Arava (Leflunomide) vs Other RA Treatments: Pros, Cons & Comparison

• Oct, 12 2025
• 1

Living with rheumatoid arthritis (RA) means juggling pain, joint damage, and a long list of medication choices. One drug that often pops up is Arava, known generically as Leflunomide. It’s an oral disease‑modifying antirheumatic drug (DMARD) that many patients turn to when methotrexate isn’t enough or causes intolerable side effects. But how does it really stack up against the other options on the market? Below is a straight‑talk guide that breaks down the science, safety, and cost so you can decide if Arava is the right fit for your RA journey.

Key Takeaways

• Arava blocks a key enzyme in immune cells, slowing joint inflammation without the injection hassle.
• It works slower than biologics but faster than some older DMARDs, with noticeable improvement in 8‑12 weeks.
• Common side effects include liver enzyme elevation and high blood pressure; pregnancy is a strict no‑go.
• Alternatives such as methotrexate, sulfasalazine, hydroxychloroquine and biologics differ in route, speed, and safety profile.
• Cost in Australia ranges from subsidised generic versions to premium biologics, influencing the choice for many patients.

What is Arava (Leflunomide)?

Leflunomide is an oral synthetic DMARD approved for moderate to severe rheumatoid arthritis. Sold under the brand name Arava, the medication comes in 10mg and 20mg tablets and is typically started at 100mg daily for three weeks (a loading dose) before tapering to a maintenance dose of 10‑20mg per day.

How Arava Works

Arava’s magic lies in inhibiting dihydroorotate dehydrogenase (DHODH), an enzyme crucial for pyrimidine synthesis in rapidly dividing lymphocytes. By throttling this pathway, Leflunomide reduces the proliferation of activated T‑cells and B‑cells, which are the main culprits behind joint inflammation.

When Doctors Choose Arava

Physicians usually prescribe Arava when:

• Methotrexate is ineffective or not tolerated.
• Patients prefer an oral regimen over injections.
• There’s a need for a second‑line DMARD before stepping up to biologics.

It’s also favoured in patients with liver concerns that preclude higher methotrexate doses, provided liver function is monitored closely.

Alternatives Overview

Below is a quick snapshot of the most common DMARDs and biologics you’ll hear about.

Methotrexate is the gold‑standard first‑line oral DMARD, usually started at 7.5‑15mg weekly and titrated up to 25mg as needed. It works by inhibiting folate metabolism, which dampens immune cell proliferation.

Sulfasalazine is an older synthetic DMARD taken twice daily, often at 500‑1000mg. Its anti‑inflammatory effect comes from modulating cytokine production.

Hydroxychloroquine is a mild DMARD, commonly dosed at 200‑400mg daily. It interferes with antigen presentation and is especially useful in patients with milder disease or overlapping lupus.

Etanercept belongs to the biologic family of tumor necrosis factor (TNF) inhibitors. It’s a weekly subcutaneous injection (50mg) that directly neutralises TNF‑α, a key driver of joint damage.

Adalimumab is another TNF inhibitor, delivered as a 40mg subcutaneous injection every two weeks. It offers a robust response in patients who have failed traditional DMARDs.

Tofacitinib is a Janus kinase (JAK) inhibitor taken orally at 5mg twice daily. It blocks multiple cytokine signalling pathways and is often positioned after methotrexate failure.

Side‑Effect Profile Comparison

Every RA drug has trade‑offs. Here’s how the major side effects line up:

• Arava (Leflunomide): Liver enzyme rise (ALT/AST), hypertension, alopecia, and teratogenicity. Rarely, severe skin reactions (Stevens‑Johnson syndrome).
• Methotrexate: nausea, mouth ulcers, liver toxicity, and bone‑marrow suppression; requires folic acid supplementation.
• Sulfasalazine: gastrointestinal upset, rash, and rare blood dyscrasias; contraindicated in sulfa allergy.
• Hydroxychloroquine: retinal toxicity (requires annual eye exams), GI upset, and skin hyperpigmentation.
• Etanercept / Adalimumab: injection site reactions, increased infection risk (including TB), and rare demyelinating disease.
• Tofacitinib: elevated lipids, liver enzymes, risk of herpes zoster, and thromboembolic events.

Overall, Arava sits in a middle ground-more systemic than hydroxychloroquine but less immunosuppressive than biologics.

Cost & Accessibility (Australian Context)

Price often decides which drug a patient can stay on. Approximate monthly costs (including PBS subsidies where applicable) are:

• Arava (generic Leflunomide): AU$30‑70.
• Methotrexate (generic): AU$5‑20.
• Sulfasalazine: AU$25‑40.
• Hydroxychloroquine: AU$10‑15.
• Etanercept (Biologics): AU$1,200‑1,500 (largely PBS‑covered after specialist approval).
• Adalimumab: AU$1,300‑1,600 (similar PBS pathway).
• Tofacitinib: AU$800‑1,000 (often needs private insurance).

Because Arava is oral and inexpensive, it’s attractive for patients who can’t afford or don’t qualify for biologic subsidies.

Direct Comparison Table

Choosing the Right DMARD for You

Decision‑making in RA isn’t one‑size‑fits‑all. Here’s a quick decision tree you can discuss with your rheumatologist:

1. If you need rapid control (<4 weeks) and can handle injections, biologics like Etanercept or Adalimumab are top picks.
2. If you prefer oral meds and have mild‑to‑moderate disease, start with Methotrexate. Monitor liver enzymes and supplement with folic acid.
3. If methotrexate causes nausea or liver issues, switch to Arava (Leflunomide). Remember to do a baseline pregnancy test and regular blood pressure checks.
4. For patients with comorbid kidney disease, consider Hydroxychloroquine or a low‑dose Sulfasalazine because they’re less renally cleared.
5. If you’ve tried two synthetic DMARDs without success, a JAK inhibitor like Tofacitinib may be the next step, especially if you’re okay with oral dosing and can manage infection risk.

These pathways are guidelines, not prescriptions. Your rheumatologist will factor in disease activity scores (DAS28), radiographic progression, and personal lifestyle.

Transitioning Between Therapies

Switching drugs is common, but it needs a plan:

• Wash‑out period: Leflunomide has a long half‑life (≈2 weeks). If moving to a biologic, doctors often give a cholestyramine wash‑out (8g three times daily for 11 days) to clear the drug faster.
• Overlap strategy: When adding a new DMARD, keep the old one for 2‑4 weeks to maintain disease control, then taper.
• Monitoring: Re‑check liver enzymes, CBC, and renal function 2 weeks after any switch.
• Pregnancy considerations: Stop Leflunomide at least 2 years before trying to conceive, or use accelerated clearance with cholestyramine.

Following these steps reduces flare‑ups and keeps side‑effects in check.

In a Arava comparison you’ll find that the drug offers a solid middle ground: oral convenience, moderate cost, and a safety profile that’s manageable with regular labs. Pair this knowledge with your doctor’s expertise, and you’ll be better equipped to choose the right RA therapy for your lifestyle and health goals.