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Leflunomide Washout — SCE Rheumatology MCQ

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ModerateRheumatology PharmacologyLeflunomide WashoutSCE Rheumatology

A 55-year-old woman with rheumatoid arthritis takes leflunomide 20 mg daily. Her previously normal alanine aminotransferase is now five times the upper limit of normal, and repeat testing confirms the result. Leflunomide-induced hepatotoxicity is suspected. In addition to monitoring liver enzymes, which is the most appropriate action?

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Correct answer: D — Stop leflunomide and start colestyramine washout because its active metabolite persists and undergoes enterohepatic recycling

Leflunomide must be discontinued when ALT exceeds three times the upper limit of normal, and a washout should be initiated in this patient with suspected hepatotoxicity. Its active metabolite, A771726 (teriflunomide), has an elimination half-life of approximately two weeks and persists because of enterohepatic recycling. Colestyramine 8 g three times daily for 11 days is the standard accelerated-elimination regimen; activated powdered charcoal is an alternative, so B is incorrect. Simply stopping treatment does not rapidly remove the metabolite, excluding A and E. A771726 is highly protein-bound and is not effectively removed by haemodialysis, excluding D. Liver enzymes should continue to be monitored until they have normalised.

Reference: Leflunomide 20 mg film-coated tablets, Summary of Product Characteristics, sections 4.4, 4.6, 4.9 and 5.2; text revised 26 May 2025. https://www.medicines.org.uk/emc/product/4943/smpc