with active rheumatoid arthritis unresponsive to methotrexate monotherapy was less costly and more effective than the strategy excluding leflunomide. Given the current evidence, together with our clinical experience and the patient’s preference, methotrexate was administered to the patient. There was an inadequate response after 6 months of treatment. And then, adding leflunomide to methotrexate attained a remarkable response 3 months later. The patient is still being followed up.
Conclusion　 treatment with leflunomide and methotrexate in RA patients can improve the clinical outcomes. Long-term efficacy and toxicity remain to be established.

Citation： TIAN Panwen,WU Hongmei,WANG Danlin. Evidence-based Treatment of a Patient with Rheumatoid Arthritis with Leflunomide. Chinese Journal of Evidence-Based Medicine, 2008, 08(1): 58-61. doi: 10.7507/1672-2531.20080014 Copy

1.	2版. 北京: 人民卫生出版社, 2005. 2548-2557.
2.	American college of rheumatology subcommittee on rheumatoid arthritis guidelines. Guidelines for the management of rheumatoid arthritis: 2002 update. Arthritis Rheum, 2002, 46(2): 328-346.
3.	The Evidence-Based Medicine Working Group. Users’ Guides to the Medical Literature: A Mannual for Evidence-Based Clinical Practice. Chicago: AMA Press. 2002.
4.	Phillips B, Ball C, Sackett D, et al. Levels of evidence and grades of recommendation. Available from: URL: http://www.cebm.net/.
5.	Osiri M, Shea B, Robinson V, et al. Leflunomide for treating rheumatoid arthritis. Cochrane Database Syst Rev, 2003,(1): CD002047.
6.	Bao C, Chen S, Gu Y, et al. Leflunomide, a new disease-modifying drug for treating active rheumatoid arthritis in methotrexate-controlled phase II clinical trial. Chin Med J (Engl), 2003, 116(8): 1228-1234.
7.	Kremer JM, Genovese MC, Cannon GW, et al. Concomitant leflunomide therapy in patients with active rheumatoid arthritis despite stable doses of methotrexate. A randomized, double-blind, placebo-controlled trial. Ann Intern Med, 2002, 137(9): 726-733.
8.	Kremer JM, Genovese MC, Cannon GW, et al. Combination leflunomide and methotrexate (MTX) therapy for patients with active rheumatoid arthritis failing MTX monotherapy: open-label extension of a randomized, double-blind, placebo controlled trial. J Rheumatol, 2004, 31(8): 1521-1531.
9.	Kuzmanova SI, Solakov PT, Batalov AZ, et al. Leflunomide in the treatment of refractory rheumatoid arthritis. Folia Med (Plovdiv), 2003, 45(3): 43-47.
10.	Maetzel A, Strand V, Tugwell P, et al. Economic comparison of leflunomide and methotrexate in patients with rheumatoid arthritis: an evaluation based on a 1-year randomized controlled trial. Pharmacoeconomics, 2002, 20(1): 61-70.
11.	Schadlich PK, Zeidler H, Zink A, et al. Modelling cost effectiveness and cost utility of sequential DMARD therapy including leflunomide in rheumatoid arthritis in Germany: I. Selected DMARDs and patient-related costs. Pharmacoeconomics, 2005, 23(4): 377-393.
12.	Schadlich PK, Zeidler H, Zink A, et al. Modelling cost effectiveness and cost utility of sequential DMARD therapy including leflunomide for rheumatoid arthritis in Germany: II. The contribution of leflunomide to efficiency. Pharmacoeconomics, 2005, 23(4): 395-420.

1. 2版. 北京: 人民卫生出版社, 2005. 2548-2557.
2. American college of rheumatology subcommittee on rheumatoid arthritis guidelines. Guidelines for the management of rheumatoid arthritis: 2002 update. Arthritis Rheum, 2002, 46(2): 328-346.
3. The Evidence-Based Medicine Working Group. Users’ Guides to the Medical Literature: A Mannual for Evidence-Based Clinical Practice. Chicago: AMA Press. 2002.
4. Phillips B, Ball C, Sackett D, et al. Levels of evidence and grades of recommendation. Available from: URL: http://www.cebm.net/.
5. Osiri M, Shea B, Robinson V, et al. Leflunomide for treating rheumatoid arthritis. Cochrane Database Syst Rev, 2003,(1): CD002047.
6. Bao C, Chen S, Gu Y, et al. Leflunomide, a new disease-modifying drug for treating active rheumatoid arthritis in methotrexate-controlled phase II clinical trial. Chin Med J (Engl), 2003, 116(8): 1228-1234.
7. Kremer JM, Genovese MC, Cannon GW, et al. Concomitant leflunomide therapy in patients with active rheumatoid arthritis despite stable doses of methotrexate. A randomized, double-blind, placebo-controlled trial. Ann Intern Med, 2002, 137(9): 726-733.
8. Kremer JM, Genovese MC, Cannon GW, et al. Combination leflunomide and methotrexate (MTX) therapy for patients with active rheumatoid arthritis failing MTX monotherapy: open-label extension of a randomized, double-blind, placebo controlled trial. J Rheumatol, 2004, 31(8): 1521-1531.
9. Kuzmanova SI, Solakov PT, Batalov AZ, et al. Leflunomide in the treatment of refractory rheumatoid arthritis. Folia Med (Plovdiv), 2003, 45(3): 43-47.
10. Maetzel A, Strand V, Tugwell P, et al. Economic comparison of leflunomide and methotrexate in patients with rheumatoid arthritis: an evaluation based on a 1-year randomized controlled trial. Pharmacoeconomics, 2002, 20(1): 61-70.
11. Schadlich PK, Zeidler H, Zink A, et al. Modelling cost effectiveness and cost utility of sequential DMARD therapy including leflunomide in rheumatoid arthritis in Germany: I. Selected DMARDs and patient-related costs. Pharmacoeconomics, 2005, 23(4): 377-393.
12. Schadlich PK, Zeidler H, Zink A, et al. Modelling cost effectiveness and cost utility of sequential DMARD therapy including leflunomide for rheumatoid arthritis in Germany: II. The contribution of leflunomide to efficiency. Pharmacoeconomics, 2005, 23(4): 395-420.

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Evidence-based Treatment of a Patient with Rheumatoid Arthritis with Leflunomide

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