Agreed. In Ontario, until recently we HAD to use leflunomide prior to access to biologics and had to use high dose Mtx and had to use at least one combination so many Ontario rheumatologists used triple and then Mtx + Leflunomide or even sometimes triple + leflunomide. Sometimes it was a home run, sometimes diarrhea or other side effects (oral ulcers, cytopenias, transaminitis). However, there is a lot of experience out there with it and we can't forget about it but have to observe carefully for side effects that may occur in the lab monitoring (as the symptoms patients may get from it are obvious, but the labs can be affected). Thanks, Janet