| Management |
Caution is advised if leflunomide is used in combination with rifampin. The potential for increased risk of leflunomide toxicities including peripheral neuropathy, immunosuppression, bone marrow suppression, and hepatotoxicity should be considered. Liver enzymes and bilirubin should be measured prior to initiation of leflunomide therapy and at least monthly for the first six months of treatment and every 6 to 8 weeks thereafter. Patients with preexisting liver disease or elevated baseline liver enzymes (i.e., ALT greater than two times ULN) should not receive leflunomide. Patients who develop elevated serum ALT greater than three times ULN while receiving leflunomide should discontinue treatment and be given washout procedures with cholestyramine or activated charcoal to accelerate elimination of leflunomide's active metabolite from plasma, which otherwise may take up to two years. Follow-up monitoring should be conducted at least weekly until the ALT value is within normal range, and washout procedures repeated as necessary. All patients treated with leflunomide should be advised to seek medical attention if they experience potential signs and symptoms of hepatotoxicity such as fever, rash, itching, anorexia, nausea, vomiting, fatigue, malaise, right upper quadrant pain, dark urine, pale stools, and jaundice. |
