Leflunomide in Pakistani patients with rheumatoid arthritis: prospective study in daily rheumatology practice

Frequency of Interstitial Lung Disease in Rheumatoid Arthritis Patients: A Hospital-Based Study

Introduction: Among various extra-articular manifestations of rheumatoid arthritis (RA), interstitial lung disease (ILD) is the most frequent and concerning manifestation. The reported frequency of RA-associated ILD (RA-ILD) varies in the literature. The objective of the present study was to determine the frequency of ILD in RA patients at a teaching hospital in Rawalpindi.

Methods: 175 male and female patients between 18-70 years were enrolled in the study from January 21, 2022, till July 24, 2022. Patients diagnosed with RA were screened for the concomitant presence of ILD (increased pulmonary markings on chest X-rays and total lung capacity ≤ 80%, predicted on pulmonary function tests). In addition, the frequency of RA-ILD was noted and compared across various subgroups of patients based on age, gender, and disease duration.

Results: The mean age of the patients was 45.3 ± 11.5 years. The male-to-female ratio was 1:3.1. The mean disease duration was 6.2 ± 3.5 years at the time of presentation. A total of 118 (67.4%) patients were diagnosed with RA-ILD. The frequency of RA-ILD was significantly higher among patients with a prolonged duration of disease, < 5 years vs. ≥ 5 years (59.1% vs. 75.9%; p-value=0.018). Among 118 patients with RA-ILD, usual interstitial pneumonia (UIP) was the most frequent pattern and was noted in 74 (62.7%) patients, followed by nonspecific interstitial pneumonitis (NSIP), which was noted in 44 (37.3%) patients. When compared, there was no statistically significant difference in the frequency of high-resolution CT (HRCT) pattern of RA-ILD across various subgroups of patients based on age (p-value=0.969), gender (p-value=0.934), and duration of disease (p-value=0.881).

Conclusion: In the present study, a substantial proportion of RA patients suffered RA-ILD, which warrants routine screening of these patients for undiagnosed pulmonary involvement so that timely identification and anticipated management may improve the outcome of such cases in future clinical practice.

Safety of the Methotrexate-leflunomide Combination in Rheumatoid Arthritis: Results of a Multicentric, Registry-based, Cohort Study (BiobadaBrasil)

OBJECTIVE

To evaluate the safety of the methotrexate (MTX)-leflunomide (LEF) combination in rheumatoid arthritis (RA), comparing it with other therapeutic schemes involving conventional synthetic (cs-) and biologic (b-) disease-modifying antirheumatic drugs (DMARDs) or Janus kinase inhibitors (JAKi).

METHODS

Patients with RA starting a treatment course with a csDMARD (without previous use of bDMARD or JAKi) or their first bDMARD/JAKi were followed up in a registry-based, multicentric cohort study in Brazil (BiobadaBrasil). The primary outcome was the incidence of serious adverse events (SAEs); secondary outcomes included serious infections. Multivariate Cox proportional hazards models and propensity score matching analysis (PSMA) were used for statistical comparisons.

RESULTS

In total, 1671 patients (5349 patient-years [PY]) were enrolled; 452 patients (1537 PY) received MTX + LEF. The overall incidence of SAEs was 5.6 per 100 PY. The hazard of SAEs for MTX + LEF was not higher than for MTX or LEF (adjusted HR [aHR] 1.00, 95% CI 0.76-1.31, P = 0.98). MTX + LEF presented a lower hazard of SAEs (aHR 0.56, 95% CI 0.36-0.88, P = 0.01) and infectious SAEs (aHR 0.48, 95% CI 0.25-0.94, P = 0.03) than bDMARDs/JAKi with MTX or LEF. MTX + LEF presented lower hazard of SAEs than MTX + sulfasalazine (SSZ; aHR 0.33, 95% CI 0.16-0.65, P = 0.002). Analysis using PSMA confirmed the results obtained with traditional multivariate Cox analysis.

CONCLUSION

In our study, MTX + LEF presented a relatively good overall safety profile in comparison to MTX + SSZ and schemes involving advanced therapies in RA.

Onset of Hypertension in Leflunamide Treated Low Socioeconomic Rheumatoid Arthritis Patients: An Unseen Iceberg

OBJECTIVE

To determine the frequency of new-onset hypertension in patients with Rheumatoid arthritis taking leflunomide, in comparison with methotrexate in Asian setting.

MATERIAL AND METHODS

Perspective case-control study was conducted in 2014 in a tertiary care hospital located in Karachi, Pakistan. Adult patients, having rheumatoid arthritis were randomly prescribed leflunomide or methotrexate. Patients having chronic hypertension, proteinuria and chronic kidney disease were excluded. Patients were monthly followed for blood pressure and heart rate measurements. Hypertension was defined using JNC 7 criteria.

RESULTS

Out of 144 patients enrolled, 80 patients received Leflunomide while 64 were started on methotrexate. Mean systolic blood pressure in leflunomide group at the start and at the end of study was 108.5 and 135.4mmHg, respectively while in methotrexate group, mean systolic BP was 109.8 and 110.5 mmhg, respectively. After one year follow up, 33 out of 80 (41%) patients were receiving leflunomide had pre-hypertension or hypertension, while only 3 out of 64 patients (4.7%) were receiving methotrexate had hypertension.

CONCLUSION

Risk of developing hypertension in patient receiving Leflunomide is much higher in Asian population like Pakistan as compared to western population.