A 52-year-old man with a history of rheumatoid arthritis comes to the clinic due to increasing pain and swelling involving several joints over the past 6 weeks. The patient also has fatigue and morning stiffness that can last for hours. He was diagnosed with rheumatoid arthritis 2 years ago after he presented with symmetrical polyarthritis, a high-titer rheumatoid factor, and positive cyclic citrullinated peptide antibodies. Treatment with methotrexate and nonsteroidal anti-inflammatory agents resulted in reduction of joint pain and swelling. At his last visit 3 months ago, the patient had only mild joint pains without any morning stiffness. His other medical problems include hypertension, diverticulosis, and hyperlipidemia.
His temperature is 37.4 C (99.4 F), blood pressure is 135/82 mm Hg, and pulse is 77/min. Gentle squeezing of his hands and feet evokes pain. Several small joints of the fingers and toes are swollen and tender. There is mild boggy swelling of the left knee. Subcutaneous nodules are seen over the elbows. The remainder of the physical examination is unremarkable.
Laboratory results are as follows:

Which of the following is the best next step in management of this patient?

Question

A 52-year-old man with a history of rheumatoid arthritis comes to the clinic due to increasing pain and swelling involving several joints over the past 6 weeks.  The patient also has fatigue and morning stiffness that can last for hours.  He was diagnosed with rheumatoid arthritis 2 years ago after he presented with symmetrical polyarthritis, a high-titer rheumatoid factor, and positive cyclic citrullinated peptide antibodies.  Treatment with methotrexate and nonsteroidal anti-inflammatory agents resulted in reduction of joint pain and swelling.  At his last visit 3 months ago, the patient had only mild joint pains without any morning stiffness.  His other medical problems include hypertension, diverticulosis, and hyperlipidemia.
His temperature is 37.4 C (99.4 F), blood pressure is 135/82 mm Hg, and pulse is 77/min.  Gentle squeezing of his hands and feet evokes pain.  Several small joints of the fingers and toes are swollen and tender.  There is mild boggy swelling of the left knee.  Subcutaneous nodules are seen over the elbows.  The remainder of the physical examination is unremarkable.
Laboratory results are as follows:

Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_9923_f1c9_853d_f99dfe4cbce1_MD0002_00 This patient with rheumatoid arthritis (RA) had an initial response to methotrexate but now has treatment-resistant disease. Signs of active RA include synovitis and inflammation of multiple joints, prolonged morning stiffness lasting >1 hour, and an elevated erythrocyte sedimentation rate. Adding a biologic disease-modifying antirheumatic drug (DMARD), such as a tumor necrosis factor-α (TNF) antagonist, is the most appropriate next step (step-up therapy). However, TNF blockers increase the risk of reactivation of latent tuberculosis (TB), often resulting in extrapulmonary and disseminated disease. As a result, all patients should undergo TB screening (either skin tuberculin test or interferon-gamma release assay) before starting TNF blockers, and those with positive tests should then be treated for latent TB prior to starting TNF antagonist therapy. Patients should also be screened for hepatitis B and C prior to initiation of TNF blockers. (Choice B) RA has been associated with membranous nephropathy, secondary amyloidosis, proliferative nephropathy, and vasculitis. RA is commonly associated with perinuclear antineutrophil cytoplasmic antibodies (p-ANCA). However, it is unclear how specific this finding is as many patients have positive ANCA without systemic vasculitis. (Choice C) Lyme disease typically involves the large joints (eg, knees). This patient did not have a preceding rash and has hand arthritis, making Lyme disease less likely. (Choice D) Methotrexate is the most commonly used DMARD for RA. It can sometimes cause nodules or worsen existing ones, but it is rarely discontinued. However, this patient has actively worsening disease and requires additional treatment. (Choice E) Adding another nonbiologic DMARD (sulfasalazine or hydroxychloroquine) to methotrexate is acceptable although less preferable than adding a biologic DMARD. However, sulfasalazine is usually not given as monotherapy for RA. Educational objective: Methotrexate is the most common first-line treatment for rheumatoid arthritis (RA). Patients with RA who experience worsening disease while taking methotrexate are usually started on TNF antagonists. All patients should have screening for tuberculosis and hepatitis B and C prior to initiating TNF antagonists. __________ References: Screening of tuberculosis by interferon-gamma assay before biologic therapy for rheumatoid arthritis. (http://www.ncbi.nlm.nih.gov/pubmed/19211305) Diagnosis and management of rheumatoid arthritis (http://www.ncbi.nlm.nih.gov/pubmed/22150658) Rheumatoid arthritis (http://www.ncbi.nlm.nih.gov/pubmed/20870100)

A 52-Year-Old Man with a History of Rheumatoid Arthritis Comes