Jm. Kremer, Methotrexate and leflunomide: Biochemical basis for combination therapy inthe treatment of rheumatoid arthritis, SEM ARTH RH, 29(1), 1999, pp. 14-26
Objectives: Methotrexate is currently one of the most widely prescribed dis
ease-modifying antirheumatic drugs (DMARDs) for the treatment of rheumatoid
arthritis (RA). Combination therapy of methotrexate with other DMARDs incr
eases the clinical success of low-dose methotrexate treatment. Leflunomide
is a new DMARD that may have a high potential for success in combination th
erapy with methotrexate, This review compares the mode of action of methotr
exate and leflunomide and speculates on how this contributes to therapeutic
efficacy in RA when these agents are used singly or in combination.
Methods: A literature review of the biochemical mechanisms considered to be
the basis for the therapeutic efficacy of methotrexate and leflunomide in
treating RA is presented.
Results: Low-dose methotrexate inhibits cytokine production, purine biosynt
hesis, and, in an animal model, causes the release of adenosine, a potent a
ntiinflammatory agent. Leflunomide, through inhibition of de novo pyrimidin
e biosynthesis, can regulate lymphocyte proliferation.
Conclusions: The biochemical mechanisms underlying the therapeutic efficacy
of low-dose methotrexate and leflunomide in the treatment of RA are quite
different. The potentially complementary mechanisms of action of these two
effective DMARDs should provide a rationale for their use in combination th
erapy for patients whose condition no longer responds to methotrexate alone
. Semin Arthritis Rheum 29: 14-26. Copyright (C) 1999 by W.B. Saunders Comp
any.