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Leflunomide hepatotoxicity — SCE Rheumatology MCQ

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HardRheumatological pharmacologyLeflunomide hepatotoxicitySCE Rheumatology

During shared-care monitoring, a patient taking leflunomide 20 mg/day has ALT 3.4 times ULN on two samples. Viral hepatitis and biliary obstruction have been excluded; bilirubin is normal. Which management sequence is required?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: B — Stop leflunomide and begin an accelerated washout regimen

Explanation lettering: E = shown as B · B = shown as C · C = shown as D · D = shown as E

E is correct. The UK SmPC requires leflunomide discontinuation and washout when ALT exceeds 3 times ULN. Cholestyramine 8 g three times daily for 11 days is a specified regimen, with liver tests followed to normalisation. Dose reduction is an option for selected 2–3-times-ULN elevations, not this result; immediate DMARD switching without washout may compound toxicity.

Reference: Leflunomide 10 mg tablets UK SmPC. https://www.medicines.org.uk/emc/product/101936/smpc