A 45-year-old woman comes to the office due to gradually progressive pain, stiffness, and swelling of her hand joints for the past several months. The patient has had prolonged morning stiffness and significant restriction of her daily activities due to the pain, as well as generalized fatigue. She describes the symptoms over the last several weeks as "disabling," and she needs assistance with activities of daily living in the morning. The patient has tried over-the-counter pain medications, such as acetaminophen and ibuprofen, with only minimal relief of her symptoms. She has no other medical problems. Family history is significant for diabetes mellitus on her maternal side. Which of the following drugs would provide the most rapid relief of her symptoms?

Question

A 45-year-old woman comes to the office due to gradually progressive pain, stiffness, and swelling of her hand joints for the past several months.  The patient has had prolonged morning stiffness and significant restriction of her daily activities due to the pain, as well as generalized fatigue.  She describes the symptoms over the last several weeks as "disabling," and she needs assistance with activities of daily living in the morning.  The patient has tried over-the-counter pain medications, such as acetaminophen and ibuprofen, with only minimal relief of her symptoms.  She has no other medical problems.  Family history is significant for diabetes mellitus on her maternal side.  Which of the following drugs would provide the most rapid relief of her symptoms?

Quizplus · Accepted Answer

This patient has swelling, pain, and morning stiffness in multiple joints for >6 weeks, consistent with rheumatoid arthritis (RA). The foundation of management for RA is disease-modifying antirheumatic drugs (DMARDs), which alleviate pain and inflammation and reduce long-term joint destruction and disability. Examples of DMARDS are methotrexate (typically first-line), sulfasalazine, hydroxychloroquine, minocycline, and tumor necrosis factor-alpha inhibitors. However, the response to DMARD therapy typically takes weeks (Choices B, C, D, and F). Therefore, short-term treatment with anti-inflammatory therapies, including systemic and intraarticular glucocorticoids (eg, prednisone) or nonsteroidal anti-inflammatory drugs (NSAIDs), can provide rapid, temporary relief of symptoms in patients starting on DMARDs. However, they do not provide adequate long-term control of disease or prevention of joint deformity. Glucocorticoids exert their anti-inflammatory effects by inhibiting phospholipase A2, which decreases prostaglandin and leukotriene synthesis. Glucocorticoids also depress the immune response by inhibiting the transcription of multiple cytokines and adhesion proteins, which reduces leukocyte recruitment and activation. (Choice A) Colchicine is used in the management of both acute and chronic gout. Colchicine works by binding to tubulin and inhibiting microtubule polymerization. This results in disruption of neutrophil chemotaxis and phagocytosis, thereby reducing the inflammatory response to uric acid crystals. Colchicine is not effective in RA. Educational objective: The foundation of management for rheumatoid arthritis is disease-modifying antirheumatic drugs, which alleviate pain and inflammation and reduce long-term joint destruction. However, the response to treatment may take several weeks. Nonsteroidal anti-inflammatory drugs and glucocorticoids can provide rapid symptom relief in the interim. __________ References: Efficacy of prednisone 1-4 mg/day in patients with rheumatoid arthritis: a randomised, double-blind, placebo controlled withdrawal clinical trial. (http://www.ncbi.nlm.nih.gov/pubmed/19074913)

A 45-Year-Old Woman Comes to the Office Due to Gradually