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Voortman M, Drent M, Stern BJ. Neurosarcoidosis and Neurologic Complications of Sarcoidosis Treatment. Clin Chest Med 2024; 45:91-103. [PMID: 38245373 DOI: 10.1016/j.ccm.2023.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2024]
Abstract
Sarcoidosis is an immune-mediated multisystem granulomatous disorder. Neurosarcoidosis (NS) accounts for 5% to 35% of cases. The diagnostic evaluation of NS can be a clinical challenge. Gadolinium-enhanced magnetic resonance imaging (MRI) is the gold standard to evaluate central nervous system NS. In almost all cases treatment is warranted. Although glucocorticoids remain the first-line therapy in patients with sarcoidosis, in NS timely initiation of second- or third-line treatment is strongly recommended. Of these, tumor necrosis factor-alpha inhibitors are the most promising. However, the treatment itself may be responsible for/associated with developing neurologic symptoms mimicking NS. Thus, it is important to consider the possibility of drug-induced neurologic symptoms in sarcoidosis.
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Affiliation(s)
- Mareye Voortman
- Department of Pulmonology, Division of Heart & Lungs, University Medical Centre Utrecht, PO Box 85500, Utrecht 3508 GA, The Netherlands.
| | - Marjolein Drent
- Faculty of Health, Medicine and Life Science, Maastricht University, Maastricht, The Netherlands; Department of Respiratory Medicine, ILD Center of Excellence, St. Antonius Hospital, Nieuwegein, The Netherlands; ILD Care Foundation Research Team, Heideoordlaan 8, Ede 6711NR, The Netherlands
| | - Barney J Stern
- Department of Neurology, School of Medicine, Johns Hopkins University, 601 North Caroline Street, Neurology Room 5066B, Baltimore, MD 21287, USA
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Elrefaey A, Memon AB. Painful Small Fiber Neuropathy Associated With Teriflunomide: A Case Series and Literature Review Related to Teriflunomide and Leflunomide. Cureus 2023; 15:e45079. [PMID: 37705563 PMCID: PMC10496022 DOI: 10.7759/cureus.45079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/12/2023] [Indexed: 09/15/2023] Open
Abstract
Teriflunomide and its prodrug, leflunomide, are disease-modifying medications used to treat relapsing-remitting multiple sclerosis (RRMS) and rheumatoid arthritis (RA), respectively. Peripheral neuropathy is a rare side effect associated with both medications, although the incidence rate and exact pathological mechanism remain unknown. We present a retrospective case series of three patients with RRMS, who developed painful small fiber neuropathy at various timeframes (<6 months, one year, and four years, respectively) while on teriflunomide treatment (14 mg/day); we also engage in a literature review of small and large fiber neuropathy associated with teriflunomide and leflunomide use. All three patients developed small fiber neuropathy following teriflunomide exposure. Laboratory workup was negative for metabolic, infectious, vitamin deficiency-related, and autoimmune etiologies, except for one patient who had chronic metabolic syndromes (impaired glucose, hyperlipidemia) before medication intake. However, the patient developed neuropathy following teriflunomide treatment. Electrophysiological findings were negative for large fiber neuropathy in all three patients with positive skin biopsy, with reduced epidermal nerve fiber density (ENFD) in two of the three patients. Teriflunomide was discontinued in all cases, after which symptoms stabilized. Current literature on leflunomide supports a direct neurotoxic effect or buildup of toxic intermediates from uridine synthesis inhibition. Cessation of teriflunomide use in the described cases resulted in symptom stabilization. Early recognition and treatment may lead to good clinical outcomes in these patients.
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Affiliation(s)
- Ahmed Elrefaey
- Neurology, Faculty of Medicine, Ain Shams University, Cairo, EGY
| | - Anza B Memon
- Neurology, John D. Dingell VA Medical Center, Detroit, USA
- Neurology, Wayne State University School of Medicine, Detroit, USA
- Neurology, Henry Ford Health, Detroit, USA
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Zaottini F, Picasso R, Pistoia F, Sanguinetti S, Pansecchi M, Tovt L, Viglino U, Cabona C, Garnero M, Benedetti L, Martinoli C. High-resolution ultrasound of peripheral neuropathies in rheumatological patients: An overview of clinical applications and imaging findings. Front Med (Lausanne) 2022; 9:984379. [PMID: 36388946 PMCID: PMC9661426 DOI: 10.3389/fmed.2022.984379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 09/12/2022] [Indexed: 11/13/2022] Open
Abstract
Peripheral neuropathies are surprisingly common and can be associated with a number of conditions, including rheumatological diseases. Whether the co-existence of peripheral neuropathies with rheumatological disorders is coincidental or related to a common pathogenic mechanism, these disabling conditions can affect the outcome of rheumatological patients and should be targeted with specific treatment. The clinical presentation of peripheral neuropathy can be multifaceted and difficult to recognize in polysymptomatic patients. However, physicians adopting state-of-art diagnostic strategies, including nerve imaging, may improve the detection rate and management of neuropathies. In particular, a diagnostic approach relying exclusively on clinical history and nerve conduction studies may not be sufficient to disclose the etiology of the nerve damage and its anatomical location and thus requires integration with morphological studies. High-Resolution Ultrasound (HRUS) is increasingly adopted to support the diagnosis and follow-up of both joint disorders in rheumatology and peripheral neuropathies of different etiologies. In this review, the different types of nerve disorders associated with the most common syndromes of rheumatological interest are discussed, focusing on the distinctive sonographic features.
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Affiliation(s)
- Federico Zaottini
- San Martino Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Genoa, Italy
| | - Riccardo Picasso
- San Martino Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Genoa, Italy
- *Correspondence: Riccardo Picasso,
| | - Federico Pistoia
- Dipartimento di Medicina Sperimentale, Scuola di Scienze Mediche e Farmaceutiche, Università di Genova, Genoa, Italy
| | - Sara Sanguinetti
- Dipartimento di Medicina Sperimentale, Scuola di Scienze Mediche e Farmaceutiche, Università di Genova, Genoa, Italy
| | - Michelle Pansecchi
- Dipartimento di Scienze della Salute, Scuola di Scienze Mediche e Farmaceutiche, Università di Genova, Genoa, Italy
| | - Luca Tovt
- Dipartimento di Scienze della Salute, Scuola di Scienze Mediche e Farmaceutiche, Università di Genova, Genoa, Italy
| | - Umberto Viglino
- Dipartimento di Scienze della Salute, Scuola di Scienze Mediche e Farmaceutiche, Università di Genova, Genoa, Italy
| | - Corrado Cabona
- San Martino Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Genoa, Italy
- Eye Clinic, Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Science, School of Medical and Pharmaceutical Sciences, University of Genoa, Genoa, Italy
| | - Martina Garnero
- San Martino Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Genoa, Italy
- Eye Clinic, Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Science, School of Medical and Pharmaceutical Sciences, University of Genoa, Genoa, Italy
| | - Luana Benedetti
- San Martino Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Genoa, Italy
- Eye Clinic, Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Science, School of Medical and Pharmaceutical Sciences, University of Genoa, Genoa, Italy
| | - Carlo Martinoli
- San Martino Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Genoa, Italy
- Dipartimento di Scienze della Salute, Scuola di Scienze Mediche e Farmaceutiche, Università di Genova, Genoa, Italy
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Merheb D, Dib G, Zerdan MB, Nakib CE, Alame S, Assi HI. Drug-Induced Peripheral Neuropathy: Diagnosis and Management. Curr Cancer Drug Targets 2021; 22:49-76. [PMID: 34288840 DOI: 10.2174/1568009621666210720142542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 05/07/2021] [Accepted: 05/21/2021] [Indexed: 01/09/2023]
Abstract
Peripheral neuropathy comes in all shapes and forms and is a disorder which is found in the peripheral nervous system. It can have an acute or chronic onset depending on the multitude of pathophysiologic mechanisms involving different parts of nerve fibers. A systematic approach is highly beneficial when it comes to cost-effective diagnosis. More than 30 causes of peripheral neuropathy exist ranging from systemic and auto-immune diseases, vitamin deficiencies, viral infections, diabetes, etc. One of the major causes of peripheral neuropathy is drug induced disease, which can be split into peripheral neuropathy caused by chemotherapy or by other medications. This review deals with the latest causes of drug induced peripheral neuropathy, the population involved, the findings on physical examination and various workups needed and how to manage each case.
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Affiliation(s)
- Diala Merheb
- Department of Internal Medicine, Saint George Hospital University Medical Center, Beirut, Lebanon
| | - Georgette Dib
- Department of Internal Medicine, Division of Neurology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Maroun Bou Zerdan
- Department of Internal Medicine, Division of Hematology and Oncology, Naef K. Basile Cancer Institute, American University of Beirut Medical Center, Beirut, Lebanon
| | - Clara El Nakib
- Department of Internal Medicine, Division of Hematology and Oncology, Naef K. Basile Cancer Institute, American University of Beirut Medical Center, Beirut, Lebanon
| | - Saada Alame
- Department of Pediatrics, Clemenceau Medical Center, Faculty of Medical Sciences, Lebanese University, Beirut,, Lebanon
| | - Hazem I Assi
- Department of Internal Medicine Naef K. Basile Cancer Institute American University of Beirut Medical Center Riad El Solh 1107 2020 Beirut, Lebanon
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Abstract
PURPOSE OF REVIEW Sarcoidosis is a complex disease with many faces, and the clinical manifestation and course of neurosarcoidosis are particularly variable. Although neurosarcoidosis occurs in up to 10% of sarcoidosis patients, it can lead to significant morbidity and some mortality. RECENT FINDINGS Three criteria are usually required for a diagnosis of (neuro)sarcoidosis: clinical and radiologic manifestations, noncaseating granulomas, and no evidence of alternative disease. Recent guidelines have helped to clarify criteria for diagnosing neurosarcoidosis. No firm guidelines exist on whether, when, and how treatment should be started. Treatment depends on the presentation and distribution, extensiveness, and severity of neurosarcoidosis. As regards evidence-based treatment, only a few randomized controlled trials have been done. Hence, several aspects of (neuro)sarcoidosis management are not fully addressed by the current literature. SUMMARY Significant advances have been made in the potential and accuracy of diagnostics for neurosarcoidosis. Treatment should be approached within the context of the patient's anticipated clinical course, avoidance of adverse drug effects, and, if necessary, from the perspective of the comprehensive management of a chronic disease. A multidisciplinary approach to the management of sarcoidosis is strongly recommended.
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Affiliation(s)
- Mareye Voortman
- ILD Center of Excellence, Department of Pulmonology, St. Antonius Hospital, Nieuwegein
- Department of Pulmonology, Division of Heart & Lungs, University Medical Centre Utrecht, Utrecht
- ild care foundation research team, Ede
| | - Marjolein Drent
- ILD Center of Excellence, Department of Pulmonology, St. Antonius Hospital, Nieuwegein
- ild care foundation research team, Ede
- Department of Pharmacology and Toxicology, FHML, Maastricht University, Maastricht, The Netherlands
| | - Robert P. Baughman
- Department of Medicine, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
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Other Forms of Immunosuppression. KIDNEY TRANSPLANTATION - PRINCIPLES AND PRACTICE 2019. [PMCID: PMC7152196 DOI: 10.1016/b978-0-323-53186-3.00020-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Khedr EM, El Fetoh NA, Herdan O, El-Hammady DH, Khalifa H, Gamal RM, Ali AM. Clinical and subclinical neuropsychiatric abnormalities in rheumatoid arthritis patients. EGYPTIAN RHEUMATOLOGY AND REHABILITATION 2015. [DOI: 10.4103/1110-161x.155625] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Hong SH, Kwon JT, Lee JH, Lee S, Lee AY, Cho WY, Bat-Erdene M, Choi BD, Cho MH. Ascidian Tunicate Extracts Attenuate Rheumatoid Arthritis in a Collagen-induced Murine Model. Nat Prod Commun 2014. [DOI: 10.1177/1934578x1400900632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Murine rheumatoid arthritis models are often used to investigate the potential therapeutic effects of candidate drugs. The present study has been conducted in order to investigate the therapeutic efficacy of ascidian tunicate extracts in a collagen-induced arthritis DBA1/J mice model. Four types of formulas, ascidian tunicate extracts (ATE), crude ascidian tunicate glycans (ATEC), ascidian tunicate extracts with licorice extracts (ATEL), and crude ascidian tunicate glycans with licorice extracts (ATECL) were orally administered into DBA/1J mice for 3 weeks and paw edema and thickness were evaluated. Changes in inflammatory proteins and cytokines levels were monitored in hind leg tissues by Western blot and quantitative PCR analysis. The oral administration of ascidian tunicate extracts alleviated paw edema and improved the histological hind leg cartilage status. The extracts also reduced the matrix metalloproteinase-9 (MMP-9) protein and prostaglandin E synthase (PGES) levels. In addition, the extracts-treated groups showed increased interleukin-10 (IL-10) levels compared with the non-treated group. These findings suggest that orally administered ascidian tunicate extracts might have potential therapeutic effects for the treatment of rheumatoid arthritis.
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Affiliation(s)
- Seong-Ho Hong
- Laboratory of Toxicology, College of Veterinary Medicine, Seoul National University, Seoul 151–921, Korea
| | - Jung-Taek Kwon
- Environmental Health Research Department, National Institute of Environmental Research, Incheon 404–708, Korea
| | - Jae-Ho Lee
- Laboratory of Toxicology, College of Veterinary Medicine, Seoul National University, Seoul 151–921, Korea
| | - Somin Lee
- Laboratory of Toxicology, College of Veterinary Medicine, Seoul National University, Seoul 151–921, Korea
- Graduate Group of Tumor Biology, Seoul National University, Seoul, 151–742, Korea
| | - Ah Young Lee
- Laboratory of Toxicology, College of Veterinary Medicine, Seoul National University, Seoul 151–921, Korea
| | - Won-Young Cho
- Laboratory of Toxicology, College of Veterinary Medicine, Seoul National University, Seoul 151–921, Korea
- Graduate Group of Tumor Biology, Seoul National University, Seoul, 151–742, Korea
| | - Munkhjargal Bat-Erdene
- Department of Seafood Science and Technology/The Institute of Marine Industry, Gyeongsang National University, 445 Inpyeong-dong, Tondyeong 650–160, Korea
| | - Byeong-Dae Choi
- Department of Seafood Science and Technology/The Institute of Marine Industry, Gyeongsang National University, 445 Inpyeong-dong, Tondyeong 650–160, Korea
| | - Myung-Haing Cho
- Laboratory of Toxicology, College of Veterinary Medicine, Seoul National University, Seoul 151–921, Korea
- Graduate School of Convergence Science and Technology, Seoul National University, Suwon 443–270, Korea
- Graduate Group of Tumor Biology, Seoul National University, Seoul, 151–742, Korea
- Advanced Institute of Convergence Technology, Seoul National University, Suwon 443–270, Korea
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Kim HK, Park SB, Park JW, Jang SH, Kim TH, Sung YK, Jun JB. The effect of leflunomide on cold and vibratory sensation in patients with rheumatoid arthritis. Ann Rehabil Med 2012; 36:207-12. [PMID: 22639744 PMCID: PMC3358676 DOI: 10.5535/arm.2012.36.2.207] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2011] [Accepted: 01/11/2012] [Indexed: 11/05/2022] Open
Abstract
Objective To evaluate the prevalence and risk factors of peripheral neuropathy in patients with rheumatoid arthritis (RA) treated with leflunomide (LEF) by quantitative sensory testing (QST). Method A total of 94 patients were enrolledin this study, out of which 47 patients received LEF. The other 47 patients received alternative disease-modifying antirheumatic drugs and served as the control group. The demographic characteristics, laboratory findings, concomitant diseases, and medication history were evaluated at the time of QST. The cooling (CDT) and vibratory detection threshold (VDT) as the representative components of QST were measured. Results Age, gender, RA duration, ESR, and CRP did not show any significant differences between the two groups. VDT did not demonstrate any significant difference in both groups. However, CDT in LEF group was significantly higher than that of the control group (8.6±2.7 in LEF vs. 5.6±3.8 in control). The proportion of RA patients in the LEF group showing abnormally high CDT was over 2 times greater than that of the control group, but these findings were not statistically significant. Age, RA duration (or LEF medication in LEF group), ESR, and CRP did not show significant correlation with CDT in both groups. VDT significantly correlated with age in both groups. Conclusion LEF treatment in patients with RA may lead to abnormal CDT in QST. CDT value was not affected by age, RA duration, disease activity, or LEF duration. It remains to be determined whether QST may be a valuable non-invasive instrument to evaluate the early sensory changes in patients with RA taking LEF.
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Affiliation(s)
- Hyung Kuk Kim
- Department of Rehabilitation Medicine, Hanyang University College of Medicine, Seoul 133-792, Korea
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Baughman RP, Nunes H. Complicated Sarcoidosis: Challenges in Dealing with Severe Manifestations. Autoimmune Dis 2011. [DOI: 10.1007/978-0-85729-358-9_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Steinbach S, Proft F, Schulze-Koops H, Hundt W, Heinrich P, Schulz S, Gruenke M. Gustatory and olfactory function in rheumatoid arthritis. Scand J Rheumatol 2010; 40:169-77. [PMID: 21077800 DOI: 10.3109/03009742.2010.517547] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To evaluate the gustatory and olfactory functions of patients with rheumatoid arthritis (RA) compared to sex- and age-matched healthy subjects and to investigate a potential relationship between disease activity [using the 28-joint Disease Activity Score (DAS28)] and chemosensory capacity. Furthermore, to dissect possible impacts of standard anti-inflammatory medications on the gustatory and olfactory functions. METHODS Patients with established RA underwent standardized assessment of their gustatory and olfactory functions. The patients were also examined for their disease activity, had their specific blood-test results analysed, and were asked to answer a standardized questionnaire about their quality of life, the negative effects of their disease, and about comorbidities. RESULTS A total of 101 RA patients (75 women, 26 men, mean age: 57.9 ± 13.8 and 64.2 ± 10.9 years, respectively) were analysed. In relation to age- and sex-related subjects, both female and male RA patients had a significantly decreased taste score (p < 0.001) and also a significantly decreased olfactory score (p < 0.05), indicating that a substantial number of patients suffer from hypogeusia or hyposmia. This abnormality did not correlate with disease activity, the duration of the disease, disease-modifying anti-rheumatic drug (DMARD) or tumour necrosis factor (TNF) inhibitor use, and the loss of the chemosensory functions, together indicating that hypogeusia and hyposmia are frequent clinical manifestations in RA patients independent of the inflammatory activity of their disease. CONCLUSION The results indicate that there is a significant decrease in the olfactory and gustatory function in RA patients compared to those of healthy controls, which can seriously and substantially affect the quality of the patients' life.
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Affiliation(s)
- S Steinbach
- Department of Otorhinolaryngology, Philipps-University Marburg, Munich, Germany.
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Jones PBB, White DHN. Reappraisal of the clinical use of leflunomide in rheumatoid arthritis and psoriatic arthritis. Open Access Rheumatol 2010; 2:53-71. [PMID: 27789998 PMCID: PMC5074775 DOI: 10.2147/oarrr.s9448] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Leflunomide is a disease-modifying antirheumatic drug (DMARD) that has been in routine clinical use for the treatment of rheumatoid arthritis (RA) and psoriatic arthritis for a decade. In RA, clinical trials of up to two years' duration showed that leflunomide monotherapy was equivalent to methotrexate in clinical and radiographic disease outcomes (tender and swollen joint counts, physician and patient global assessments, American College of Rheumatology and Disease Activity Score responses, slowing or halting of radiographic progression). In a number of studies, quality of life measurements indicated that leflunomide is superior to methotrexate. Leflunomide has been studied in combination with methotrexate and shows efficacy in patients only partly responsive to this agent. Recent trials have shown that leflunomide can be used safely with biologic DMARDs, including antitumor necrosis factor agents and rituximab as part of the treatment algorithm in place of methotrexate as a cotherapy. Leflunomide has demonstrated efficacy as a monotherapy in psoriatic arthritis, and it also has a beneficial effect in psoriasis. Postmarketing studies have shown that retention on treatment with leflunomide is equal to methotrexate and superior to other DMARDs. In general, its side effect profile is acceptable compared with other DMARDS, with nausea, diarrhea, and hair fall occurring commonly, but only rarely leading to discontinuation. Liver toxicity is the most significant problem in clinical use although it is uncommon. Peripheral neuropathy, hypertension, pneumonitis, and cytopenia occur more rarely. Leflunomide is contraindicated in pregnancy and should be used with caution in women during child-bearing years. In this review, the place of leflunomide in therapy is discussed and practical advice informed by evidence is given regarding dosing regimens, safety monitoring, and managing side effects. Leflunomide remains one of the most useful of the nonbiologic DMARDs.
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Affiliation(s)
- Peter BB Jones
- Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland
- Rheumatology Department, Waikato Hospital, Hamilton, New Zealand
| | - Douglas HN White
- Rheumatology Department, Waikato Hospital, Hamilton, New Zealand
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Abstract
Despite improvements in the identification of causes of peripheral neuropathy, idiopathic polyneuropathy remains common. Medication and toxic neuropathy account for a small but important percentage of potentially preventable or reversible causes of neuropathy. New drugs that can induce neuropathy have been approved over the past several years, including the anticancer agents bortezomib, ixabepilone, and oxaliplatin. We review the neurotoxic effects of tumor necrosis factor-alpha blockers infliximab and etanercept, the inflammatory arthritis agent leflunomide, and the antibiotic linezolid. The controversy of statin-induced neuropathy continues to unfold; the large Fremantle Diabetes Study has suggested that statins may have neuroprotective effects. Dichloroacetate is a promising agent for lactic acidosis-associated disorders, but toxic neuropathy is a treatment-limiting factor. We also describe a progressive inflammatory neuropathy in swine slaughterhouse workers that appears to be a toxin-induced immune response.
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Jian X, Guo G, Ruan Y, Lin D, Li X. Severe Cutaneous Adverse Drug Reaction to Leflunomide: A Report of Two Cases. Cutan Ocul Toxicol 2008; 27:5-9. [DOI: 10.1080/15569520701662866] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Leca N, Muczynski KA, Jefferson JA, de Boer IH, Kowalewska J, Kendrick EA, Pichler R, Davis CL. Higher levels of leflunomide are associated with hemolysis and are not superior to lower levels for BK virus clearance in renal transplant patients. Clin J Am Soc Nephrol 2008; 3:829-35. [PMID: 18372319 DOI: 10.2215/cjn.03930907] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND OBJECTIVES Leflunomide use in renal transplantation has been increasing. Outcome correlation and safety data are still to be refined. The goals of this study were to report one center's experience with leflunomide, specifically the correlation of leflunomide levels with the outcomes of BK nephropathy and the observed toxic effects during the treatment with leflunomide. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Leflunomide was used in 21 patients with BK nephropathy. These patients were divided into two groups on the basis of the leflunomide levels achieved: Low-level group (<40 microg/ml) and high-level group (>40 microg/ml). RESULTS During 13 mo of follow-up, there was no difference in the rate of serum BK viral clearance between the groups. There were three graft losses in the low-level group and one in the high-level group; however, creatinine levels were higher at the time of starting leflunomide in the low-level group. Leflunomide was also used in six patients with chronic allograft injury. No graft loss was observed during the follow-up period of 16 mo. Treatment with leflunomide seemed to be associated with a new toxicity, hemolysis, seen in four of the 27 patients so treated. Patients with hemolysis had high leflunomide levels (81.4 +/- 14 microg/ml) and worsening allograft function. Two patients had histologic evidence of thrombotic microangiopathy, which led to graft loss in one patient. CONCLUSIONS The clinical correlation between leflunomide levels and outcomes needs to be further refined. This study described a possible association of leflunomide with thrombotic microangiopathy, especially at higher levels.
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Affiliation(s)
- Nicolae Leca
- Department of Medicine, Division of Nephrology, University of Washington, Seattle, Washington 98195, USA.
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