From the FDA Drug Label
Leflunomide is not recommended for patients with severe immunodeficiency, bone marrow dysplasia, or severe, uncontrolled infections. Patients taking leflunomide should have platelet, white blood cell count and hemoglobin or hematocrit monitored at baseline and monthly for six months following initiation of therapy and every 6 to 8 weeks thereafter.
Low T cells, WBC, and HGB indicate a potential immunodeficiency or bone marrow suppression.
- Given the patient's low T cells, WBC, and HGB, and slightly increased red blood cells, it is not safe to start Arava (leflunomide) due to the potential for increased risk of infections and further bone marrow suppression 1, 1, 1.
- The patient's condition may be considered as having a severe immunodeficiency or bone marrow dysplasia, which is a contraindication for leflunomide use.
- Close monitoring of the patient's hematologic parameters is necessary before initiating leflunomide therapy.
From the Research
Starting Arava (leflunomide) with low T cells, white blood cells, hemoglobin, and slightly increased red blood cells is not recommended without close medical supervision and monitoring due to the potential for worsening immunosuppression and hematologic abnormalities. Given the patient's existing low T cells, white blood cells, and hemoglobin, along with slightly increased red blood cells, it is crucial to approach the initiation of Arava with caution. Arava, as an immunosuppressant, works by inhibiting pyrimidine synthesis, which can affect rapidly dividing cells, including immune cells, potentially exacerbating the existing low blood counts 2.
Key Considerations
- The medication's mechanism of action involves the inhibition of dihydro-orotate dehydrogenase, an enzyme necessary for pyrimidine synthesis, which is crucial for the proliferation of T and B lymphocytes 2.
- The potential for Arava to further decrease white blood cell counts, including T cells, necessitates careful consideration and monitoring 3, 4.
- Regular blood monitoring is essential to assess the impact of Arava on the patient's blood cell counts and to adjust the dose as necessary to minimize adverse effects while maintaining therapeutic efficacy.
Recommendations
- Consultation with a rheumatologist or specialist is necessary before starting Arava to evaluate the complete blood work and medical history of the patient.
- Comprehensive blood tests, including a complete blood count, liver function tests, and screening for tuberculosis and hepatitis, should be performed before initiating Arava.
- Adjustment of the starting dose may be necessary based on the patient's blood abnormalities, with consideration of starting with a lower dose and closely monitoring blood counts.
- Regular blood monitoring (every 2-4 weeks initially, then every 8-12 weeks) is crucial while the patient is taking Arava to promptly identify and manage any adverse effects on blood cell counts.
Alternative Considerations
- The patient's doctor might consider alternative medications with less impact on blood cells.
- Close monitoring of the patient's condition and adjustment of the treatment plan as necessary to balance the therapeutic benefits of Arava with the potential risks to the patient's immune system and hematologic status.