J Rheum Dis 2020; 27(2): 116-119  
Combination of Methotrexate and Leflunomide for Adult-onset Still’s Disease: A Case Report and Literature Review
Eunyoung Emily Lee, M.D., Min Jung Kim, M.D., Yeong Wook Song, M.D., Ph.D., Jin Kyun Park, M.D., Ph.D.
Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
Correspondence to: Jin Kyun Park http://orcid.org/0000-0003-2167-9393
Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea.
E-mail:jinkyunpark@gmail.com
Received: February 6, 2020; Revised: March 11, 2020; Accepted: March 12, 2020; Published online: April 1, 2020.
© Korean College of Rheumatology. All rights reserved.

This is a open Access article, which permits unrestricted non-commerical use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
The treatment of adult-onset Still’s disease (AOSD) aims to control systemic inflammation and prevent organ damage. Systemic inflammation can be controlled with corticosteroid (CS) monotherapy in most cases. However, symptoms often flare as CS is tapered, often requiring long-term CS treatment, with its associated risks of infection, cardiovascular disease, and osteoporosis. Disease-modifying antirheumatic drugs (DMARDs) are often used as CS-sparing agents; however, the choice of DMARD has been largely empirical. Methotrexate (MTX) is recommended as the first-line steroid-sparing drug due to its well-known efficacy and safety in rheumatoid arthritis (RA). When MTX treatment is unsuccessful in AOSD, the choice of a second-line drug has not been established. In RA, leflunomide (LEF) has been used as an alternative to or in combination with MTX. To date, there has been no adequate assessment of the combination of LEF and MTX in AOSD. Here, we report a case of refractory chronic AOSD successfully treated with the MTX-LEF combination.
Keywords: Still’s disease, Adult-onset, Antirheumatic agents, DMARD, Methotrexate, Leflunomide


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