Should Leflunomide (Arava) Be Routinely Stopped Before Joint Replacement Surgery?

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Should Leflunomide Be Routinely Stopped Before Joint Replacement Surgery?

http://www.medscape.com/viewarticle/520326

Question

Should leflunomide be routinely stopped before surgery, specifically joint

replacement?

Response from Arthur Kavanaugh, MD

University of California at San Diego, Division of Rheumatology, Allergy,

and Immunology, La Jolla, California.

As is the case with other antirheumatic therapies, there is a paucity of

evidence guiding the use of leflunomide perioperatively. In fact, compared

with other types of therapies (eg, methotrexate, tumor necrosis factor

inhibitors) for which there is minimal and largely anecdotal evidence, there

are even less data surrounding leflunomide!

For these other therapies, many clinicians will halt therapy for short

periods of time prior to and following therapy. For example, some clinicians

will discontinue methotrexate for 2 weeks prior to surgery and resume it

once the surgical wound has healed. The rationale for this approach is that

the potential flare of disease activity while off therapy is a mild risk

compared with the potential for increasing the risk of a perioperative wound

infection, particularly in the case of joint arthroplasty, for which the

consequences would be severe.

While such a practice may seem reasonable, it is not based on a wealth of

high-quality data. A potential consideration that is different in the case

of leflunomide is its enterohepatic circulation and very long half-life.

Therefore, serum concentrations remain for many weeks after discontinuing

therapy. Nevertheless, some clinicians would treat it as they do

methotrexate, with perhaps a greater washout time before the surgery. This

is an area in which more information certainly is needed.