Can a patient continue leflunomide (Arava) during tooth extraction?
Yes, a patient can continue leflunomide (Arava) during a tooth extraction without interruption. This recommendation is based on the most recent and highest-quality evidence from the 2022 ACR/AAHKS guideline for perioperative management of antirheumatic medications.
Primary Recommendation
For patients with rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, juvenile idiopathic arthritis, or systemic lupus erythematosus undergoing dental procedures including tooth extraction, continue the usual dose of leflunomide through the procedure 1. This represents a conditional recommendation based on low-to-moderate quality evidence, but it is the most current guidance available from the American College of Rheumatology.
Supporting Evidence and Rationale
The 2017 and 2022 ACR/AAHKS guidelines specifically address perioperative management of DMARDs (disease-modifying antirheumatic drugs) including leflunomide. The evidence demonstrates:
Continuing DMARDs like leflunomide does not increase infection risk—in fact, randomized controlled trials showed that continuing DMARDs was associated with a decreased risk of infections (RR 0.39,95% CI 0.17-0.91) compared to stopping them 2, 3
Stopping DMARDs increases disease flare risk (RR 0.06 for flares when continuing vs. stopping) 2, 3
The guideline groups leflunomide with methotrexate, hydroxychloroquine, and sulfasalazine as medications that should be continued perioperatively 1
Important Caveats and Nuances
Conflicting Evidence for Major Orthopedic Surgery
There is one notable exception to this recommendation: A 2006 study found that leflunomide was associated with significantly higher wound-healing complications after elective orthopedic surgery (40.6% vs. 13.6% with methotrexate, p=0.01), leading those authors to recommend stopping leflunomide preoperatively for major orthopedic procedures 4.
However, this finding applies specifically to major orthopedic surgery (joint replacements), not dental extractions. The ACR guidelines acknowledge this concern but still recommend continuing leflunomide for total hip and knee arthroplasty based on the overall evidence 2, 3, 1.
Dental Extraction is Lower Risk Than Major Surgery
Tooth extraction represents a much lower-risk procedure than total joint arthroplasty, with:
- Smaller surgical field
- Less tissue trauma
- Shorter healing time
- Lower infection risk overall
The guidelines do not distinguish between major surgery and minor procedures like dental extractions when recommending continuation of leflunomide, suggesting the benefit of continuing the medication outweighs any theoretical risk for routine dental work.
Clinical Management Approach
Before the Extraction
- Do not stop leflunomide before the procedure
- Ensure good oral hygiene and address any active dental infections before elective extractions
- Consider prophylactic antibiotics based on standard dental indications (not specifically because of leflunomide)
During and After the Extraction
- Continue leflunomide at the usual dose throughout the perioperative period
- Monitor the extraction site for normal healing
- Watch for signs of infection (increased pain, swelling, erythema, drainage)
- Maintain good oral hygiene post-extraction
Special Circumstances Requiring Caution
Consider a more cautious approach (potentially consulting with the prescribing rheumatologist) if the patient has:
- History of severe or recurrent infections
- Severe immunodeficiency or uncontrolled infection
- Multiple extractions planned (higher cumulative risk)
- Poor wound healing history
Infection Risk Context
The FDA label for Arava notes that leflunomide has immunosuppressive potential and may increase susceptibility to infections 5. However, if a serious infection occurs during dental healing, the medication can be interrupted and an accelerated elimination procedure initiated using cholestyramine or activated charcoal 5. This provides a safety mechanism if complications arise.
Practical Bottom Line
Continue leflunomide through routine tooth extraction. The evidence supporting continuation is stronger than evidence for stopping, particularly for procedures less invasive than major orthopedic surgery. The risk of disease flare from stopping the medication likely exceeds any marginal increase in infection risk for a routine dental extraction. Monitor healing closely and maintain good communication between the dentist and rheumatologist if any concerns arise.