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Case Report
Repeated cholestyramine washouts in a pregnant patient on leflunomide: A case report
1 Third Year Medical Student, Texas Tech University Health Sciences Center, Odessa, Texas, USA
2 Chief of Rheumatology, Texas Tech University Health Sciences Center, Odessa, Texas, USA
3 Research aide, Third Year Medical Student, Texas Tech University Health Sciences Center, Odessa, Texas, USA
4 Senior Research Scientist, Texas Tech University Health Sciences Center, Odessa, Texas, USA
5 Research lab director, Texas Tech University Health Sciences Center, Odessa, Texas, USA
Address correspondence to:
Srikanth Mukkera
MD, FACR, 701 West 5th Street, Odessa, Texas 79763,
USA
Message to Corresponding Author
Article ID: 100117Z08VK2022
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Ku V, Mukkera S, Manales NJ, Sanchez A, Gandhi K. Repeated cholestyramine washouts in a pregnant patient on leflunomide: A case report. J Case Rep Images Obstet Gynecol 2022;8(1):10–13.ABSTRACT
Introduction: Leflunomide is a disease modifying antirheumatic drug (DMARD) that is commonly used for the treatment of rheumatoid arthritis (RA). It is considered as a category X drug because it is contraindicated during pregnancy (studies in pregnant women have demonstrated a risk to the fetus, and/or human or animal studies have shown fetal abnormalities; risks of the drug outweigh the potential benefits). In women attempting to conceive, it is necessary to ensure that leflunomide levels are undetectable in plasma to prevent the risk of fetal malformations. An 11-day treatment of cholestyramine has been shown to lower leflunomide active metabolite levels to near undetectable levels.
Case Report: In this case report, we discuss an RA patient taking leflunomide, who had an unintended pregnancy requiring two treatment courses of cholestyramine for complete washout of leflunomide. A C-section was performed at 39 weeks and 3 days due to concerns about the fetus’ health and was complicated by postpartum hemorrhage. The infant received Apgar scores of 9 and 9 at 1 and 5 minutes. The infant was also found with no birth anomalies and was deemed healthy at a check-up of nine months of age.
Conclusion: Although a single 11-day treatment is typically sufficient to safely lower the concentration of leflunomide, it is important to remeasure the leflunomide active metabolite levels after the treatment course of cholestyramine to ensure that levels have reached zero. When leflunomide levels remain significantly elevated, a second treatment course of cholestyramine is required, otherwise the fetus could potentially be exposed to its teratogenic properties.
Keywords: Cholestyramine, Leflunomide, Pregnancy, Rheumatoid arthritis
SUPPORTING INFORMATION
Acknowledgments
We appreciate the Texas Tech University Health Sciences Center, Permian Basin, TX, and Evangelyna Nguyen at the TTUHSC-PB Research Lab for their assistance with submitting and revising this case report.
Author ContributionsVanessa Ku - Conception of the work, Design of the work, Acquisition of data, Analysis of data, Drafting the work, Revising the work critically for important intellectual content, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Srikanth Mukkera - Conception of the work, Design of the work, Acquisition of data, Drafting the work, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Nathan Joshua Manales - Revising the work critically for important intellectual content, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Asley Sanchez - Drafting the work, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Kushal Gandhi - Analysis of data, Revising the work critically for important intellectual content, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Guarantor of SubmissionThe corresponding author is the guarantor of submission.
Source of SupportNone
Consent StatementWritten informed consent was obtained from the patient for publication of this article.
Data AvailabilityAll relevant data are within the paper and its Supporting Information files.
Conflict of InterestAuthors declare no conflict of interest.
Copyright© 2022 Vanessa Ku et al. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information.
