Mitochondrial dysfunction induced by leflunomide and its active metabolite

Toxicology. 2018 Mar 1:396-397:33-45. doi: 10.1016/j.tox.2018.02.003. Epub 2018 Feb 8.


Leflunomide, an anti-inflammatory drug used for the treatment of rheumatoid arthritis, has been marked with a black box warning regarding an increased risk of liver injury. The active metabolite of leflunomide, A771726, which also carries a boxed warning about potential hepatotoxicity, has been marketed as teriflunomide for the treatment of relapsing multiple sclerosis. Thus far, however, the mechanism of liver injury associated with the two drugs has remained elusive. In this study, cytotoxicity assays showed that ATP depletion and subsequent LDH release were induced in a time- and concentration-dependent manner by leflunomide in HepG2 cells, and to a lesser extent, by A77 1726. The decline of cellular ATP levels caused by leflunomide was dramatically exacerbated when galactose was substituted for glucose as the sugar source, indicating a potential mitochondrial liability of leflunomide. By measuring the activities of immuno-captured mitochondrial oxidative phosphorylation (OXPHOS) complexes, we found that leflunomide and A77 1726 preferentially targeted complex V (F1FO ATP synthase), with IC50 values of 35.0 and 63.7 μM, respectively. Bongkrekic acid, a mitochondrial permeability transition pore blocker that targets adenine nucleotide translocase, profoundly attenuated mitochondrial membrane depolarization, ATP depletion, and LDH leakage induced by leflunomide and A77 1726. Substantial alterations of mitochondrial function at the transcript level were observed in leflunomide-treated HepG2 cells, whereas the effects of A77 1726 on the cellular transcriptome were much less profound. Our results suggest that mitochondrial dysfunction may be implicated in the hepatotoxicity associated with leflunomide and A77 1726, with the former exhibiting higher toxicity potency.

Keywords: ANT; ATP synthase; Drug-induced liver injury; Leflunomide; Oxidative phosphorylation.

Publication types

  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adenosine Triphosphate / metabolism
  • Anti-Inflammatory Agents, Non-Steroidal / toxicity*
  • Bongkrekic Acid / pharmacology
  • Chemical and Drug Induced Liver Injury / metabolism
  • Endoplasmic Reticulum Stress / drug effects
  • Galactose / metabolism
  • Glucose / metabolism
  • Hep G2 Cells
  • Humans
  • Isoxazoles / toxicity*
  • L-Lactate Dehydrogenase / metabolism
  • Leflunomide
  • Membrane Potential, Mitochondrial / drug effects
  • Mitochondria, Liver / drug effects
  • Mitochondrial Diseases / chemically induced*
  • Mitochondrial Membrane Transport Proteins
  • Mitochondrial Permeability Transition Pore
  • Oxidative Phosphorylation / drug effects


  • Anti-Inflammatory Agents, Non-Steroidal
  • Isoxazoles
  • Mitochondrial Membrane Transport Proteins
  • Mitochondrial Permeability Transition Pore
  • Bongkrekic Acid
  • Adenosine Triphosphate
  • L-Lactate Dehydrogenase
  • Leflunomide
  • Glucose
  • Galactose