Efficacy and tolerability of leflunomide in difficult-to-treat polymyalgia rheumatica and giant cell arteritis: a case series

Abstract

Polymyalgia rheumatica (PMR) and giant cell arteritis (GCA) are related inflammatory rheumatic conditions affecting adults over the age of 50 years. Both conditions respond to initial glucocorticoid (GC) therapy. However, most patients require 12-36 months of a tapering steroid regime. Adverse events at 2 years are seen in up to 65% of patients with PMR and 86% of patients with GCA with over 50% developing serious events. There is also a high incidence of relapse in both diseases -40% within 2 years for GCA and 50% of patients with PMR at some point having a relapse. Effective steroid-sparing adjuvant therapies are urgently required especially in incomplete, poorly sustained or non-responders to glucocorticoids. In this case series, we found that Leflunomide is efficacious, with 22 out of our 23 patients exhibiting a complete or partial response. It was also steroid sparing and well tolerated. It may be a useful adjunctive agent in difficult-to-treat GCA and PMR. Prospective randomised controlled trials of Leflunomide in both GCA and PMR are now required.

Giant Cell Arteritis: Beyond Corticosteroids

“…Leflunomide may be an effective corticosteroid-sparing agent in patients with difficult to treat GCA and two case series showed either a partial or complete response and was well-tolerated [12,13]. Mycophenolate mofetil has been effective in a case series of three elderly patients at high risk of long term high dose glucocorticoid due to comorbidities [14].…”

Aortitis

“…It was well tolerated, with favorable impact on both clinical and laboratory picture and helped steroid tapering in the majority of cases [ 100 ]. In a recent prospective study leflunomide was used at 20 mg/day in 15 patients with TA whose disease was refractory to GC and other immunosuppressant agents.…”

Giant cell arteritis

“…Despite this fact, there is a paucity of data regarding the best glucocorticoid regimen in GCA (Table 3). An initial prednisone dose of Leflunomide Open label case series 2012 GC þ leflunomide 9 (refractory GCA) 9/9 complete or partial response (at a median of 2 months) [98] (continued on next page) 40e60 mg/day seems to be adequate for most patients. This is supported by recent observational data that patients receiving an initial oral prednisone dose >40 mg/day were more likely to reach a dose of <5 mg/day and discontinue glucocorticoids sooner than those initially receiving 40 mg/day without an increase in observed glucocorticoid adverse events [74].…”

“…Two case series of leflunomide as a corticosteroid-sparing agent in GCA have been published with nine and 12 patients [98,99]. Each study showed improvement in prednisolone dose tapering, suggesting that further study of this drug is warranted.…”