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Leflunomide hepatotoxicity — SCE Rheumatology MCQ

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ModerateRheumatological pharmacologyLeflunomide hepatotoxicitySCE Rheumatology

A 47-year-old man has inflammatory musculoskeletal symptoms evolving over several weeks with features suggestive of leflunomide hepatotoxicity. Examination shows there is objective synovitis or organ involvement on examination. Investigations show targeted investigations support an immune-mediated rheumatological disorder. The diagnosis is established and symptoms remain clinically important despite initial supportive measures. There is no contraindication to disease-modifying or anti-inflammatory escalation. What is the most appropriate management?

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Correct answer: C — Stop leflunomide and consider washout

Stop leflunomide and consider washout is the best answer because stop leflunomide and consider washout is the most appropriate next step for leflunomide hepatotoxicity in this clinical setting. Start methotrexate with folic acid is a plausible distractor, but it does not account for the key discriminator in the stem. Increase NSAID therapy and Urgent antibiotics would be more appropriate in a different clinical pattern or at another point in the pathway, while Screen for latent tuberculosis is suboptimal for this presentation. Clinical pearl: rheumatology management is generally treat-to-target, but infection risk, pregnancy plans and shared-care monitoring often determine the safest answer.

Reference: BSR csDMARD monitoring guideline; BSR biologic/targeted DMARD safety guideline; BNF