Rheumatology: leflunomide in pregnancy: practice question

A General Medicine question in the style of the NEET PG paper. Answer it first, then read why the right option is right and why each of the others is wrong.

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General Medicine · Rheumatology: leflunomide in pregnancy

Sample item

A 34-year-old woman with rheumatoid arthritis has been on leflunomide for a year and finds she is 6 weeks pregnant. What is the most appropriate management?

AStop leflunomide and give cholestyramine for accelerated drug elimination, then check the plasma levelBReplace leflunomide with methotrexateCStop leflunomide and reassure, because its half-life is shortDContinue leflunomide and add folic acid

Original practice item, not a recalled exam question. Nothing here is recorded.

The answer and the reasoning

A. Stop leflunomide and give cholestyramine for accelerated drug elimination, then check the plasma level

Leflunomide is teratogenic, and its active metabolite teriflunomide has a very long half-life (about 2 weeks) because of enterohepatic recirculation, so it persists for months after stopping. Cholestyramine (8 g three times daily for 11 days) interrupts this recirculation and rapidly lowers levels, and the plasma level should be confirmed below 0.02 mg/L. Safer options for rheumatoid arthritis in pregnancy include hydroxychloroquine and sulfasalazine.

Option by option

A. Stop leflunomide and give cholestyramine for accelerated drug elimination, then check the plasma level (correct)
Correct. Washout with cholestyramine removes the long-lived metabolite quickly.
B. Replace leflunomide with methotrexate
Methotrexate is also teratogenic and is contraindicated in pregnancy.
C. Stop leflunomide and reassure, because its half-life is short
Stopping alone is insufficient since the metabolite persists for months through enterohepatic recirculation.
D. Continue leflunomide and add folic acid
Folic acid does not offset leflunomide teratogenicity, and continuing the drug exposes the fetus.

Source note: Original NextPrep sample item — pending expert review. This item is original practice material awaiting independent expert review, so confirm important facts in a standard textbook.

Questions about this General Medicine question

What is the answer to this General Medicine question?

The best answer is A, Stop leflunomide and give cholestyramine for accelerated drug elimination, then check the plasma level. Leflunomide is teratogenic, and its active metabolite teriflunomide has a very long half-life (about 2 weeks) because of enterohepatic recirculation, so it persists for months after stopping.

Why is "Replace leflunomide with methotrexate" not the answer?

Methotrexate is also teratogenic and is contraindicated in pregnancy.

Why is "Stop leflunomide and reassure, because its half-life is short" not the answer?

Stopping alone is insufficient since the metabolite persists for months through enterohepatic recirculation.

Why is "Continue leflunomide and add folic acid" not the answer?

Folic acid does not offset leflunomide teratogenicity, and continuing the drug exposes the fetus.

What concept does this question test?

It tests Rheumatology: leflunomide in pregnancy in General Medicine. Cholestyramine (8 g three times daily for 11 days) interrupts this recirculation and rapidly lowers levels, and the plasma level should be confirmed below 0.02 mg/L. Safer options for rheumatoid arthritis in pregnancy include hydroxychloroquine and sulfasalazine.

How hard is this question?

We tag it as a multi-step question: it asks you to combine more than one idea. The tag is our own editorial judgement, not an official difficulty rating, so read the reason for every option, not only the answer.

How should I study Rheumatology: leflunomide in pregnancy?

For each disease know the classic presentation, the best test, and the first-line treatment. Then use the flashcards and the other General Medicine questions on this site to test what stuck.

Is this a real NEET PG question?

No. It is an original practice item (editorial status: sample, version 1). NextPrep does not publish recalled or leaked questions, and independent faculty review of this item has not been completed yet, so confirm important facts in a standard textbook.